Every finding on record at Garden Crest Rehabilitation Center

Based on observation, interview, and record review the facility failed to develop and implement an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs for one of three sampled residents (Resident 1) assessed and identified as at risk of wandering(unsupervised movement within a secure area) and elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) on 5/7/2026. This deficient practice had the potential for Resident 1 to have received inadequate care and/or supervision which led to Resident 1's elopement from the facility on 5/11/2026 and sustaining a fall.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 5/7/2026, with diagnoses that included parkinsonism (a progressive brain disorder that occurs when nerve cells in the brain die or become damaged) unspecified, fall, subsequent encounter (the healing or recovery phase of care), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), mild, without behavioral disturbance (acting out, agitated, aggressive or mood/personality changes), psychotic disturbance (hallucinations or strong delusions), mood disturbance (disruptive sadness, irritability), and anxiety (excessive worry, fear, and nervousness), major depressive disorder (a serious long lasting mental illness characterized by a consistent low mood, loss of interest in activities, and low energy), unspecified, personal history of transient ischemic attack ( TIA-A temporary blockage of blood flow to the brain), and cerebral infarction (a stroke caused by a blocked blood vessel in the brain) without residual deficits(lasting physical or cognitive impairment that remain after a major event such as a stroke has been treated). During a review of Resident 1's History and Physical (H&P) dated 5/8/2026, the H&P indicated Resident 1 lacked capacity to make and understand decisions, cannot make know activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Situation Background and Recommendation form (SBAR: a form that is documentation of a complete assessment in response to a change in condition) dated 5/11/2026 at 7:00 PM, the SBAR form indicated: 6:45pm: Resident noted missing from wheelchair location in St [station] B. Notified all staff to search for resident in entire facility and surrounding area.7pm: 911 called.7:05pm: Informed wife7:26pm: [Local firefighter] called to notify that resident was found in [local intersection] and taken to [Local] ER due to skin abrasions related to fall during time outside facility. RP notified7:34pm: MD notified.7:40pm: [Local] ER called to inform resident will return to facility. Police arrived. During a review of Resident 1's General Acute Care Hospital (GACH) emergency department (ED) progress note dated 5/11/2026 at 8:16 PM, the ED progress note indicated Resident 1 was taken to the GACH by ambulance from the street to the ED after Resident 1 had wandered from the facility, had fallen, and injured his (Resident 1's) right elbow. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/13/2026, the MDS indicated Resident 1 had moderate cognitive impairment (impaired ability to think, understand, and reason). The MDS indicated Resident 1 needed substantial to maximal assistance (helper does more than half the effort) for oral (mouth) hygiene, personal hygiene, showering/bathing self, upper and lower body dressing. The MDS indicated Resident 1 was dependent on the staff (helper does all of the effort) for toileting hygiene. The MDS indicated Resident 1 needed partial/moderate assistance (helper does less than half of the effort) from sitting to stand and once standing able to have walked 10 feet. During a review of Resident 1's Care Plan Report, the Care Plan Report indicated there was no initial care plan for being at risk for wandering/elopement in Resident 1's medical record. During a concurrent interview and record review on 5/12/2026 at 3:34 PM, with Registered Nurse (RN)1, Resident 1's Nursing-Wander Risk assessment dated [DATE], and complete Care Plan Report were reviewed. RN 1stated Resident 1 was at risk for wandering on admission. RN 1 stated the purpose of creating a care plan for the risk of wandering/elopement was for the staff to have known how to monitor Resident , to ensured staff observed if Resident 1 was exhibiting behaviors of wandering or being an escapist (a resident who attempts to leave the facility without authorization or staff), and to have provided appropriate care and interventions for his behaviors. RN 1 confirmed by stating that when Resident 1 was assessed for being at risk for wandering on 5/7/2026, a care plan was not created for Resident 1, and there was no initial care plan specifically for being at risk of wandering/elopement. RN 1 stated a care plan would have been specifically based on Resident 1's initial assessment (evaluation) for risk wandering/elopement risk and MDS assessments. RN 1 stated Resident 1's care plan for elopement and wandering risk, was not created until after Resident 1 eloped from the facility on 5/11/2026. RN 1 stated if the staff had observed Resident 1 for wandering from day one (5/7/2026), any licensed nurse could have and should have initiated a care plan. RN 1 stated by not having had a care plan initiated for Resident 1 there were no interventions in place to prevent Resident 1 from eloping. RN 1 stated care plans were part of communication amongst staff and without a care plan the staff would not have known how to monitor Resident 1. During an interview on 5/12/2026 at 4:07 PM, with the Director of Nursing (DON), the DON stated care plans (in general) were a guide for a resident's condition, with a plan on how the staff were to address the condition and the level of care provided for the residents. The DON stated care plans were a guide for the staff to provide the best possible care for residents, including goals that were attainable and with interventions that were to be done in terms of nursing care. The DON stated care plans were created immediately when residents were admitted to the facility. The DON stated any licensed nurse could create, add a care plan, update, revise, adjust if an intervention did not work. The DON stated Resident 1 was at risk for wandering/elopement that was based on assessment when he (Resident 1) was admitted to the facility (5/7/2026). The DON stated all care was based on assessment and diagnosis such as Resident 1's diagnosis of Parkinson's disease and dementia as part of his risks for wandering/elopement. The DON stated by not having had a care plan for Resident 1's risk of wandering/elopement there could have been an incident that occurred before Resident 1's elopement that the staff would not have known about such as wandering into other residents' rooms or Resident 1 attempting to leave the facility. The DON stated a care plan would have had documented specific interventions in place for Resident 1. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 1/2026, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated The comprehensive, person-centered care plan includes the resident's stated goals upon admission and desired outcomes. The P&P indicated Each resident's comprehensive person -centered care plan is consistent with the resident's rights to receive the services and/or items included in the plan of care. The P&P indicated Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. During a review of the facility's document titled, Charge Nurse/Nurse Supervisor dated 1/2026, indicated, Coordinate nursing care to accommodate resident's person-centered plan of care. The Charge Nurse/Nurse Supervisor document indicated Assist in coordinating nursing services with other resident services to ensure the continuity of the residents' plan of care. During a review of the facility's document titled, Registered Nurse (RN) dated 1/2026, indicated Consult and coordinate with the interdisciplinary team (IDT) and healthcare professionals to assess, plan, implement and evaluate individualized resident care plans. The RN document indicated Ensure initial baseline and periodic comprehensive assessments and care plans are completed within required timeframes.

Based on observation, interview and record review, the facility failed to immediately notify the physician of change in treatment when one of three sampled residents (Resident 1) was readmitted back from the General Acute Care Hospital(GACH) after a treatment for ruling out fracture (break or cause to break) on 12/27/2025 with right arm device upon readmission. This deficient practice has the potential for Resident 1 not provided with proper care and treatment from the Primary Care Physician (PCP). During a record review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] with a diagnoses of type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities).During a record review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 12/23/25 indicated that Resident 1's cognitive (thought process) was severely impaired. The MDS indicated that Resident 1 is dependent (helper does all the efforts) during toileting, lower body dressing, and putting on/taking off footwear. During a review of Resident 1's electronic medical records progress notes, dated 12/27/2025 at 22:25, indicated that Resident 1 came back from the hospital, via ambulance.with arm splint and sling on right arm due to fracture on right elbow following GACH visit. There was no documentation that the attending physician was notified of Resident 1's return to the facility, the new diagnosis of an elbow fracture, or with right arm device.During a record review of Resident1's after summary visit report from GACH dated 12/27/2025 indicated a new diagnosis of radius (elbow bone) fracture and right elbow joint pain. GACH discharge instructions to make a follow up appointment with orthopedics and under nursing communication order indicated application, splint (a support device made of hard material that keeps an injured area from moving), right posterior (back) long arm. During a concurrent interview and record review of the Progress Notes with the Director of Nurses (DON) on 1/13/2026 at 12:59 p.m., the DON stated that all Licensed Nurse are expected to notify the Physician when residents are readmitted from the GACH or when there is a change of condition. The DON stated that there is no documentation that the PCP was notified of the readmission on [DATE] in Resident 1's electronic record progress notes which are her expectation that the nurses should have done. DON stated that it is important to notify Resident 1's physician of readmission to be able to properly monitor Resident 1 and ensure continuity of care. During a concurrent interview and record review on 1/13/2026 at 1:26 p.m. with Treatment Nurse (TX), TX stated that she did not notify Resident 1's Physician regarding right arm device because she forgot. During a review of the facility's policy and procedure titled, admission Assessment and Follow up: Role of the Nurse, revised on 01/2025, indicated Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings.

Based on observation, interview and record review, the facility failed one of three sampled residents (Resident 1) by not: Completing a comprehensive assessment for one of three sample Residents (Resident 1) after readmission from General Acute Care Hospital (GACH).2. Informing and obtaining order from the Primary Care Physician (PCP) of the discharge instruction of for application, splint (a support device made of hard material that keeps an injured area from moving), right posterior (back) long arm. Developing and implementing resident centered care plan for right arm device for one of three sample residents (Resident 1), 3.Monitoring the use of the right arm device for one of three sample residents (Resident 1). These deficient practices had the potential to result in harm to Resident 1, including compromised circulation (poor blood flow) of the right arm, skin integrity breakdown, nerve compression, pain, swelling, and decrease functional use of the extremity. Findings: During a review of Resident 3's admission Records, the admission Records indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses including peripheral vascular disease (a condition where blood vessels outside the heart and brain narrow, block, or spasm, reducing blood flow to the limbs (arms/legs) and organs), type two diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), non-pressure chronic ulcer (a small open sore or wound generally found in the stomach or on the skin) on right foot. During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/23/2025 indicated Resident 1 has severe cognitive impairment (significant trouble with thinking, memory, concentration, and decision-making). Resident 1 is dependent (helper does all the effort) on toileting hygiene, lower body dressing, putting on/taking off footwear. During a review of Resident 1's History and Physical (H&P) dated 12/19/2025, the H&P indicated Resident 1 does not have capacity to understand and make decisions. During a review of Resident 1's SBAR Communication Form (a healthcare tool to quickly and clearly share a patient's status, using a structured format) dated 12/27/2025, the SBAR Communication Form indicated Resident seen at 12PM with staff while giving care, resident unable to move right arm and complains of severe pain when touched and move gently. Family member at the bedside and aware of the situation. PCP was notified and was able to see resident at around 12:05PM. Resident 1 was unable to move his right arm, PCP ordered Resident 1 to be sent out via 911. At around 12:10 911 called and Resident 1 was sent to GACH at 12:20. During a review of Resident 1's Progress Notes dated 12/27/2025 at 10:25 p.m., the Progress Note indicated Resident 1 returned from the GACH via ambulance. The progress note indicated Resident 1 had arm splint and sling on his right arm due to fracture (a broken bone) on right elbow and experiencing discomfort over the affected arm. During an interview on 1/13/2026 at 10:47 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when she started working shift on 12/28/2025 she saw Resident 1 was back from the hospital, had a cast on his right arm due to radial head fracture(break in the top part of the thumb-side bone in your forearm, right where it connects to your elbow). LVN 1 stated when she came back to work Resident 1 did not have the cast on. LVN 1 stated the DON informed her that the cast had been removed because the fracture was ruled out with X-ray (a type of medical imaging that uses radiation to take pictures of the inside of your body results). During an interview on 1/13/2026 at 11:23 p.m. with Director of Rehabilitation (DOR), the DOR stated that Resident 1 returned to the facility with immobilizer (a brace or splint that stops you from bending your arm) on his right arm. The DOR stated that he did not conduct an assessment for Resident 1 when Resident returned from the hospital with immobilizer on his arm. The DOR stated that he would conduct resident assessments on admission and when there is a change in resident's condition even though there is a limitation on the arm. The DOR stated since fracture on resident right arm was ruled out, the incident was not considered as change in Resident 1's condition. During an interview on 1/13/2026 at 12:44 p.m. with Director of Nursing (DON), the DON stated that she instructed one of the License Nurse to call GACH where Resident 1 was transferred on 12/27/2025 the DON stated that she requested the X-ray results from the hospital on [DATE] and the x-ray result indicated Resident 1 did not have a fracture. The DON stated that Resident 1 returned to the facility from GACH on 12/27/2025 around 10:30 PM with immobilizer on his right arm. The DON stated when residents are readmitted back to the facility her expectation is that family and physician must be notified by the Licensed Nurses readmitting a resident. The notification should be documented in Progress Notes or Resident Assessments. The Licensed Nurse must contact the GACH to gather pertinent records. The facility must conduct comprehensive assessment and skin assessment of the resident upon residents return. The DON further stated that the facility must initiate and implement care plan for any change in residents' condition. During a subsequent interview on 1/13/2026 at 12:44 p.m. and record review with the DON the record indicated no documentation of: comprehensive assessment conducted for Resident 1 upon readmission, physician order for right arm device use and monitoring for Resident 1, developing and implementing a resident-centered care plan for right arm device for Resident 1, and monitoring the use of the right arm device for Resident 1. During a review of facilities Policies and Procedures (P&P) reviewed 1/2025, titled Care Plans, Comprehensive Person-Centered, the P&P indicated that the interdisciplinary team reviews and updates the care plan when the resident has been readmitted to the facility from a hospital stay.

Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate (observed or identified preparation or administration of medications or biologicals which is not in accordance with the physician's order, manufacturer's specifications for the preparation and administration of the medication or biological, and professional standards of practice) was not five percent (5%) or greater. On 12/16/2025 at 9:31 AM, Licensed Vocational Nurse 1 (LVN 1) failed to administer Simethicone (an anti-gas medication used to relieve symptoms like pressure, bloating, and fullness caused by excess gas in the stomach and intestines) and Aspirin (makes blood less sticky, preventing platelets from clumping and forming dangerous clots that cause heart attacks, strokes, and other vascular issues) timely for one out of three residents (Resident53) observed during the medication administration. This failure resulted in a cumulative med error rate of 7.14% observed during the medication administration and placed Resident 53 at risk of experiencing abdominal (stomach) discomfort and complications leading to hospitalization.Findings: During a review of Resident 53's admission Record, the admission Record indicated the facility admitted the resident on 12/2/2025 with diagnoses that included malignant neoplasm (an abnormal mass of tissue from uncontrolled cell growth which could be cancerous) the large intestine (colon), surgical aftercare following surgery on the digestive system, intestinal obstruction (a blockage in the small or large intestine that stops food, fluids, and gas from passing through, often causing severe abdominal pain, vomiting, bloating, and constipation), dysarthria (a motor speech disorder making speech slurred, slow, quiet, or hard to understand due to weak or uncoordinated muscles in the mouth, tongue, vocal cords, or diaphragm) following cerebral infarction (stroke, loss of blood flow to part of the brain), atherosclerotic heart disease (plaque buildup in the arteries), and gastro-esophageal reflux disease (chronic condition where stomach acid frequently flows back into the esophagus, causing irritation, heartburn, and regurgitation) During a review of Resident 53's Minimum Data Set (MDS, a standardized resident assessment tool) dated 9/3/2025, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 53 required substantial/maximal assistance (helper does more the half the effort) for oral hygiene and was dependent on facility staff (helper does all the effort) for eating, toileting hygiene, showering, bathing herself, upper body dressing, lower body dressing, personal hygiene, and putting on and taking off footwear. The MDS indicated Resident 53 had a feeding tube (a soft, flexible tube that delivers liquid food (formula), fluids, and medicine directly into the digestive system when a person can't eat or swallow enough by mouth due to illness or injury). During a review of Resident 53's Order Summary Report dated 12/2/2025, the Order Summary Report indicated the resident had physician orders for:1. Aspirin 325 Milligrams (mg, a unit of measure for mass) 1 tablet via the gastrostomy tube (g-tube, a feeding tube inserted through the abdomen directly into the stomach, used to provide nutrition, fluids, and medicine when a person can't eat or drink enough by mouth due to swallowing issues, poor intake, or aspiration risk) one time a day for antiplatelet.2. Simethicone 1.8 ml via g-tube three times a day for gas relief. During a review of Resident 53's Medication Administration Record (MAR) dated 12/1/2025 to 12/31/2025, the MAR indicated Resident 53 was receiving the Aspirin 325 mg every day and the Simethicone 1.8 ml three times a day. The MAR indicated Resident 53 was to receive the Aspirin at 9 AM and the Simethicone at 8 AM, 12 PM, and 9 PM. During an observation on 12/16/2025 at 9:31 AM with LVN 1 in resident 53's room, LVN 1 observed preparing and administering medication to Resident 53. LVN 1 prepared and administered the following medication to Resident 53: 1. Amlodipine (a medication used to treat high blood pressure) 10 mg.2. Atorvastatin (a medication used to lower cholesterol levels) 40 mg.3. Losartan Potassium (a medication used to treat high blood pressure) 25 mg.4. MiraLAX (a medication used to treat constipation, a blockage of stool) 17 Grams (gm, a unit of measure for mass).5. Potassium Chloride (a medication used to treat low potassium levels in the blood) 40 Milliequivalent (meq, a unit of measure for electrolytes) /15 Milliliters (ml, a unit of measure for fluid volume).6. Vitamin C (a type of supplement that provides the essential minerals crucial for immune function) 500 mg.7. Zinc Sulfate (a type of supplement) 220 mg.8. Calcium and Vitamin D3 (a type of supplement) 660-400 mg.9. Metformin (a medication used to lower blood sugar levels) 500 mg.10. Metoprolol (a medication used to treat high blood pressure) 25 mg.11. Hydralazine (a medication used to treat high blood pressure) 10 mg.12. Simethicone 1.8 ml.13. Peridex Mouth/Throat Solution (a medication used to treat the inflammation of gums) 5 ml. During a concurrent interview and record review on 12/16/2025 at 10:20 AM with LVN 1, Resident 53's physician order for Aspirin was reviewed. Resident 53's physician order indicated the resident was to receive Aspirin 325 mg via the g-tube one time a day. LVN 1 stated he could not administer Aspirin to Resident 53 because there was no supply of Aspirin 325 mg in the medication cart that he (LVN 1) could crush and give to Resident 53. LVN 1 stated the medication cart only had Aspirin 325 mg of enteric coated (a tablet with a special polymer barrier that prevents it from dissolving in the acidic environment of the stomach) that could not be crushed. LVN 1 stated he (LVN 1) would have to obtain Aspirin from the facility's stock of over-the-counter medication and give Resident 53 the Aspirin later that day (12/16/2025). During a concurrent observation, interview, and record review on 12/16/2025 at 2:11 PM with LVN 1, Resident 53's new container of Aspirin was observed and Resident 53's MAR dated 12/1/2025 to 12/31/2025 was reviewed. LVN 1 stated Aspirin 325 mg had not been given that morning (12/16/2025) because the Aspirin on hand was enteric coated and could not be crushed and given through a g-tube. LVN 1 stated the facility did not have the non-enteric coated Aspirin available in the supply room, so LVN 1 contacted the pharmacy to deliver the medication. LVN 1 stated he (LVN 1) was able to administer 325 mg of non-enteric coated Aspirin to Resident 53 at 1:04 PM. LVN 1 stated he (LVN 1) was Resident 53's nurse on 12/16/2025. LVN 1 stated he should have let the Director of Nursing (DON) know that the facility was almost out of Aspirin 325 supply so it could have been re-ordered. LVN 1 stated Resident 53's Aspirin was due to be given at 9 AM every day. LVN 1 stated Resident 53's Simethicone was due at 8 AM that morning (12/16/2025). LVN 1 stated he (LVN 1) gave Resident 53's Simethicone late that morning (12/16/2025) because he (LVN 1) was busy and could not give the medication on time. LVN 1 stated Resident 53 was supposed to get Simethicone three times a day. LVN 1 stated the window to give medication was one hour before the medication was due and one hour after the medication was due. LVN 1 stated medication had to be given on time because there was a potential for the medication to interact with other medication. During a concurrent interview and record review on 12/17/2025 at 2:35 PM with the Director of Nursing (DON), Resident 53's MAR dated 12/1/2025 to 12/31/2025 was reviewed. The DON stated when charge nurses saw there were only five pills remaining, they had to request for a refill from the pharmacy or obtain the medication from the over-the-counter stock. The DON stated LVN 1 should have requested and obtained a refill for the Aspirin when he (LVN 1) noticed there were five or less pills in the bottle. The DON stated if a medication is due at 8:00 AM the charge nurse has an hour before and an hour after the medication is due to administer the medication. The DON stated the Simethicone for Resident 53 should have been given between 7 AM -9 AM on 12/16/2025. The DON stated the administration of Simethicone to Resident 53 at 9:31 AM meant the medication was given late by 30 mins. The DON stated Resident 53 was administered Aspirin 3 hours late on 12/16/2025. The DON stated Resident 53's medication should have been given on time. The DON stated there was a potential for Resident 53's Simethicone and Aspirin to not be effective and lead to the resident experiencing abdominal discomfort or hospitalization if the medications were given late. During a review of the facility's Policy and Procedure (P&P) titled Administering Medication dated 1/2025, the P&P indicated Medications are administered in accordance with prescriber orders, including any required time frame. Medication administered times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions; and honoring resident choices and preferences, consistent with his or her care plan.Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and distribution practices, by failing to:1. Ensure three of three dry food storage containers stored in the kitchen's dry storage room, were labeled with a use by date (the last day the manufacturer guarantees the food's peak quality, flavor, and nutrient value). 2. Ensure seven of seven scoops used for dry storage foods were not left stacked upon each other, dirty. 3. Ensure 19 of 19 food dome covers (bell-shaped or dome-shaped lid used to cover food) were not stored next to a trash receptacle used for the disposal of paper towels. These deficiencies had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness to residents who received food from the facility's kitchen.Findings: During the initial kitchen tour with the Dietary supervisor (DS) on 12/15/25 at 7:50AM, three dry storage containers were observed in the kitchen's dry storage room labeled rice, flour, and sugar without a use by date. Seven scoops used for dry storage foods were observed stacked together, each scoop placed inside/on top of each other with a white powder-like substance on the bottom scoop. The DS stated that scoops should not be placed on top/inside of each other. The DS stated each scoop had to be placed on a tray. The DS stated each scoop had to be designated to a dry storage bin either for flour, sugar, or rice and each scoop had to be kept clean. The DS stated the dry storage containers had to be dated and labeled with the prepared and use by date. The DS stated there was potential for cross-contamination and for staff not to know when the food was to be used by and for food-borne illness (an illness that comes from eating contaminated food). During an observation on 12/15/2025 at 7:50 AM in the facility's kitchen, a trash receptacle used for disposal of paper towels after handwashing was observed positioned directly next to a cart holding 19 food dome covers. During a concurrent observation and interview on 12/15/2025 at 7:52 AM in the facility's kitchen with Dietary Aid (DA 1), DA 1 confirmed by stating the food dome covers were stored next to the trash receptacle and could cause cross contamination of resident's food. DA 1 stated the food dome covers would be rewashed. During an interview on 12/15/2025 at 8:05 PM with the Dietary Supervisor (DS), the DS confirmed by stating food dome covers were stored adjacent to the trash receptacle and could cause cross-contamination of resident's food. During an interview on 12/17/2025 at 1:45 PM with the Infection Preventionist (IP), the IP stated that storing food dome covers next to the trash receptacle in the kitchen could expose residents to infection. The IP stated that she (IP) provided an in-service to kitchen staff regarding infection control practices on 12/15/2025 upon becoming aware that the food dome covers were stored adjacent to a trash receptacle. During an interview on 12/17/2025 at 1:50 PM with the Director of Nursing (DON), the DON stated that storing the food dome covers adjacent to a trash receptacle could create an infection control concern, potentially contaminate resident's food, and cause residents to become ill. The DON stated the food dome covers should not be stored adjacent to the trash receptacle and should be kept at least six feet away from potential contamination sources. The DON stated the food dome covers had to be rewashed. During a review of facility's policy and procedures (P&P) titled Storing Utensils, Tableware, and Equipment with a revised date of 1/2025, the P&P indicated Cleaned and sanitized utensils and equipment will be stored at least six inches off the floor in a clean, dry location in a way that keeps them from contamination by splash, dust or other means. During a review of facility's policy and procedures (P&P) titled Food preparation and Service with a revised date of 1/2025, the P&P indicated Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. During a review of the 2022 U.S. Food and Drug Administration Food Code, code 4-903.11 titled Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. code indicated, (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on observation, interview, and record review, the facility failed to store over the counter (OTC, medication available without a prescription for treating mild ailments) medications at proper temperature controls in one of one medication stockroom, as per the facility's Policy and Procedure (P&P) titled Storage of Medications dated 5/2025. This failure had the potential to expose medication stored in the stockroom to extreme temperatures leading to a decrease in medication efficacy (how well a medication works or its ability to produce the intended result) and the potential for all 56 residents to receive ineffective medication.Findings: During an interview on 12/17/2025 at 2:08 PM with Registered Nurse 1 (RN 1), RN 1 stated the facility had one medication room and a stockroom where OTC medication was stored. During a concurrent observation and interview on 12/17/2025 at 2:20 PM with the Director of Nursing (DON), the facility's stockroom was observed. The stock room was observed with shelves that stored bottles of Citrate (a medication used to treat constipation), Vitamin D3 (a type of supplement, vitamins and minerals used to provide nutrients), [NAME]-Vite (a supplement specifically formulated for people with kidney disease), Ferrous Sulfate (medication used to treat low iron levels), Benadryl (a medication used to treat allergies), Loratadine (a medication used to treat allergies), Aspirin (a medication used to treat mild to moderate pain and inflammation), Vitamin b12 (a type of supplement), Multivitamins and Minerals (types of supplements), Zinc (a type of supplement), Vitamin C (a type of supplement), Cranberry pills (a dietary supplement taken for urinary tract health), Vitamin b1 (a type of supplement), Bisacodyl (a medication used to treat constipation), Docusate Sodium (a medication used to treat constipation), Geri-tussin (medication used to treat a cold and cough), Lactobacillus (a probiotic, a medication used to help maintain the number of health bacteria in the stomach and intestines), Clear lax (a medication used to treat constipation), Sorbitol (a medication used to treat constipation), and Tylenol (acetaminophen, a medication used to treat pain a reduce fever). There was no thermometer observed in the stockroom. The DON stated the stockroom stored some of the facility's OTC medication. The DON confirmed the stockroom did not have a thermometer. The DON stated that the room felt comfortable but did not know the temperature of the room. The DON stated she did not know if the temperature in the stockroom was appropriate to store medication because there was no way of knowing what the temperature was. The DON stated there was a potential for the over-the-counter medication stored in the stockroom to lose efficacy if the temperature in the room was too high or too low. During a record review of the facility's Policy and Procedure (P&P) titled Storage of Medications dated 5/2025, the P&P indicated All medications stored within the facility will have proper handling according to state and/or federal law. All medications shall be stored under appropriate conditions, temperatures, and in an orderly manner. Medications shall be stored at appropriate temperatures. Medications required to be stored at room temperature shall be stored at a temperature of not less than 15 degrees Celsius (59 degrees Fahrenheit) or more than 30 degrees Celsius (86 degrees Fahrenheit).

Based on interview and record review, the facility failed to report an allegation (claim that someone did something wrong) of misappropriation (taking or using someone else's money or belongings without their permission) of resident property immediately, but not later than 2 hours after the allegation was made to the California Department of Public Health (CDPH) for one out of one sampled resident (Resident 63) on 5/16/2025. As per the facility's policy and procedures (P&P) titled Abuse, Neglect, Exploitation (treating someone unfairly or taking improper advantage of them for personal gain, using a resident's vulnerability, or situation for one's own benefit) or Misappropriation - Reporting and Investigating, dated 1/2025. This deficient practice delayed an onsite inspection by the California Department of Public Health to ensure Resident 63's allegation was investigated. This deficient practice also had the potential to place Resident 63 at further risk for abuse.Findings: During a review of Resident 63's admission Record, the admission Record indicated the facility originally admitted Resident 63 on 1/13/2021 and readmitted Resident 63 on 12/11/2025 with diagnoses that included type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acute respiratory failure with hypoxia (when the body's tissues and cells don't get enough oxygen to function properly), ischemic cardiomyopathy (the heart muscle gets weak and enlarged because the heart is not getting enough oxygen-rich blood), morbid obesity (having a severe level of excess body fat), myocardial infarction type 2 (the heart muscle is damaged because the heart is not getting enough oxygen due to an imbalance, not from a sudden clot, but from something else stressing the body, like severe illness, low blood count, or fast heart rate, making the heart work too hard or depriving the heart of fuel), unspecified glaucoma (diseases involving eye pressure increases that lead to permanent vision loss and blindness), and dependence on oxygen (a colorless, odorless gas that is essential for breathing). During a review of Resident 63'a Progress Notes dated 5/16/2025 at 2:09 PM, the Progress Notes indicated Spoke to patient about the investigation of the missing money that he is now claiming that it is around $2k dollars, and when over the timeline of when was it that he ask [unknown staff] that was placing in bed with the foyer and the other lady that was helping him. Patient said that he ask the lady to place it in the second drawer he said this was at night time and then is later said that it was around 3-4pm. The note also indicated Told patient we will follow up with [unknown staff] and the with the police report. During a review of Resident 63's Minimum Data Set (MDS - a standardized resident assessment tool, dated 10/7/2025, the MDS indicated Resident 63 had the ability to understand others and had the ability to make himself understood. During a review of Resident 63's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 12/12/2025, the H&P indicated Resident 63 had fluctuating (varying) capacity (a person's ability to think clearly and make good decisions isn't constant; the person's ability to think goes up and down) to understand and make decisions. During an interview on 12/15/2025 at 10:26 AM, with Resident 63, Resident 63 stated he had lived at the facility for approximately 2 years. Resident 63 stated he reported to the Administrator (ADM) and Social Services Director (SSD) that approximately $2000 was stolen from his room approximately 6 months prior to the date of interview. Resident 63 stated he could not remember the exact date or time. Resident 63 stated the facility reported the alleged stolen $2000 to the police. During an interview on 12/16/2025 at 8:14 AM with the SSD, the SSD stated he (SSD) was familiar with Resident 63's allegation regarding the stolen money. The SSD stated Resident 63 had fluctuating (changing) dollar amounts regarding how much money was stolen. The SSD stated at times Resident 63 reported missing $300 and at other times $3000. The SSD stated he (SSD) reported the allegation of stolen money to local law enforcement only, but could not say the exact date and time, only that it was around May 2025. The SSD stated he (SSD) was a mandated reporter (someone legally required to report suspected physical or financial abuse or neglect). The SSD stated he (SSD) had to check his (SSD) notes to see if the SSD notified the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) or CDPH of the allegation of stolen money. During a follow up interview on 12/16/2025 at 9:07 AM with the SSD, the SSD stated Resident 63's allegation of stolen money on 5/16/2025 was not reported to the Ombudsman or CDPH. The SSD stated that he (SSD) notified local law enforcement and received a police report number. The SSD stated he (SSD) should have reported the allegation to CDPH. The SSD stated he (SSD) was not well versed in the facility's abuse and misappropriation of property policies. During an interview on 12/16/2025 at 9:19 AM with the Director of Staff Development (DSD), the DSD stated she (DSD) educated staff (in general) during abuse trainings and that facility staff had to report any allegations of abuse (financial, physical, misappropriation of property) to the police, CDPH, and Ombudsman. During a concurrent interview and record review on 12/16/2025 at 9:52 AM with the Director of Nursing (DON), DSD, and SSD, the facility's P&P titled Theft and Loss Program dated 1/2025 and the facility's P&P titled Abuse, Neglect, Exploitation (treating someone unfairly or taking improper advantage of them for personal gain, using a resident's vulnerability, or situation for one's own benefit) or Misappropriation - Reporting and Investigating, dated 1/2025 were reviewed. The SSD stated he (SSD) only referred to the facility's Theft and Loss Program policy which indicated the facility will report to local law enforcement agency within 36 hours when the Administrator has reason to believe resident's property with a then current value of $100.00 (one hundred dollar) or more has been stolen. Facility will keep logs that contain pertinent information for 12 months when Resident 63 made the allegation on 5/16/2025 regarding $2000 being stolen. The DSD and DON stated facility staff should have referred to the policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 1/2025, which indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported when Resident 63 made the allegation regarding $2000 being stolen. During a telephone interview on 12/16/2025 at 10:20 AM with the Ombudsman (OMB), the OMB stated the OMB did not receive any notification from the facility regarding any misappropriation of property in May 2025 for Resident 63. During a concurrent interview and record review on 12/16/2025 at 11:40 AM with the ADM, the ADM reviewed the facility's P&Ps titled Theft and Loss Program and Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 1/2025. The ADM stated Resident 63's allegation on 5/16/2025 of $2,000 being stolen would have only been reported to CDPH and the Ombudsman when the ADM's investigation was completed. The ADM stated that she (ADM) did not report the allegation Resident 63 made on 5/16/2025 because the ADM was not aware of the facility's policy and procedures titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. The ADM stated the facility should have referred to the Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy and reported Resident 63's allegations to CDPH and the Ombudsman. During an interview on 12/16/2025 at 11:57 AM with the DSD and DON, the DSD and DON stated the facility should have reported Resident 63's allegation of misappropriation of property on 5/16/2025 to protect Resident 63. The DON and DSD stated the facility had to report to CDPH and the Ombudsman any abuse or misappropriation of property allegations made by any of the facility's residents. During a review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 1/2025, the policy indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. During a review of the facility's P&P titled Theft and Loss Program dated 1/2025, the policy indicated the facility will report to local law enforcement agency within 36 hours when the Administrator has reason to believe resident's property with a then current value of $100.00 (one hundred dollar) or more has been stolen. Facility will keep logs that contain pertinent information for 12 months.

Based on observation and interviews, the facility failed to ensure 14 out of 18 (room [ROOM NUMBER], 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37, and 38) resident rooms met the required 80 square feet per resident. This deficient practice had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents. Findings: During a review of the facility's room wavier letter dated 12/4/2025, the letter indicated the facility was requesting a room variance (room size different from required amount) for 14 out of 18 resident rooms (room [ROOM NUMBER], 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37, and 38). The room waiver letter indicated the following rooms had less than 80 square feet per bed: Room Number Floor Area Capacity room [ROOM NUMBER] 151.69 2 room [ROOM NUMBER] 289.53 4 room [ROOM NUMBER] 150.5 2 room [ROOM NUMBER] 151.69 2 room [ROOM NUMBER] 150.5 2 room [ROOM NUMBER] 150.5 2 room [ROOM NUMBER] 150.5 2 room [ROOM NUMBER] 151.38 2 room [ROOM NUMBER] 149.63 2 room [ROOM NUMBER] 148.44 2 room [ROOM NUMBER] 146.5 2 room [ROOM NUMBER] 147.25 2 room [ROOM NUMBER] 146.06 2 room [ROOM NUMBER] 148.4 2 The room waiver request letter indicated the rooms were in accordance with the special needs of the residents and would not inhibit residents from getting in and out of wheelchairs and affording sufficient freedom of movement. The space of each room will not have adverse effect on the residents' health and safety; and would not impede the ability of any resident in the rooms to attain his/her highest practicable well-being. The room wavier letter indicated all measurements will be taken to ensure the comfort of each resident, staff, and visitor and would not be compromised by the facility's existing room square footage. During an observation on 12/15/2025 at 2:00PM, the Maintenance supervisor (MS) measured rooms [ROOM NUMBERS]. The rooms measured as follows: room [ROOM NUMBER] 150.5 2 room [ROOM NUMBER] 146.5 2 During multiple observations of nursing care conducted from 12/15/2025 to 12/16/2025 in rooms [ROOM NUMBERS], nursing staff were observed with adequate space to provide care to the residents in each resident room [ROOM NUMBER] and room [ROOM NUMBER]. Each resident was observed to have privacy curtains, working call-lights, storage, and a bedside table with personal belongings stored in each resident's choice of location. During an interview on 12/15/2025 at 2:25pm with Resident 90 in room [ROOM NUMBER], Resident 90 stated the room was big enough to accommodate him (Resident 90). Resident 90 stated the size of the room didn't seem small. Resident 1 stated that all his (Resident 90) belongings fit in the room and there had never been an issue. Resident 90 stated that he was happy about how warm the room was. During an interview on 12/15/2025 at 2:45 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was assigned to the station1 that services room [ROOM NUMBER]. LVN 1 stated the residents in room twenty-three never complained about the space in the room preventing the residents from doing anything or from receiving care. LVN 1 stated the residents received nursing services with no issues with the room size. During an interview with Resident 91 on 12/15/2025 at 3:00PM in room [ROOM NUMBER]. Resident 91 had been in the same room since admission and had not had any issues with the space in the room and stated there was enough room for the staff when providing care. A review of the facility's policy and procedures (P&P) titled Resident bedrooms revised on 8/2024, the policy indicated resident bedrooms had to be designed and equipped for adequate nursing care, comfort and privacy of resident and would measure at least 80 square feet per resident in multiple resident bedrooms The Department is recommending continuation of the room waiver request.

Based on observation, interview, and record review the facility failed to provide Range of Motion (ROM, full movement potential of a joint) and mobility (ability to move) treatments and services to prevent and/or limit a decline in joint (where two bones meet) for two of four sampled residents (Resident 1 and Resident 3) by failing to ensure to: -Complete a Joint Mobility Assessment (JMA, a tool that evaluates a joint's ability to move through its full range of motion by measuring flexibility, stiffness, and quality of movement) accurately and quarterly for Resident 1. -Follow the Physical Therapy recommendations as indicated in Resident 1's JMA. -Provide Passive Range of Motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 1's right hand as ordered by the resident's physician. -Provide ROM exercises as ordered by Resident 3's physician. These failures had the potential for Resident 1 and Resident 3 to develop a decline in ROM, and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion).Findings:1.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and contracture. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/2/2024, the MDS indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on help for showering, bathing herself, lower body dressing, putting on footwear, and taking off footwear. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 8/6/2024 for the Restorative Nursing Assistant (RNA, nursing aide who helps residents maintain their function and joint mobility) to perform PROM exercises to the resident's bilateral (both) upper extremities (BUE, both arms) seven times a week as tolerated every day. The Order Summary Report indicated the goal was to increase the Resident 1's ROM and prevent a decline in the resident's ROM. During a review of Resident 1's JMA dated 11/1/2024, the JMA indicated the resident had contracted bilateral lower extremities (BLE, both legs), limited ROM in the BLE, and no new deterioration (decline) noted in BLE and BUE. The JMA indicated Resident 1 was to continue the RNA program for PROM exercise and to be monitored by the nursing staff. The JMA indicated to notify nursing staff (unidentified) if Resident 1 had any change of condition or pain. During a review of Resident 1's RNA Administration dated 3/1/2025 to 3/31/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day. The RNA Administration indicated there was no documentation present on 3/9/2025 and 3/16/2025. During a review of Resident 1's RNA Administration dated 4/1/2025 to 4/30/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day shift. The RNA Administration indicated there was no documentation present on 4/10/2025, 4/19/2025, and 4/20/2025. During a review of Resident 1's RNA Administration dated 5/1/2025 to 5/31/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day shift. The RNA Administration indicated there was no documentation present on 5/15/2025 and 5/21/2025. During a review of Resident 1's JMA dated 5/27/2025, the JMA indicated the resident had minimal - severe loss of lower extremity PROM. The JMA indicated the resident had a diagnosis/condition that put her at risk for contracture development. The JMA indicated a recommendation for Resident 1 to receive a Physical Therapy (PT) evaluation, and RNA services for PROM of the BUE. During a review of Resident 1's RNA Administration dated 6/1/2025 to 6/30/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day shift. The RNA Administration indicated there was no documentation present on 6/14/2025. During a review of Resident 1's RNA Administration dated 7/1/2025 to 7/31/2025, the RNA Administration indicated the RNA was to perform PROM to the residents BUE seven times a week as tolerated every day shift. The RNA Administration indicated there was no documentation present on 7/6/2025 and 7/13/2025. During an observation on 8/28/2025 at 11:03 AM, in Resident 1's room, RNA 2 was observed performing PROM exercises for Resident 1. RNA 2 was observed providing PROM to Resident 1's right upper extremity. RNA 2 was observed providing PROM to Resident 1's right shoulder, right elbow, and right wrist. RNA 2 was observed performing PROM of Resident 1's left upper extremity. RNA 2 was observed providing PROM to residents left shoulder, left elbow, left wrist, and left hand. During an interview on 8/28/2025 at 11:23 PM with RNA 2, RNA 2 stated she (RNA2) provided PROM to Resident 1's bilateral shoulders, elbows, wrists, and hands. RNA 2 stated she (RNA2) forgot to perform PROM on Resident 1's right hand. RNA 2 stated she (RNA2) was supposed to provide PROM on Resident 1's right hand but did not. RNA 1 stated it was important to perform PROM on Resident 1's hands so the resident's hands would not contract. During a concurrent interview and record review on 8/28/2025 at 11:55 AM, with PT 1, Resident 1's JMA dated 11/1/2024 and 5/27/2025 were reviewed. PT 1 stated changes in ROM were monitored through the JMAs. PT 1 stated JMA's were done on admission, quarterly, annually, and with a change of condition. PT 1 stated Resident 1 had a JMA done on 11/2/2024 and 5/27/2025. PT 1 stated after Resident 1's JMA dated 11/1/2024, Resident 1 should have had another JMA done in 2/2025 but did not have one done. PT 1 stated a lot could have happened in six months. PT 1 stated Resident 1's ROM could have gotten worse, and her joints could have gotten tighter and more painful. PT 1 stated he (PT1) performed Resident 1's JMA on 5/27/2025. PT 1 stated he (PT1) made a recommendation for Resident 1 to have a PT evaluation. PT 1 stated he (PT1) recommended a PT evaluation to determine the true integrity of Resident 1's joints. PT 1 stated Resident 1's JMA recommendation for a PT evaluation was not carried out. PT 1 stated once he (PT1) determined Resident 1 needed a PT evaluation he should have spoken to the Director of Rehab (DOR) and asked for a PT evaluation order. PT 1 stated it was important that JMA recommendations were carried out to ensure Resident 1 would not get worse. PT 1 stated he (PT1) performed resident JMAs through observation and interview. PT 1 stated he (PT1) performed JMAs by asking Certified Nursing Assistants (CNAs, in general) for information about the residents (in general). PT 1 stated he (PT1) did not touch the residents (in general) during JMAs. PT 1 stated PROM was not performed when Resident 1's JMA was done on 5/27/2025. PT 1 stated the integrity of a joint could not be determined by looking at the resident. During a concurrent interview and record review on 8/28/2025 at 1:15 PM, with the DOR, Resident 1's JMA dated 11/1/2024 and 5/27/2025 were reviewed. The DOR stated Resident1 did not have a JMA done in 2/2025. The DOR stated that JMAs were supposed to be done on admission, quarterly, annually, and with a change in condition. The DOR stated if a JMA was not done quarterly there could potentially be a gap in the resident's care. The DOR stated if a JMA was not done quarterly they wouldn't know if the resident had any changes in their ROM. The DOR stated when performing a JMA the PT was supposed to use PROM. The DOR stated that when performing PROM, the PT needed to touch the resident. The DOR stated a JMA could not be performed without moving and touching the resident. The DOR stated PROM had to be performed when doing a JMA to feel what had happened in the resident's joint. The DOR stated if a JMA was done without using PROM then the JMA was inaccurate. During an interview and record review on 8/28/2025 at 1:55 PM, with the Director of Staff Development (DSD), Resident 1's RNA Administration dated 3/1/2025 to 3/31/2025, 4/1/2025 to 4/30/2025, 5/1/2025 to 5/31/2025, 6/1/2025 to 6/30/2025, and 7/1/2025 to 7/31/2025 were reviewed. The DSD stated Resident 1 did not have RNA services done on 3/9/2025, 3/16/2025, 4/10/2025, 4/19/2025, 4/20/2025, 5/15/2025, 5/21/2025, 6/14/2025, 7/6/2025, and 7/13/2025. The DSD stated she (DSD) was not sure why RNA services were not done on these dates. The DSD stated it was important that Resident 1 be seen as the RNA as ordered by the physician. The DSD stated there was a potential for Resident 1 to have a decline in ROM if RNA services were not provided as ordered by the physician. 2. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 4/19/2024 with diagnoses that included spinal stenosis (a condition where the spinal canal, the bony tunnel that protects the spinal cord and nerve roots, becomes narrowed), type 2 diabetes, abnormalities of gait and mobility (deviations from a typical walking pattern, characterized by changes in balance, coordination, and the ability to move effectively), muscle weakness, osteoporosis, and repeated falls. During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 3 substantial/maximal assistance with eating, oral hygiene, toileting hygiene, showering, bathing herself, upper body dressing, lower body dressing, and personal hygiene. The MDS indicated Resident 3 was dependent on help for putting on and taking off footwear. During a review of Resident 3's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 8/9/2024 for the RNA to perform BUE Active Assisted Range of Motion (AAROM, a type of physical therapy exercise where the resident uses their own muscle strength to move a body part, but receives assistance from a therapist or device to achieve a greater or more comfortable range of motion) seven times a week or as tolerated every day shift. During a review of Resident 3's RNA Administration dated 3/1/2025 to 3/31/2025, the RNA Administration indicated the RNA was to perform BUE AAROM seven times a week or as tolerated everyday shift for Resident 3. The RNA Administration indicated there was no documentation for 3/8/2025, 3/11/2025, 3/18/2025, 3/30/2025. During a review of Resident 3's RNA Administration dated 4/1/2025 to 4/30/2025, the RNA Administration indicated the RNA was to perform BUE AAROM seven times a week or as tolerated every day shift for Resident 3. The RNA Administration indicated there was no documentation for 4/3/2025, 4/10/2025, and 4/28/2025. During a review of Resident 3's RNA Administration dated 5/1/2025 to 5/31/2025, the RNA Administration indicated the RNA was to perform BUE AAROM seven times a week or as tolerated every day shift for Resident 3. The RNA Administration indicated there was no documentation for 5/22/2025 and 5/26/2025. During a review of Resident 3's RNA Administration dated 7/1/2025 to 7/31/2025, the RNA Administration indicated the RNA was to perform BUE AAROM seven times a week or as tolerated every day shift for Resident 3. The RNA Administration indicated there was no documentation for 7/2/2025, 7/6/2025, 7/10/2025, and 7/15/2025. During an interview and record review on 8/28/2025 at 1:42 PM, with the Director of Staff Development (DSD), Resident 3's RNA Administration dated 3/1/2025 - 3/31/2025, 4/1/2025 to 4/30/2025, 5/1/2025 to 5/31/2025, and 7/1/2025 to 7/31/2025 were reviewed. The DSD stated Resident 1 did not have RNA services done on 3/8/2025, 3/11/2025, 3/18/2025, 3/30/2025, 4/3/2025, 4/10/2025, 4/26/2025, 5/22/2025, 5/26/2025, 7/2/2025, 7/6/2025, 7/10/2025, and 7/15/2025. The DSD stated she (DSD) was not sure why RNA services were not done on these dates. The DSD stated it was important that Resident 1 be seen by the RNA as ordered by Resident 3's physician. The DSD stated there was a potential for Resident 3 to have a decline in ROM if RNA services were not provided as ordered by the physician. During an interview on 8/28/2025 at 3:40 PM with the Director of Nursing (DON), the DON stated physician orders for RNA services should be followed. The DON stated RNA services help keep the residents from getting stiff. The DON stated if physician orders for RNA services were not followed the residents could become contracted. The DON stated JMAs are conducted on admission, quarterly, annually and as needed. The DON stated a JMA was used to assess if the resident had a decline in ROM. The DON stated if a JMA was not done quarterly the resident could have had a decline in ROM. The DON stated if there were recommendations for PT when a JMA was done, those recommendations should have been carried out. The DON stated the Resident 1's physician should have been notified of the PT's recommendations. The DON stated if recommendations were not carried out the resident could decline. The DON stated if the JMAs were conducted wrong and inaccurately, the resident would not get the care they needed and would potentially have a decline in ROM. During a review of the facility's Policy and Procedure (P&P) titled Resident Mobility and Range of Motion dated 7/2017, the P&P indicated Residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. During a review of the facility's P&P titled Charting and Documentation dated 7/2017, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During a review of the facility's P&P titled Restorative Nursing Services dated 7/2017, the P&P indicated Resident will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies) During a review of the facility's P&P titled Screening dated 6/2023, the P&P indicated It is the policy of this Rehabilitation Department to complete patient screenings periodically, dependent on the facility policy for screens.The Joint Mobility Screening form is to be completed by PT and/or OT.Types of Screens: Admission, Re-admission, Quarterly, Annually, Change of Condition, Post-fall.Quarterly and Annual screens (both Rehabilitation and/or Joint Mobility Screening forms) may be done as per facility policy and in conjunction with the MDS assessment schedule. During a review of the facility's Job Description titled Certified Nursing Assistant dated 10/2020, the Job Description indicated Perform restorative and rehabilitative procedures as instructed in accordance with the individualized plan of care. During a review of the facility's P&P titled Specialized Rehabilitative Services dated 1/2025, the P&P indicated Our facility will provide rehabilitative services to residents as indicated by the MDS. In addition to rehabilitative nursing care, the facility provides specialized rehabilitative services by qualified professional personnel. Specialized rehabilitative services include the following: Physical therapy; Speech pathology/audiology; Occupational /activity therapy. Therapeutic services are provided only upon the written order of the resident's attending physician.

Based on observation, interview, and record review, the facility failed to implement and maintain infection control procedures for two of four sampled residents (Residents 2 and Resident 3) by failing to:-Ensure Restorative Nursing Aide 1 (RNA 1) cleaned and disinfected a gait belt (safety device worn around the waist that can be used to help safely transfer a person from one surface to another) in between use for Resident 2 and Resident 3.-Ensure RNA 1 used the appropriate cleaning agent to effectively clean and disinfect a cloth gait belt after providing Restorative Nursing Aide services (RNA, nursing aide program that helps residents maintain their function and joint mobility) services to Resident 2 and Resident 3.These failures placed Resident 2 and Resident 3 at risk for potential infections that could cause a decline in the residents' health and quality of life.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 6/28/2025 with diagnoses including a local infection of the skin and subcutaneous tissue (layer of fat, connective tissue, and blood vessels that lies beneath the skin), acquired absence (the loss or removal of a body part or organ that was not present from birth but occurred later in life due to injury, trauma, disease, or surgery) of the toes on both feet, and Type 2 Diabetes Mellitus (condition in which the body does not metabolize blood sugar correctly) with diabetic neuropathy (nerve damage caused by diabetes). During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 4/19/2024 with diagnoses including spinal stenosis (narrowing of the space within the spine that contains the spinal cord and nerve roots), muscle weakness, and gout (form of arthritis that occurs when uric acid builds up in the blood and causes joint inflammation). During an observation on 8/27/2025 at 11:17 am, in the hallway, RNA 1 was observed assisting Resident 2 with walking exercises using a knee scooter (wheeled mobility aid with a padded platform to support the injured leg and handlebars for steering and braking). RNA 1 held onto Resident 2's cloth gait belt which was fastened around his waist. At the end of the session, RNA 1 removed the cloth gait belt from Resident 2's waist, placed the gait belt on top of a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) which was in the hallway next to Resident 2's room, walked to the bathroom with the FWW and gait belt, came back into the hallway, and walked to Resident 3's room. RNA 1 did not clean and disinfect the cloth gait belt. RNA 1 walked into Resident 3's room, assisted Resident 3 with dressing activities seated in a wheelchair, transported Resident 3 into the hallway, placed the cloth gait belt previously used on Resident 2 onto Resident 3's waist, and assisted Resident 3 with walking exercising using a FWW in the hallway. At the end of the session, RNA 1 removed the cloth gait belt from Resident 3's waist, performed hand hygiene, and wiped down the cloth gait belt and FWW with disinfecting wipes. During an interview on 8/27/2025 at 11:32 am with RNA 1, RNA1 stated she (RNA1) did not clean and disinfect the cloth gait belt after she (RNA1) used it with Resident 2 and before she (RNA1) used it again with Resident 3. RNA 1 stated she (RNA1) should have cleaned and disinfected the cloth gait belt in between resident use but did not. RNA 1 stated the RNAs (in general) were instructed to use the disinfectant wipes to disinfect all equipment which included cloth gait belts. RNA 1 stated it was important to disinfect shared equipment between residents to prevent the spread of infection. During a concurrent interview and record review on 8/27/2025 at 2 pm, the Infection Preventionist Nurse (IPN, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) stated all shared resident equipment must be cleaned and disinfected in between and after each resident use. The IPN stated staff (in general) used Super Sani-Cloth disinfectant wipes to disinfect shared equipment which included cloth gait belts. The IPN stated cloth gait belts were made of porous (having small spaces or holes through which liquid or air may pass) material. The IPN reviewed the Super Sani-Cloth disinfectant wipes manufacturing instructions and confirmed the disinfectant wipes could only effectively be used on hard, non-porous surfaces. The IPN stated Sani-Cloth disinfecting wipes were ineffective for disinfecting cloth gait belts because they were made of soft, porous materials. The IPN stated the only way to properly clean and disinfect cloth gait belts was to launder them after each resident use. The IPN stated it was important to clean and disinfect shared equipment properly and according to manufacturer's instructions to maximize infection control, ensure the cleaning was effective, and to prevent the spread of infection. During an interview on 8/28/2025 at 3:40 pm with the Director of Nursing (DON), the DON stated staff (in general) must clean and disinfect all shared equipment in between and after each resident use. The DON stated it was important to clean and disinfect shared equipment using the appropriate cleaning agent and according to manufacturer's instructions to prevent the spread of infection. During a review of the Super Sani-Cloth manufacturer's instructions, titled General Guidelines for Use, dated 2021, the guidelines indicated the disposable wipes disinfected surfaces in two minutes and were to be used on hard, non-porous environmental surfaces. During a review of the facility's Policy and Procedures (P/P), titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 1/2025, the P/P indicated reusable items were cleaned and disinfected or sterilized between residents. The P/P indicated reusable resident care equipment was decontaminated and/or sterilized between residents according to manufacturer's instructions.

Based on interview and record review, the facility failed to ensure to conduct the Joint Mobility Assessment (JMA, a tool that evaluates a joint's ability to move through its full range of motion by measuring flexibility, stiffness, and quality of movement) accurately for one of four sampled residents (Resident 1).This failure had the potential for Resident 1 to experience a decline in Range of Motion (ROM, full movement potential of a joint).Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/2/2024, the MDS indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on help for showering, bathing herself, lower body dressing, putting on footwear, and taking off footwear. During a review of Resident 1's JMA dated 5/27/2025, the JMA indicated Resident 1 had minimal - severe loss of lower extremity Passive Range of Motion (PROM, movement at a given joint with full assistance from another person). The JMA indicated the resident had a diagnosis/condition that put her at risk for contracture development. The JMA indicated a recommendation for Resident 1 to receive a Physical Therapy (PT) evaluation, and RNA services for PROM of both upper extremities (BUE, arms). During a concurrent interview and record review on 8/28/2025 at 11:55 AM, with Physical Therapist 1 (PT 1), Resident 1's JMA dated 5/27/2025 was reviewed. PT 1 stated he (PT1) performed Resident 1's JMA on 5/27/2025. PT 1 stated he (PT1) performed resident JMAs through observation and interview. PT 1 stated he (PT1) performed JMAs by asking Certified Nursing Assistants (CNAs in general) for information about the residents (in general). PT 1 stated he (PT1) did not touch the residents (in general) during JMAs. PT 1 stated PROM was not performed when Resident 1's JMA was done on 5/27/2025. PT 1 stated the integrity of a joint could not be determined by looking at the resident. During a concurrent interview and record review on 8/28/2025 at 1:15 PM, with the Director of Rehab (DOR), Resident 1's JMA dated 5/27/2025 was reviewed. The DOR stated when performing a JMA the PT was supposed to use PROM. The DOR stated that when performing PROM, the PT needed to touch the resident. The DOR stated a JMA could not be performed without moving and touching the resident. The DOR stated PROM had to be performed when doing a JMA to feel what had happened in the resident's joint. The DOR stated if a JMA was done without using PROM then the JMA was inaccurate. During an interview on 8/28/2025 at 3:40 PM with the Director of Nursing (DON), the DON stated if the JMAs were conducted inaccurately, the resident would not get the care they needed. The DON stated if the JMA was conducted inaccurately the resident would potentially have a decline in ROM. During a review of the facility's P&P titled Charting and Documentation dated 7/2017, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to provide safe care and services for one of three sampled residents (Resident 1) by failing to: 1.Ensure Certified Nursing Assistant 1 (CNA1) and CNA 2 provided two-person physical assistance (help from two person) when they (CNA1 and CNA2) assisted Resident 1 who had a diagnosis of osteoporosis (weak and brittle bones), contracture (a stiffness, shortening at any joint, that reduces the joint's range of motion) with activities of daily living (ADL's, activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, bathing, turning, and eating). This failure had a high potential for Resident 1 to sustain injuries and harm. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), age -related osteoporosis with current pathological fracture (broken bone caused by disease) of the right femur (thigh bone), anxiety disorder (a condition in which a person had excessive worry and feelings of fear, dread and uneasiness), unspecified osteoarthritis, and contracture of unspecified joint. During a review of Resident 1's Care Plan Report dated 4/9/2024 indicated Resident 1 had contractures-multiple joints and was at risk for pain, stiffness, fractures, decrease in range of motion (ROM-how far and in what direction you can a joint or muscle), and other complications. The Care Plan Report indicated interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) including to handle Resident 1 gently during care/ADLs. The Care Plan Report indicated to provide 2 person- assist with ADLs/care. During a review of Resident 1's Initial History and Physical (H&P - a comprehensive document that records a patient's medical history and a detailed physical examination performed by a healthcare provider) dated 1/17/2025, the H&P indicated Resident 1 did not have the capacity (ability) to understand and make decisions. The H&P indicated Resident 1 had a history of osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteopenia (low bone mass). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment (difficulty with thinking, learning, and remembering), functional limitation in both upper extremity (shoulder, elbow, wrist, hand), both lower extremity impairment (hips, knee, ankle and foot) that interfered with functions of daily living or place Resident 1 at risk for injury. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort and helper lifts or hold trunk or limbs and provides more than half the effort) from staff for eating, oral hygiene, upper body dressing, and rolling left and right. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) on the staff for toileting hygiene, shower/bathe self and lower body dressing with dressing. During a review of Resident 1's SBAR Communication Form (SBAR-a simple, structed way to share important information), Situation (what's happening), Background (relevant history), Assessment (professional judgement), and Recommendation (action to resolve the situation) dated 8/4/2025, the SBAR indicated staff (unidentified) reported Resident 1 had grimacing (expression) of pain on the right hip when doing peri-care (the process of cleaning the genital and anal area). The SBAR indicated Charge Nurse (CN-lead nurse) notified the Registered Nurse Supervisor (team leader for nurses) Resident 1 had right hip swelling, pain when moved, and warm to touch. The SBAR indicated Resident 1 was not able to rate pain (a numbered scale to help understand how much it hurts) level. The SBAR indicated the CN provided Tylenol (pain medication) for relief. The SBAR indicated the Medical Doctor (MD) was made aware and ordered an x-ray (a form of electromagnetic radiation, similar to visible light). During a review of Resident 1's Patient Report dated 8/4/2025, the Patient Report indicated right hip, unilateral (one sided) with pelvis (the bony structure inside your hips, buttocks and pubic region), 2-3 views (images taken from different angels to get a more complete picture) X-ray indicated Resident 1 had an interval development (change or progression) of an oblique (a break in a long bone at a curved or diagonal angle to its length, typically caused by falls or other traumas) and displaced proximal femoral fracture (a fracture in the upper part of the thighbone where the bone fragments have moved out of alignment). During an interview on 8/19/2025 at 10:20 AM, with Licensed Vocational Nurse (LVN)1, LVN 1 stated the plan of care for the residents (in general) included orders, screening, observations, assessments, and the diagnoses of the residents. LVN 1 stated she (LVN1) would check the care plan for interventions, or if there was a change or decline. LVN 1 stated the nursing staff (in general) were responsible for following the care plan. During an interview on 8/18/2025 at 4:05 PM, with CNA2, CNA 2 stated she (CNA2) did not know what osteoporosis was and that she (CNA2) did not get report from the licensed nurses (in general) regarding Resident 1's osteoporosis. CNA2 stated she (CNA2) worked at the facility for 29 years. CNA2 stated she (CNA2) would be assigned to Resident 1 before Resident 1's fracture and that she (CNA2) would provide ADLs to Resident 1 without a two-person assist. CNA2 stated that in the morning of 8/4/2025, she (CNA2) noticed Resident 1's right leg was swollen and warm to touch and reported to a nurse (unidentified). During a telephone interview on 8/19/2025 at 10:59 AM with CNA 1, CNA 1 stated he (CNA1) worked on 8/3/2025 from 11 PM, to 7 PM on 8/4/2025. CNA1 stated he (CNA1) worked alone when he (CNA1) assisted Resident 1 with ADLs. CNA 1 stated Resident 1 was a one -person assist only (a single helper is needed to move or support someone for a task, but the person being helped still does most of the work themselves). CNA 1stated, I can ask for help if repositioning is required. CNA 1 stated osteoporosis has to do with fragile bones. During an interview on 8/19/2025 at 12:37 PM, with Registered Nurse (RN) 1, RN1 stated the licensed nurses (in general) needed to notify the CNAs (in general) regarding the residents' (in general) care plan and what was required during the beginning of each shift. RN1 stated she (RN1) did not know if the CNAs had access to the residents' care plans. RN1 stated the licensed nurses (in general) were responsible for monitoring the CNAs and to notify them (CNAs) how many CNAs were required for ADLs. RN1stated, I'm not sure how communication is monitored to insure care. During a concurrent interview and record review on 8/19/2025 at 2:37 PM, with the Director of Nursing (DON) Resident 1's Care Plan Report dated 4/9/2024, and the MDS dated [DATE] were reviewed. The DON stated Resident 1 had contractures and osteoporosis which was the weakening of bones. The DON stated the staff (in general) needed to be gentle and needed to provide care with two CNAs. The DON stated Resident 1 had contractures and if the CNAs (in general) applied pressure to the weak fragile bones, the bones could break and result in a fracture. The DON stated if Resident 1 required two person-assist during care and there if there was only one CNA, the CNA would have to push harder to turn Resident 1. The DON stated if Resident 1 required two CNAs but only one CNA would turn, change, and provided care, the pressure applied by the CNA (in general) on Resident 1 to turn, would be higher than if there were two CNAs. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised on 7/2024, the P&P indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care): mobility (transfer and ambulation, including walking): elimination(toileting). The P&P indicated, A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. and the following MDS definitions: Total Dependence: Full staff performance of an activity with no participation by the resident for any aspect of the ADL. During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, revised on 3/2022, the P&P indicated Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). The P&P indicated The IDT includes but is not limited to the resident's attending physician; a registered nurse with responsibility for the resident; a nursing assistant with responsibility for the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised on 7/2024, the P&P indicated The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition: at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview and record review, the facility failed to report an allegation of staff to resident abuse to the State Survey Agency (SSA, the Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Health, which is responsible for nursing facility certification and for conducting surveys to determine compliance with Medicare and Medicaid requirements) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within two hours for one of five sampled residents (Resident 1). This failure had the potential to result in a delay of an onsite inspection by the SSA and had the potential for Resident 1 to experience ongoing abuse. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety (a feeling of fear, dread, and uneasiness), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool) dated 5/2/2025, the MDS indicated the resident had severely impaired cognition (diminished ability to think, understand, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 1 was dependent on help (helper does all the effort) for toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) Summary for Providers documentation dated 5/15/2025 at 10:38 PM, the SBAR Summary for Providers documentation indicated the resident had an unwitnessed fall around 10 PM. The SBAR Summary for Providers documentation indicated Resident 1 was found in bed with a forehead laceration (a tear or cut in the skin) and skin tear (a wound that occurs when the outer layer of skin separates from the underlying layer) on her bilateral (both) elbows. The SBAR Summary for Providers documentation indicated Resident 1's was assessed and provided with wound care. The SBAR Summary for Providers documentation indicated Resident 1 was unable to be consoled (someone is too sad or upset to be comforted) and was noted to be grimacing (to make a facial expression of pain) with her fists clenched (hands with fingers curled tightly into the palm). The SBAR Summary for Providers documentation indicated Resident 1 was confused. The SBAR Summary for Providers documentation indicated Resident 1's physician was immediately notified and provided the recommendation to transfer the resident to the General Acute Care Hospital (GACH, a health facility that provides short-term, inpatient medical and surgical services for a wide range of conditions) 1 via 911 for further evaluation. During a review of Resident 1's After Summary Visit from GACH 1 dated 5/16/2025 at 3:19 AM, the After Summary Visit indicated Resident 1 was provided with treatment for the laceration and skin tears. The After Summary Visit indicated Resident 1 had a Computed Tomography (CT - diagnostic imaging procedure that uses a machine to create detailed images of the inside of the body) of her head which did not show any head bleed or skull fracture (break in bone). During a review of Resident 1's Nurse's Notes dated 5/16/2025 at 4 AM, the Nurse's Notes indicated Resident 1 returned to the facility from GACH 1 via gurney accompanied by two Emergency Medical Technicians (EMT's). The Nurse's Notes indicated Resident 1 was awake and talking. During a review of Resident 1's SBAR Summary for Providers documentation dated 5/16/2025 at 7:28 PM, the SBAR Summary for Providers documentation indicated the resident had an allegation of abuse. The SBAR Summary for Providers documentation indicated Resident 1's physician was notified and recommended to continue to monitor the resident for adverse effects of the alleged abuse. During a review of the document titled Report of Suspected Dependent Adult/Elder Abuse dated 5/16/2025, the document indicated on 5/15/2025 at 9:45 PM, Resident 1 was found on the floor next to her bed. The document indicated Resident 1 sustained a laceration on her forehead with bleeding and a left and right elbow skin tear. The document indicated Resident 1 was transferred to the GACH. The document indicated on 5/16/2025 at 5 PM, the Registered Nurse (RN) Supervisor overheard the Certified Nurse Assistant (CNA) who was outside the room heard Resident 1 say You pushed me to the (CNA) who was inside the room. The document indicated investigation was ongoing. During a review of a fax confirmation from the facility to the SSA dated 5/16/2025 at 6:59 PM, the fax confirmation indicated the facility notified the SSA of Resident 1's allegation of abuse. During a review of a fax confirmation from the facility to the Ombudsman dated 5/16/2025 at 7:04 PM, the fax confirmation indicated the facility was notified the ombudsman of Resident 1's allegation of abuse. During a review of a document titled Summary of Investigation dated 5/20/2025, the document indicated on 5/15/2025 CNA 1 found Resident 1 on the floor. The document indicated CNA 1 immediately assessed the resident. The document indicated Resident 1 was conscious and talking in Spanish. The document indicated bleeding was noted on Resident 1's forehead. The document indicated CNA 1 assisted Resident 1 back to bed then notified the Licensed Vocational Nurse (LVN). The document indicated LVN assessed Resident 1, notified the Registered Nurse (RN) Supervisor, and provided treatment to the resident. The document indicated the RN Supervisor called 911 and notified Resident 1's physician and family. The document indicated Resident 1 received treatment for the laceration of the left forehead and a CT scan which was negative for fracture. The document indicated Resident 1 was returned to the facility on [DATE] at 2:30 AM. The document further indicated that on 5/16/2025 at 5:00 PM, during the investigation of Resident 1's incident, CNA 2 informed the RN Supervisor that she overheard the resident saying in Spanish you pushed me to the CNA who found her during the fall. During a telephone interview on 5/28/2025 at 2:21 PM with RN 1, RN 1 stated on 5/15/2025 between 9:45 PM - 10:00 PM Licensed Vocational Nurse (LVN) 1 had notified him that Resident 1 had fallen. RN 1 stated when he went into Resident 1's room, the resident was already back in bed and Certified Nurse Assistant (CNA) 1 was also there. RN 1 stated Resident 1 had skin tears to both of her elbows and a cut on her forehead. RN 1 stated he checked Resident 1's vitals and provided treatment to the resident's wounds. RN 1 stated 911 was called and Resident 1 was transferred to the GACH. RN 1 stated Resident 1 could not tell him how she fell . RN 1 stated no one told him about an allegation of abuse that night. RN 1 stated that it wasn't until the next day when CNA 2 came forward and told him and LVN 1 that she heard Resident 1 say I fell , and you pushed me when the resident fell on [DATE]. RN 1 stated he reported the allegation of abuse to the Administrator right away. During an interview on 5/28/2025 at 3:04 PM with CNA 2, CNA 2 stated she did not see Resident 1 fall on 5/15/2025, but heard the resident say in Spanish you pushed me, you pushed me when she fell . CNA 2 stated she did not remember the time that happened, but stated it was around nighttime. CNA 2 stated she told LVN 1 what she heard what Resident 1 was saying immediately after she heard the resident say it. CNA 2 stated the next day on 5/16/2025 she told LVN 1 and RN 1 again that Resident 1 said you pushed me, you pushed me the night the before. CNA 2 stated this was the second time she told LVN 1 that Resident 1 said You pushed me . CNA 2 stated she did not tell the Administrator what she heard Resident 1 said only LVN 1. During an interview on 5/28/2025 at 3:12 PM with LVN 1, LVN 1 stated on 5/15/2025 around 9:00 PM to 10:00 PM, CNA 1 called his attention and told him that Resident 1 had fallen. LVN 1 stated he immediately went to Resident 1's room. LVN 1 stated as he was going to Resident 1's room, CNA 2 told him something. LVN 1 stated he couldn't really understand what CNA 2 was telling him. LVN 1 stated he thought CNA 2 was telling him Resident 1 was calling for help. LVN 1 stated when he got to Resident 1's room, the resident was already back in bed. LVN 1 stated Resident 1 had a skin tear to her right and left elbow and a cut on her left forehead. LVN 1 stated Resident 1's vitals were checked, and treatment was provided to the resident's wounds. LVN 1 stated 911 was called and Resident 1 was sent to the GACH for further evaluation. LVN 1 stated at that time he did not have any concerns about abuse. LVN 1 stated on the next day 5/16/2025 at around 4:00 PM, CNA 2 told him that she heard Resident 1 was saying you pushed me when she fell the night before on 5/15/2025. LVN 1 stated when he realized this was what CNA 2 was telling him the night before he told RN 1 and they both informed the Administrator and Director of Nursing (DON). LVN 1 stated pushing was an allegation of abuse which should be reported to the SSA, ombudsman, and law enforcement within two hours. LVN 1 stated that the allegation of abuse should have been reported the night before, but he did not realize CNA 2 was telling him Resident 1 was saying she was pushed by staff. During an interview on 5/28/2025 at 3:51 PM with the Director of Nursing (DON), the DON stated she was informed by the Administrator that Resident 1 fell and had an allegation of abuse on 5/16/2025. The DON stated through investigation of Resident 1's fall she found that on the night the resident fell on [DATE] CNA 2 told LVN 1 that Resident 1 was saying you pushed me to CNA 1. The DON stated LVN 1 did not hear the abuse allegation and only heard that Resident 1 was asking for help. The DON stated the abuse allegation was reported to the Administrator and herself when CNA 2 told LVN 1 and RN 1 about the abuse allegation a second time on 5/16/2025. The DON stated Resident 1's abuse allegation should have been reported the night the Resident fell on [DATE]; but because there was the initial misunderstanding and miscommunication between CNA 2 and LVN 1 on 5/15/2025, the allegation did not get reported until LVN 1 received clarification of what happened by CNA 2 on 5/16/2025. The DON stated allegations of abuse should be reported to the SSA, the ombudsman, and law enforcement within two hours so the facility could act immediately. The DON stated there was a potential for further abuse if abuse allegations were not reported timely. During a review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating reviewed 1/2025, the P&P indicated All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; the local/state ombudsman; the resident representative; adult protective services (where state law provides jurisdiction in long-term care); law enforcement officials; the resident's attending physician' and the facility medical director. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. BasedBased on interview and record review, the facility failed to report an allegation of staff to resident abuse to the State Survey Agency (SSA, the Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Health, which is responsible for nursing facility certification and for conducting surveys to determine compliance with Medicare and Medicaid requirements) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within two hours for one of five sampled residents (Resident 1). This failure had the potential to result in a delay of an onsite inspection by the SSA and had the potential for Resident 1 to experience ongoing abuse. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety (a feeling of fear, dread, and uneasiness), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool) dated 5/2/2025, the MDS indicated the resident had severely impaired cognition (diminished ability to think, understand, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 1 was dependent on help (helper does all the effort) for toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) Summary for Providers documentation dated 5/15/2025 at 10:38 PM, the SBAR Summary for Providers documentation indicated the resident had an unwitnessed fall around 10 PM. The SBAR Summary for Providers documentation indicated Resident 1 was found in bed with a forehead laceration (a tear or cut in the skin) and skin tear (a wound that occurs when the outer layer of skin separates from the underlying layer) on her bilateral (both) elbows. The SBAR Summary for Providers documentation indicated Resident 1's was assessed and provided with wound care. The SBAR Summary for Providers documentation indicated Resident 1 was unable to be consoled (someone is too sad or upset to be comforted) and was noted to be grimacing (to make a facial expression of pain) with her fists clenched (hands with fingers curled tightly into the palm). The SBAR Summary for Providers documentation indicated Resident 1 was confused. The SBAR Summary for Providers documentation indicated Resident 1's physician was immediately notified and provided the recommendation to transfer the resident to the General Acute Care Hospital (GACH, a health facility that provides short-term, inpatient medical and surgical services for a wide range of conditions) 1 via 911 for further evaluation. During a review of Resident 1's After Summary Visit from GACH 1 dated 5/16/2025 at 3:19 AM, the After Summary Visit indicated Resident 1 was provided with treatment for the laceration and skin tears. The After Summary Visit indicated Resident 1 had a Computed Tomography (CT - diagnostic imaging procedure that uses a machine to create detailed images of the inside of the body) of her head which did not show any head bleed or skull fracture (break in bone). During a review of Resident 1's Nurse's Notes dated 5/16/2025 at 4 AM, the Nurse's Notes indicated Resident 1 returned to the facility from GACH 1 via gurney accompanied by two Emergency Medical Technicians (EMT's). The Nurse's Notes indicated Resident 1 was awake and talking. During a review of Resident 1's SBAR Summary for Providers documentation dated 5/16/2025 at 7:28 PM, the SBAR Summary for Providers documentation indicated the resident had an allegation of abuse. The SBAR Summary for Providers documentation indicated Resident 1's physician was notified and recommended to continue to monitor the resident for adverse effects of the alleged abuse. During a review of the document titled Report of Suspected Dependent Adult/Elder Abuse dated 5/16/2025, the document indicated on 5/15/2025 at 9:45 PM, Resident 1 was found on the floor next to her bed. The document indicated Resident 1 sustained a laceration on her forehead with bleeding and a left and right elbow skin tear. The document indicated Resident 1 was transferred to the GACH. The document indicated on 5/16/2025 at 5 PM, the Registered Nurse (RN) Supervisor overheard the Certified Nurse Assistant (CNA) who was outside the room heard Resident 1 say You pushed me to the (CNA) who was inside the room. The document indicated investigation was ongoing. During a review of a fax confirmation from the facility to the SSA dated 5/16/2025 at 6:59 PM, the fax confirmation indicated the facility notified the SSA of Resident 1's allegation of abuse. During a review of a fax confirmation from the facility to the Ombudsman dated 5/16/2025 at 7:04 PM, the fax confirmation indicated the facility was notified the ombudsman of Resident 1's allegation of abuse. During a review of a document titled Summary of Investigation dated 5/20/2025, the document indicated on 5/15/2025 CNA 1 found Resident 1 on the floor. The document indicated CNA 1 immediately assessed the resident. The document indicated Resident 1 was conscious and talking in Spanish. The document indicated bleeding was noted on Resident 1's forehead. The document indicated CNA 1 assisted Resident 1 back to bed then notified the Licensed Vocational Nurse (LVN). The document indicated LVN assessed Resident 1, notified the Registered Nurse (RN) Supervisor, and provided treatment to the resident. The document indicated the RN Supervisor called 911 and notified Resident 1's physician and family. The document indicated Resident 1 received treatment for the laceration of the left forehead and a CT scan which was negative for fracture. The document indicated Resident 1 was returned to the facility on [DATE] at 2:30 AM. The document further indicated that on 5/16/2025 at 5:00 PM, during the investigation of Resident 1's incident, CNA 2 informed the RN Supervisor that she overheard the resident saying in Spanish you pushed me to the CNA who found her during the fall. During a telephone interview on 5/28/2025 at 2:21 PM with RN 1, RN 1 stated on 5/15/2025 between 9:45 PM - 10:00 PM Licensed Vocational Nurse (LVN) 1 had notified him that Resident 1 had fallen. RN 1 stated when he went into Resident 1's room, the resident was already back in bed and Certified Nurse Assistant (CNA) 1 was also there. RN 1 stated Resident 1 had skin tears to both of her elbows and a cut on her forehead. RN 1 stated he checked Resident 1's vitals and provided treatment to the resident's wounds. RN 1 stated 911 was called and Resident 1 was transferred to the GACH. RN 1 stated Resident 1 could not tell him how she fell . RN 1 stated no one told him about an allegation of abuse that night. RN 1 stated that it wasn't until the next day when CNA 2 came forward and told him and LVN 1 that she heard Resident 1 say I fell , and you pushed me when the resident fell on [DATE]. RN 1 stated he reported the allegation of abuse to the Administrator right away. During an interview on 5/28/2025 at 3:04 PM with CNA 2, CNA 2 stated she did not see Resident 1 fall on 5/15/2025, but heard the resident say in Spanish you pushed me, you pushed me when she fell . CNA 2 stated she did not remember the time that happened, but stated it was around nighttime. CNA 2 stated she told LVN 1 what she heard what Resident 1 was saying immediately after she heard the resident say it. CNA 2 stated the next day on 5/16/2025 she told LVN 1 and RN 1 again that Resident 1 said you pushed me, you pushed me the night the before. CNA 2 stated this was the second time she told LVN 1 that Resident 1 said You pushed me . CNA 2 stated she did not tell the Administrator what she heard Resident 1 said only LVN 1. During an interview on 5/28/2025 at 3:12 PM with LVN 1, LVN 1 stated on 5/15/2025 around 9:00 PM to 10:00 PM, CNA 1 called his attention and told him that Resident 1 had fallen. LVN 1 stated he immediately went to Resident 1's room. LVN 1 stated as he was going to Resident 1's room, CNA 2 told him something. LVN 1 stated he couldn't really understand what CNA 2 was telling him. LVN 1 stated he thought CNA 2 was telling him Resident 1 was calling for help. LVN 1 stated when he got to Resident 1's room, the resident was already back in bed. LVN 1 stated Resident 1 had a skin tear to her right and left elbow and a cut on her left forehead. LVN 1 stated Resident 1's vitals were checked, and treatment was provided to the resident's wounds. LVN 1 stated 911 was called and Resident 1 was sent to the GACH for further evaluation. LVN 1 stated at that time he did not have any concerns about abuse. LVN 1 stated on the next day 5/16/2025 at around 4:00 PM, CNA 2 told him that she heard Resident 1 was saying you pushed me when she fell the night before on 5/15/2025. LVN 1 stated when he realized this was what CNA 2 was telling him the night before he told RN 1 and they both informed the Administrator and Director of Nursing (DON). LVN 1 stated pushing was an allegation of abuse which should be reported to the SSA, ombudsman, and law enforcement within two hours. LVN 1 stated that the allegation of abuse should have been reported the night before, but he did not realize CNA 2 was telling him Resident 1 was saying she was pushed by staff. During an interview on 5/28/2025 at 3:51 PM with the Director of Nursing (DON), the DON stated she was informed by the Administrator that Resident 1 fell and had an allegation of abuse on 5/16/2025. The DON stated through investigation of Resident 1's fall she found that on the night the resident fell on [DATE] CNA 2 told LVN 1 that Resident 1 was saying you pushed me to CNA 1. The DON stated LVN 1 did not hear the abuse allegation and only heard that Resident 1 was asking for help. The DON stated the abuse allegation was reported to the Administrator and herself when CNA 2 told LVN 1 and RN 1 about the abuse allegation a second time on 5/16/2025. The DON stated Resident 1's abuse allegation should have been reported the night the Resident fell on [DATE]; but because there was the initial misunderstanding and miscommunication between CNA 2 and LVN 1 on 5/15/2025, the allegation did not get reported until LVN 1 received clarification of what happened by CNA 2 on 5/16/2025. The DON stated allegations of abuse should be reported to the SSA, the ombudsman, and law enforcement within two hours so the facility could act immediately. The DON stated there was a potential for further abuse if abuse allegations were not reported timely. During a review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating reviewed 1/2025, the P&P indicated All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; the local/state ombudsman; the resident representative; adult protective services (where state law provides jurisdiction in long-term care); law enforcement officials; the resident's attending physician' and the facility medical director. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review the facility failed to ensure the policy and procedures for discharge planning were followed for one of three sampled residents (Resident 1). This failure resulted in the resident not being properly informed and involved in their discharge plan. Findings: During a review of Resident 1 ' s Admission Record dated 5/16/25 indicated the resident was admitted to the facility on [DATE] with diagnoses including; diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) hypertension (HTN- high blood pressure), atrial fibrillation (AFib- a heart rhythm disorder where the upper chambers of the heart [atria] beat irregularly and rapidly), hyperlipidemia (HLD- a condition characterized by elevated levels of fats in the bloodstream) and chronic kidney disease (CKD- a progressive and irreversible condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). During a review of Resident 1 ' s History and Physical (H&P) dated 1/17/25 indicated the resident has the capacity to understand and make decisions. During a review of the Minimum Data Set (MDS- a resident assessment tool) dated 3/28/25 indicated Resident 1 ' s cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions intact. The same MDS further indicated Resident 1 was independent for bed mobility and required setup or clean-up assistance for eating, oral and personal hygiene and partial to moderate assistance with showering/bathing, dressing and toileting. During a review of Resident 1 ' s discharge planning care plan initiated 11/27/24 indicated interventions of: provide written and verbal instructions at the patient/family ' s level of understanding, review and discuss discharge plan with resident/family as appropriate. During a concurrent interview and record review on 5/16/25 at 3:15 pm with Case Manager (CM) 1, Resident 1 ' s case manager progress notes for discharge planning were reviewed. The progress notes indicated the resident ' s family member had been contacted a few times for discharge planning but there was not mention in the notes of the resident and if they were made aware of the plan in the last three months. CM 1 verified there were no notes indicating the resident had been involved in the discharge plan and stated there is no way to prove that it was done without a note. During a review of the facility ' s policy and procedures titled Resident Rights reviewed January 2025 indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to . be informed of, and participate in, his or her care planning and treatment. During a review of the facility ' s policy and procedures (P&P) titled Discharge Summary and Plan reviewed January 2025, the P&P indicated When a resident ' s discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge . 3. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family.

Based on interview and record review, the facility to honor the right of a resident to be free from involuntary seclusion for one of the three sampled residents (Resident 1), by placing Resident 1 in isolation without a physician ' s order. This deficient practice had the potential to result in feelings of depression, loneliness, and psychological harm for Resident 1. Findings: During a review of Resident 1's admission record, the facility admitted Resident 1 on 12/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), and dysphagia (difficulty swallowing). During a review of Resident 1 ' s physician orders dated 12/30/2024 at 5:15 pm, indicated, DROPLET (prevent the spread of infections that are spread through the air by coughing, sneezing, or talking. Precautions include wearing a mask, washing hands, and limiting movement outside of a patient's room) AND CONTACT ISOLATION (used when there is a risk of transmission through direct or indirect contact with a patient or their environment) + EYE PROTECTION. During a review of Resident 1 ' s Situation Background Assessment and Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) form dated 1/8/2025 at 6:2 pm, indicated that on 1/8/2025, Resident 1 had a change in condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) identified labored or rapid breathing and shortness of breath. The SBAR indicated, Notified by CN (Charge Nurse) that patient oxygen level is 88% (normal range between 92-100%) and that his BP (Blood Pressure) is low. Assessed res. (Resident 1), put him on 5L (Liters) via 02 (oxygen) mask but unsuccessful to raise 02, placed on high flow oxygen15L via nonrebreather mask (a medical device that delivers oxygen to patients who need more than they can get on their own), but res having labored breathing with respiration rate 40/min. Res. visibly making noises while struggling to inhale/exhale, recent flu (Influenza) dx (diagnosis) and completed ATB (antibiotic therapy), with breathing treatment PRN (as needed) unsuccessful to raise 02 via previous COC. 911 (an emergency number to get immediate help from police, fire department, or ambulance) called d/t (due to) high respiratory rate, hypoxic (a condition where there is an insufficient amount of oxygen in the body's tissues or blood) and diff. (difficulty) breathing. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/21/2025, indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 1 was required supervision or touching assistance for eating and required between substantial/maximal assistance and dependence for all other Activities of Daily Living such as: (ADLs- routine tasks/activities such as, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of Resident 1's history and physical (H&P-a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 1/23/2025 indicated Resident 1 had the capacity to make decisions. During an interview with the Infection Prevention Nurse (IPN) on 2/11/2025 at 2:20 pm, the IPN stated that Resident 1 was admitted to the facility on [DATE] with a diagnosis of Influenza A (commonly known as the flu, is a contagious respiratory illness caused by influenza viruses) and was sent to General Acute Care Hospital (GACH) on 1/8/2025. On 1/17/2025 when Resident 1 was readmitted to the facility with no orders for isolation and that Resident 1 had tested negative to Influenza A while at GACH. IPN admitted that residents in isolation had to have an active physician ' s order. IPN stated that the potential effects of placing a resident in isolation could result in resident being isolated from other residents and may lead to feelings of anxiety. During an interview with the Licensed Vocational Nurse (LVN) 1 on 2/11/2025 at 4 pm, LVN 1 admitted that Resident 1 was in isolation upon readmission from GACH on 1/17/2025 even though there was no active order. LVN 1 stated that residents should never be placed on isolation without physician ' s orders. LVN 1 stated the potential effects of isolating a resident without orders may lead to depression. During a concurrent interview and record review of Resident 1 ' s orders with the Director of Nursing (DON) on 2/11/25 at 4:19 pm, the DON confirmed that there was no active order for isolation when Resident 1 was readmitted on [DATE]. The DON was unable to state the potential effects of placing a resident in isolation without an order. During an interview with the Medical Doctor (MD) 1on 2/25/2025 at 2:47 pm, MD 1 stated residents diagnosed with influenza typically stay in isolation for 5 days especially when they are receiving treatment. He stated that Resident 1 should not have been in isolation. During a review of the facility's policy and procedures (P&P) titled Isolation - Categories of Transmission-Based Precautions, revised 1/2025, the P&P indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The same P&P indicated The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 1/2025, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Based on interview and record review, the facility to honor the right of a resident to be free from involuntary seclusion for one of the three sampled residents (Resident 1), by placing Resident 1 in isolation without a physician's order. This deficient practice had the potential to result in feelings of depression, loneliness, and psychological harm for Resident 1. Findings: During a review of Resident 1's admission record, the facility admitted Resident 1 on 12/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), and dysphagia (difficulty swallowing). During a review of Resident 1's physician orders dated 12/30/2024 at 5:15 pm, indicated, DROPLET (prevent the spread of infections that are spread through the air by coughing, sneezing, or talking. Precautions include wearing a mask, washing hands, and limiting movement outside of a patient's room) AND CONTACT ISOLATION (used when there is a risk of transmission through direct or indirect contact with a patient or their environment) + EYE PROTECTION. During a review of Resident 1's Situation Background Assessment and Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) form dated 1/8/2025 at 6:2 pm, indicated that on 1/8/2025, Resident 1 had a change in condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) identified labored or rapid breathing and shortness of breath. The SBAR indicated, Notified by CN (Charge Nurse) that patient oxygen level is 88% (normal range between 92-100%) and that his BP (Blood Pressure) is low. Assessed res. (Resident 1), put him on 5L (Liters) via 02 (oxygen) mask but unsuccessful to raise 02, placed on high flow oxygen15L via nonrebreather mask (a medical device that delivers oxygen to patients who need more than they can get on their own), but res having labored breathing with respiration rate 40/min. Res. visibly making noises while struggling to inhale/exhale, recent flu (Influenza) dx (diagnosis) and completed ATB (antibiotic therapy), with breathing treatment PRN (as needed) unsuccessful to raise 02 via previous COC. 911 (an emergency number to get immediate help from police, fire department, or ambulance) called d/t (due to) high respiratory rate, hypoxic (a condition where there is an insufficient amount of oxygen in the body's tissues or blood) and diff. (difficulty) breathing. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/21/2025, indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 1 was required supervision or touching assistance for eating and required between substantial/maximal assistance and dependence for all other Activities of Daily Living such as: (ADLs- routine tasks/activities such as, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of Resident 1's history and physical (H&P-a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 1/23/2025 indicated Resident 1 had the capacity to make decisions. During an interview with the Infection Prevention Nurse (IPN) on 2/11/2025 at 2:20 pm, the IPN stated that Resident 1 was admitted to the facility on [DATE] with a diagnosis of Influenza A (commonly known as the flu, is a contagious respiratory illness caused by influenza viruses) and was sent to General Acute Care Hospital (GACH) on 1/8/2025. On 1/17/2025 when Resident 1 was readmitted to the facility with no orders for isolation and that Resident 1 had tested negative to Influenza A while at GACH. IPN admitted that residents in isolation had to have an active physician's order. IPN stated that the potential effects of placing a resident in isolation could result in resident being isolated from other residents and may lead to feelings of anxiety. During an interview with the Licensed Vocational Nurse (LVN) 1 on 2/11/2025 at 4 pm, LVN 1 admitted that Resident 1 was in isolation upon readmission from GACH on 1/17/2025 even though there was no active order. LVN 1 stated that residents should never be placed on isolation without physician's orders. LVN 1 stated the potential effects of isolating a resident without orders may lead to depression. During a concurrent interview and record review of Resident 1's orders with the Director of Nursing (DON) on 2/11/25 at 4:19 pm, the DON confirmed that there was no active order for isolation when Resident 1 was readmitted on [DATE]. The DON was unable to state the potential effects of placing a resident in isolation without an order. During an interview with the Medical Doctor (MD) 1on 2/25/2025 at 2:47 pm, MD 1 stated residents diagnosed with influenza typically stay in isolation for 5 days especially when they are receiving treatment. He stated that Resident 1 should not have been in isolation. During a review of the facility's policy and procedures (P&P) titled Isolation - Categories of Transmission-Based Precautions, revised 1/2025, the P&P indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The same P&P indicated The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 1/2025, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on observation and interview the facility failed to implement its infection control policy by falling to ensure Certified Nursing Assistant (CNA) 1, Registered Nurse supervisor (RN) 1, and House Keeping (HK) performed hand hygiene (hand washing with soap and water and use alcohol-based hand sanitizer) while entering and exiting residents' rooms [ROOM NUMBERS], touching curtains, and bedside tables in the residents' rooms. These deficient practices had the potential to result in the spread of infectious disease (disorders that are caused by organisms, usually microscopic in size, such as bacteria, viruses, fungi, or parasites that are passed, directly or indirectly, from one person to another). Findings: During an observation on 2/1/2025 at 8:45 AM CNA 1, observed carrying a clear trash bag with bare hands, threw the trash in a trash receptacle next room [ROOM NUMBER]. CNA 1 entered room [ROOM NUMBER], pulled a curtain at room [ROOM NUMBER] bed B and pushed a bed side table. During an observation on 2/1/2025 at 9:40 AM, observed RN 1 answering a call light in room [ROOM NUMBER]. RN 1 entered room [ROOM NUMBER] not applying hand hygiene, touched the bed side table in room [ROOM NUMBER] bed A, donned a glove to assist the resident. Observed removing the gloves and exited room not applying hand hygiene. During an observation on 2/1/2025 at 11:41 AM, observed HK in utility room, touching mop bucket with bare hands, exited utility room and entered room [ROOM NUMBER] not applying hand hygiene. During an interview on 2/1/2025 at 8:55 AM with CNA 1, CNA 1 stated I should apply hand hygiene after handling trash, before touching high touch areas, touching patients, and patient equipment. The potential outcome for not applying hand hygiene is spread of infections between residents and staff. During an interview on 2/1/2025 at 9:40 AM with RN 1, RN 1 stated, I should have applied hand hygiene before entering room [ROOM NUMBER], hand hygiene is important to protect the spread of infections. During an interview on 2/1/2025 at 2:13 PM with Director of Staffing Development (DSD), DSD stated, hand hygiene is a basic infection prevention practice that needs to be practiced by staff. DSD will conduct routine monitoring of staff hand hygiene practice and will conduct in-service to enforce hand hygiene practice. During an interview on 2/3/2025 at 2:33 PM with the Director of Nursing (DON), DON stated, RN1 acknowledged the mistakes on 2/12025 on hand hygiene practice, RN will improve practicing hand hygiene. DON stated hand hygiene should be practiced by all staff. The outcome not practicing hand hygiene, residents will be at risk for infection outbreak. During a review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Program reviewed January 2025, the P&P indicated, a. Important facets of infection prevention include: educating staff and ensuring that they adhere to proper techniques and procedures; implementing appropriate enhanced barrier and transmission-based precautions when necessary; and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

Based on interview and record review, the facility failed to ensure to report the Payroll-Based Journal (PBJ - a method to collect staffing data from nursing facilities) for the 3rd quarter (April 1-June 30). This deficiency resulted in the inaccurate data reporting of direct care staff, providers, and vendors potentially placing the facility at risk of not implementing their policy. Findings: A review of the Certification and Survey Provider Enhanced Reports (CASPER) for the PBJ Staffing Data Report Fiscal Year Quarter 3 2024 (April 1 - June 30) indicated the metric was triggered for Failed to Submit Data for the Quarter. During an interview on 11/15/2024 at 12:28 p.m. with the Administrator (ADM) and payroll (Staff 1), Staff 1 stated she had been employed at the facility since 9/16/2024. The ADM stated there was no gap in between when Staff 1 started, and the last payroll staff exited. Staff 1 stated the PBJ was submitted quarterly and received from the payroll department. The ADM stated the previous payroll staff submitted the PBJ for the 3rd quarter in August 2024, but there were a few days that the Wi-Fi in the office was down in the evening but came back on. The ADM was not sure if there was a problem with the submission. The ADM stated the previous payroll staff remained late at the facility to submit the PBJ. The ADM stated the previous payroll staff failed to add the rehabilitation department to the PBJ report. The ADM stated the facility called Centers for Medicare and Medicaid Services (CMS) to report they failed to submit the rehabilitation department. The ADM stated the facility resubmitted the report with the rehabilitation department included in October. During concurrent interview and record review on 11/15/24 at 2:14 p.m. with the ADM, the CASPER Reports Submit printout was reviewed. The CASPER Reports Submit printout indicated the report was the 1705D Staffing Data Report, with the State: CA, the facility's CCN number, and the Fiscal Quarter: Quarter 3 2024 (April 1 - June 30). The report had no date of submission included in the report. The ADM stated the printout revealed the PBJ was submitted, but the ADM confirmed there was no date confirmed on the submission. The ADM stated she would try to produce the date of submission for the PBJ for the 3rd Quarter. The ADM stated that on the submission website, the date of the submission can be viewed for 24 hours. The ADM could not produce the date of submission. A review of the facility's policy and procedure (P&P) titled, Reporting Direct Care Staffing Information (Payroll-Based Journal), dated 8/2022, indicated the direct care staffing information was reported electronically to CMS through the Payroll-Based Journal system. The P&P indicated a complete and accurate direct care staffing information was reported electronically in a uniform format and the direct care staffing information was submitted on the schedule specified by CMS, but no less frequently than quarterly. The P&P indicated the staffing information must be collected and reported no later than 45 days after the end of the reporting quarter; the 3rd quarter deadline was August 14.

Based on observation, interview and record review, the facility failed to ensure three of four sampled residents (Resident 9, 32, and 46), who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had an emergency dialysis kit (a collection of supplies that people with kidney disease can use in case of an emergency) at the resident's bedside. This deficient practice had the potential for residents to receive a delayed intervention during accidental bleeding. Findings: a. A review of the Admission Record indicated Resident 46 was admitted to the facility on [DATE], with diagnoses including end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days) and dependence on renal dialysis (your blood is put through a filter outside your body, cleaned, and then returned to you). A review of Resident 46's dialysis care plan revised on 10/12/2024, indicated for the facility staff to check and change the access site dressing daily and to monitor any signs and symptoms of infection to the access site. The care plan goal indicated Resident 46 would have immediate intervention should any signs and symptoms of complications from dialysis occur. A review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 11/6/2024, indicated Resident 46 received dialysis while a resident in the facility, had no cognitive impairment, and needed maximum assistance with transfers and toileting. A review of the Physician's Orders dated 5/2/2024 indicated to monitor access site (right subclavian shunt- a catheter placed in the subclavian vein to provide access for hemodialysis) every shift for redness, swelling, drainage, and pain and to notify the MD. During an observation on 11/12/2024 at 9:54 AM in Resident 46's room, no emergency kit was noted at the bedside. During a concurrent interview and observation with the Registered Nurse (RN 1) on 11/13/2024 at 9:47 AM, the RN stated all resident's who were on dialysis should have an emergency kit at the bedside. The RN attempted to look for the emergency kit at Resident 46's bedside and was unable to find it. The RN stated that there could be a risk for bleeding and infection if there was no emergency kit available. During an interview with the Director of Nursing (DON) at 11/13/2024 at 11:22 AM, the DON stated that all dialysis residents should always have an emergency kit at bedside. The DON stated that by not having the emergency kit immediately available it can cause a delay in treatment if a resident experiences bleeding. A review of Center for Clinical Standards and Quality / Safety & Oversight Group dated 8/10/2018, indicated that the nursing home should ensure a reserve of supplies to be available in emergency circumstances. It further indicated that the emergency supply reserve was in excess of the routine supply inventory and generally included at least five (5) days of emergency supplies for each resident. 49881 b. A review of Resident 9's Admission Record indicated the facility admitted the resident on 9/27/2017 with diagnoses including end stage renal disease (irreversible kidney failure), Type II diabetes (a disease that results in high levels of sugar in the blood), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). A review of Resident 9's care plan revised on 10/13/2024, indicated the resident had a diagnosis of end stage renal disease with hemodialysis. The care plan intervention indicated to monitor hemodialysis site for signs and symptoms of infection and bleeding. A review of Resident 9's MDS dated [DATE], indicated the resident's cognition was intact and that the resident was on dialysis. A review of the Physician's Order dated 11/13/2024 indicated for Resident 9 to receive monitoring of the access site (right chest permacath- flexible tube that's inserted into a vein in the neck or upper chest for dialysis treatment and right arteriovenous fistula- a connection that's made between an artery and a vein for dialysis access) every shift for redness, swelling, drainage, and pain and to notify the MD. During a concurrent observation and interview on 11/13/2024 at 9:42 AM with Registered Nurse 1 (RN 1) in Resident 9's room, RN 1 stated Resident 9 was on dialysis and did not have an emergency kit at bedside. RN 1 stated it was important Resident 9 had an emergency kit at the bedside in case of an emergency of bleeding from the dialysis which would require immediate intervention. During an interview on 11/13/2024 at 11:21 AM, the DON stated all residents on dialysis should have an emergency dialysis kits at the bedside for an emergency like post bleeding after dialysis. The DON stated it was the standard of care for all dialysis residents to have an emergency kit at bedside. The DON stated the facility did not have a policy for dialysis emergency kit. c. A review of Resident 32's Admission Record indicated the facility admitted the resident on 6/14/2024 with diagnoses including end stage renal disease, Type II diabetes with chronic kidney disease (person has Type II diabetes and their kidneys are damaged over time due to high blood sugar levels), and dependence on renal dialysis. A review of the Physician's Order dated 9/12/2024 indicated Resident 32 to receive monitoring of the access site every shift for redness, swelling, drainage, and pain and to notify the MD. A review of Resident's 32's care plan revised on 10/5/2024, indicated the resident had a diagnosis of end stage renal disease with hemodialysis. The intervention included to monitor access site of right upper extremity arteriovenous fistula for signs and symptoms of infection and bleeding. A review of Resident 32's MDS dated [DATE], indicated the resident's cognition was moderately impaired and that the resident was on dialysis. During a concurrent observation and interview on 11/13/2024 at 9:38 AM with RN 1 in Resident 32's room, RN 1 stated Resident 32 was on dialysis and did not have an emergency kit at bedside. RN 1 stated it was important Resident 32 had an emergency kit at bedside in case of an emergency like bleeding from the dialysis site that required immediate intervention. A review of Center for Clinical Standards and Quality / Quality, Safety & Oversight Group dated 8/10/2018, indicated that the nursing home should ensure a reserve of supplies to be available in emergency circumstances. It further indicated that the emergency supply reserve is in excess of the routine supply inventory and generally include at least five (5) days of emergency supplies for each resident.

Based on interview and record review, the facility failed to ensure each resident was treated with dignity to promote enhancements of quality of life for one of three sampled residents (Resident 58). For Resident 58 the Physicians Order for Life-Sustaining Treatment (POLST) indicating Do Not Resuscitate (DNR, when the heart stops beating, or a person stops breathing, there are no rescue measures taken, including cardiopulmonary resuscitation [CPR] an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped) was not honored. This deficient practice resulted in Resident 58 receiving CPR against his wishes and not in accordance with his documented POLST instructions ([DATE]) for DNR when Resident 58 was found unresponsive on [DATE]. Findings: A review of Resident 58's Admission Record indicated the facility admitted the resident on [DATE] with diagnoses including chronic kidney disease (condition that occurs when the kidneys are damaged and cannot filter blood properly), benign prostatic hyperplasia (condition that occurs when the prostate gland enlarges, which can make it difficult to urinate), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) A review of Resident 58's History and Physical (H&P) dated [DATE] indicated the resident had fluctuating capacity to understand and make decisions and Resident 58's Family Member(FM 1) was the surrogate decision maker. A review of Resident 58's POLST dated [DATE] indicated if the patient had no pulse and was not breathing, the resident cardiopulmonary resuscitation status was DNR (allow natural death). The POLST was signed by FM 1 on [DATE]. A review of Resident 58's Situation Background Assessment and Response form (SBAR) dated [DATE] at 4:35 AM, indicated a charge nurse (unidentified staff) went to the resident room to answer a call light and found Resident 58 with coffee ground emesis, was noted to be unresponsive, and immediate CPR was initiated. The form indicated 911 was called at 4:11 AM, 911 took over and was unable to resuscitate Resident 58. The SBAR form indicated FM 1 was called at 5:30 AM and made aware of the situation. A review of Resident 58's Record of Death dated [DATE] at 4:35 AM, indicated Resident 58's principal cause of death was cardiopulmonary arrest and malignant neoplasm of the bladder. During an interview with Registered Nurse 1 (RN 1) on [DATE] at 11:31 AM, the RN 1 stated Resident 58 had a POLST dated [DATE] indicating the resident was DNR, which meant for staff not perform CPR. RN 1 confirmed Resident 58 did not have an order for his code status of DNR. RN 1 stated it was important to have a code status order so the staff were aware if the resident was full code or DNR. RN 1 stated it was important to honor resident and family wishes and not perform CPR as indicated in Resident 58's POLST form. During a phone interview on [DATE] at 11:53 AM, FM 1 stated she signed a paper indicating the resident (Resident 58) did not want compressions. FM 1 stated she had a conversation with Resident 58 (unable to recall date) and he told FM 1 he did not want compressions because he had heard his ribs can break and he did not want to have pain. FM 1 stated after the conversation with Resident 58, she signed a paper and made Resident 58 DNR. FM 1 stated she received a call on [DATE] at about 5:35 AM from a female staff (unable to recall name) from the facility reporting 911 came for Resident 58 and they could not do anything for the resident. The FM 1 stated the female staff did not state if Resident 58 received compressions and she did not ask questions. During an interview with the Director of Nursing (DON) on [DATE] at 12:19 PM, the DON stated DNR meant do not perform compressions when a resident was found unresponsive. The DON stated it was important to honor the POLST and follow the resident and family wishes. The DON stated Resident 58 did not have an order for code status in the resident's electronic health record. The DON stated it was important to have a code status order to ensure the staff know if they should perform CPR or not when a resident becomes unresponsive. A review of the facility's policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST), revised [DATE], indicated the order to Follow POLST Instructions will be added to the resident's admitting orders for physicians review. A review of the facility's policy and procedure titled, Do Not Resuscitate Order, revised ,d+[DATE], indicated the facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. A review of the facility's policy and procedure titled, Dignity, revised ,d+[DATE], indicated the facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for one of three sampled residents (Resident 16). Resident 16's preferred activity preferences were not included in the Activities care plan. This deficient practice had the potential to prevent Resident 16 from having meaningful activity to promote and enhance the resident's quality of life. Findings: A review of the Admission Record indicated Resident 16 was admitted to the facility on [DATE], with diagnoses including muscle wasting and atrophy (the loss or thinning of muscle tissue that can lead to a decrease in muscle mass and strength), sacral pressure ulcer (lower spine wound), and dependence on oxygen. A review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) completed on 10/15/2024, indicated that while in the facility it was important for Resident 16 to have books, newspapers, and magazines to read. The MDS indicated Resident 16 did not have any cognitive impairment and was totally dependent with bed mobility and transfers. A review of Resident 16's Activities care plan revised on 10/10/2024, indicated the goal was to attend and participate in activities of choice. The interventions included inviting Resident 16 to scheduled activities and ensure that activities were compatible with individual needs and abilities. The care plan did not indicate Resident 16's interests such as reading books, newspapers, or magazines. During a concurrent observation and interview on 11/12/2024 at 12:10 PM, Resident 16 was observed lying in bed reading a magazine. Resident 16 stated she had not been able to leave her room because she was unable to walk and had discomfort sitting in a wheelchair due to her hemorrhoids (swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding) and wound on her lower back. Resident 16 stated that someone came and offered magazines once or twice. During an interview with the Activity Director (AD) on 11/13/2024 at 8:57 AM, the AD stated the facility provided residents with different kinds of recreational activities that suit their preferences. The AD stated Resident 16 had a visit on 11/12/2024 and Resident 16 was given books to read as that was their preference. During a concurrent review of Resident 43's activities care plan, the AD stated Resident 43's care plan should have been updated to reflect the resident's current interests. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, and revised July 2024, indicated to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (Resident 3, Resident 31 and Resident 48), received services to prevent accidents. a.For Resident 3, who was diagnosed with left above the knee amputation (AKA- surgical removal of a person's leg above the knee) and end stage renal disease (ESRD - the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life), the facility failed to ensure Resident 3 received two or more-person physical assistance when transferring Resident 3 from wheelchair to car per the comprehensive assessment and the facility failed to develop care plan interventions regarding Resident 3's need for two-person transfer, Hoyer lift, or sliding board for transfer. As a result of this deficient practice Resident 3 was solely transferred from wheelchair to car by Certified Nursing Assistant 1 (CNA). Resident 3 sustained an injury to her right leg, that caused her severe pain and required multiple x-rays to rule out a fracture. b.For Resident 31, who had a history of repeated falls, the facility failed to implement fall prevention interventions as indicated in the risk for falls care plan. As a result, Resident 31 fell from a wheelchair and developed a head injury, face abrasion (type of open wound that's caused by the skin rubbing against a rough surface), and a face contusion (bruise, when small blood vessels break open and leak blood into the nearby area). c.For Resident 48, the facility failed to ensure the resident was wearing his wander guard (a device worn by residents to help monitor their whereabouts using an alarm system). As a result, Resident 48 had the potential to leave the facility without supervision and come to harm. Findings: a. A review of the Admission Record indicated the facility initially admitted Resident 3 on 6/6/2023 and readmitted the resident on 6/20/2023 with diagnoses including AKA and ESRD and hypotension (low blood pressure). A review of the care plan initiated 6/21/2023 indicated Resident 3 was at risk for activities of daily living (ADLs -essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) self-care performance related to her diagnoses of ESRD and left aka. The goal was that the resident will maintain current level of function through the review date. The care plan addressed the interventions for the resident including bathing/showering (avoid scrubbing and pat dry sensitive skin), bed mobility (the resident is able to turn and reposition herself), eating (provide finger foods when the resident has difficulty using utensils). A review of the care plan indicated the ADL of transferring was not addressed and interventions were not developed. The care plan also did not indicate Resident 3 required two or more person assist with transfer. A review of Resident 3's skin breakdown care plan, initiated 6/21/2023, indicated the resident was at risk for pressure injury development due to limited mobility and need for dialysis. The goal was for the resident to have intact skin, free of redness, blisters or discoloration. The care plan indicated the interventions / tasks included the resident prefers to be repositioned with two people, lifter, slider. A review of the History and Physical (H&P), dated 6/26/2023, indicated Resident 3 had a left AKA with healed stump and had fluctuation capacity to understand and make decisions. The H&P indicated Physical/Occupational Therapy would need to find her prosthesis (device designed to replace a missing part of the body or to make a part of the body work better). A review of the ADL assistance care plan, initiated 6/28/2023, indicated Resident 3 needed assistance with bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene and bathing. It indicated a goal was for the resident to maintain her present level of ADL self-performance. The interventions included to allow sufficient time for ADL task, provide verbal cues with ADL care needs and to monitor for change in self performance of ADLs. The care plan did not indicate Resident 3 required use of two or more persons or a Hoyer lift for transfer. A review of the Morse Fall Scale dated 9/25/2023, indicated Resident 3 had an impaired gait consisting of difficulty rising from chair, used chair arms to get up, grasps furniture, required an aid when ambulating and could not walk unassisted. The Morse Fall Scale indicated the resident knew her own limits and that the resident was a moderate risk for falling. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/26/2023 indicated Resident 3 had clear speech, able to make herself understood and could understand others. Resident 3 had adequate hearing and vision. The MDS indicated Resident 3 needed one-person physical assistance with bed mobility, dressing, toilet use, personal hygiene, or bathing and required two or more persons physical assistance with transfer. It also indicated the resident normally used a wheelchair for mobility and had a functional limitation in range of motion on one side of her body. A review of the Nurses Note, dated 9/28/2023 at 8:45 PM, indicated Resident 3 returned from an appointment at 4:45 PM and complained of right ankle and right lower leg pain rated an 8 out of 10 (severe pain). Resident 3 reported the pain occurred in the morning when she twisted her right lower leg upon transfer from wheelchair to car. The Nurses Note indicated Resident 3 was administered Norco (an opioid pain medication for moderate to severe pain). The resident's physician was informed, and he ordered an x-ray to rule out a fracture (broken bone) for Resident 3. A review of the Nurses Note, dated 9/29/2023 at 7:08 PM, indicated the facility was monitoring Resident 3 for lower leg and ankle pain. Resident 3 requested Norco for lower leg pain with a pain level rated at 6 out of 10 (moderate pain). A review of Resident 3's Medication Administration Record for 9/2023, indicated the facility administered Norco 5-325 milligram (mg) tablet to Resident 3: -for pain level of 8/10 on 9/28/2023 at 4:50 PM -for pain level of 6/10 on 9/28/2023 at 9:15 PM -for a pain level of 6/10 on 9/29/2023 at 5:44 AM and 2:39 PM -for a pain level of 6/10 on 9/30/2023 at 9:07 AM and; -for a pain level of 7/10 on 9/30/2023 at 5:30 PM. A review of the Order Summary Report, indicated on 9/28/2023, Resident 3 was to receive an x-ray of her right ankle due to increased pain. According to a review of the X-ray Report dated 9/28/2023, Resident 3 had a nondisplaced fracture (the bone cracks or breaks but retains its proper alignment of the distal tibia (forms the bony structure of the ankle joint). According to a review of the Second Opinion X-ray Report dated 9/28/2023, Resident 3 had mild arthritic changes of the ankle without obvious fracture of the distal tibia. A review of the pain care plan, initiated 9/28/2023, indicated Resident 3 had increased right leg pain. The goal was for the resident to verbalize adequate relief of pain to affected area. The interventions included to apply cam boot as ordered, administer pain medications as ordered and to monitor/record pain characteristics every four hours and as needed. A review of the general acute care hospital 1 (GACH 1) on call note, dated 10/1/2023, indicated Resident 3 had a twisting injury when going from wheelchair to an appointment on Thursday, x-ray was ordered but did not result until today (10/1/2023). It also indicated the x-ray shows an oblique non-displaced fracture lucency (refers to the less dense regions of structures, which appear darker on the X-ray image. To a radiologist, lucency was cause for concern when there was too much of it and if it was an atypical location) in distal tibia (shin bone). The GACH 1 note indicated the resident had pain that was controlled with Norco as needed. Resident 3 was ordered to not weight bear on her right leg and there was a request for the resident to be seen by the fracture clinic on the same day. A review of the Interdisciplinary (IDT - a group of staff from different fields) Progress Note dated 10/2/2023 indicated the IDT team met with Resident 3 and her family member (FM 1). It indicated Resident 3 stated the nurse transferred her to the car to go to her appointment that day. The nurse attempted to transfer her to the backseat of the car with a sliding board but it was too long and thus the nurse removed the sliding board and manually lifted the patient from wheelchair and transferred her to the car. Resident 3 felt that her foot got caught but did not know how it occurred. A review of the Physician's Orders dated 10/1/2023, indicated the following -Resident 3 was to not weight bear on her right leg every shift -Resident 3 was to have an orthopedic (branch of medicine that focuses on the diagnosis and treatment of bones, muscles, and ligaments) consult for follow-up treatment -Resident 3 was to have an x-ray of her right ankle due to increased pain A review of the Physician's Orders, dated 10/2/2023, indicated the facility was to transfer Resident 3 to GACH 1 for further evaluation of her right ankle pain (arthritic changes vs fracture). A review of the Emergency Department (ED) Provider note, dated 10/2/2023, indicated the resident came to the ED with the main complaint of right ankle pain. Resident 3 reported the other day she was being transferred into a car and had a twisting injury of her right ankle. Resident 3 reported that her pain had been constant since that time. A review of the GACH 1 radiology report dated 10/2/2023 of Resident 3's right ankle ndicated severe diffuse osteopenia, which limits evaluation. No acute fracture was identified. A review of the Physician's Orders dated 10/3/2023, indicated -Resident 3 was to only have weight bear on her right leg by heel touch only -Resident 3 was to have an orthopedic follow up on 10/3/2023 A review of the Orthopedic Office Visit note dated 10/3/2023, indicated Resident 3 had complaints of pain and swelling of her right foot and leg. The injury occurred on 9/28/2023 when Resident 3 hit her leg during transfer at the facility. It further indicated Resident 3 had not been ambulatory since her AKA. A review of the Physician's Orders dated 10/4/2023, indicated Resident 3 was to use a controlled ankle motion boot (CAM -lower extremity boot that provides support, protection and immobilization of the ankle after injury or surgery) for support when practicing weight bearing every shift for eight weeks and did not need to be in the boot while in bed or chair. A review of the October 2023 MAR indicated the physician ordered Resident 3 to receive an x-ray of her right lower leg due to persistent lower leg pain. A review of the radiology report dated 10/27/2023 of Resident 3's right ankle indicated lucency in the distal tibia, which was concerning for a nondisplaced fracture. A review of the radiology report dated 10/27/2023 of Resident 3's right leg indicated the resident had severe osteopenia, which may obscure a nondisplaced fracture. During an interview on 11/14/2023 at 12:15 PM, Resident 3 stated almost 8 weeks ago, she had an appointment and Certified Nursing Assistant 1 (CNA 1) squeezed her around my ribs and swung me into the car. She stomped on my leg, and squeezed me in the ribs trying to get me in the car without falling. Resident 3 stated, We almost did not make it to the car. Resident 3 stated the facility staff usually used a sliding board to get in the car. I thought she was going to put me in with the lift, but she said she couldn't do it because my daughter asked her, but I don't remember her answer. Resident 3 stated, I am supposed to wear a boot. Resident 3 stated the accident set back her physical therapy because she had recently been taken off of bed rest. During an interview on 11/14/2023 at 2:02 PM, CNA 1 stated she transferred Resident 3 to her family member's car for an appointment. CNA 1 stated she attempted to transfer Resident 3 with a sliding board but Resident 3 was not able to do it. So as a last resort transferred Resident 3 from wheelchair to the car by hugging her under her arms and carrying her to the car. Resident 3 could not reach the seat, so she had to lift her up a little to get her into the car. CNA 1 further stated she was not instructed on how to transfer Resident 3 and received one on one training after the incident and would have had another staff member assist her if she had known. During an interview on 11/14/2023 at 2:39 PM, Certified Occupational Therapy Assistant (COTA 1) stated, Resident 3 was receiving physical therapy (PT) and Occupational Therapy (OT) focusing on her core strengthening, static and dynamic balance and range of motion of her extremities, upper and lower. We tried to stand her up, but she is not there yet. COTA 1 further stated prior to the incident, Resident 3 had been on Hoyer lift transfer because she only has one leg, her prosthesis did not fit at that time, she had poor trunk control, and she could not stand up. PT verbally recommended to nursing staff to transfer Resident 3 with a Hoyer lift because with two-person transfer, Resident 3 could not bear any of her weight and that was not safe for the resident or staff. COTA 1 also stated, We were not able to provide physical therapy until last week per physician's order. During an interview on 11/15/2023 at 11:12 AM, Family Member 1 (FM 1) stated CNA 1 wheeled Resident 3 out to the car for her appointment. Basically, CNA 1 could not do it on her own. CNA 1 carried Resident 3 from the wheelchair and placed her in the car and in doing so Resident 3 hurt her leg. CNA 1 carried Resident 3 about three steps. After the transfer, Resident 3 complained of pain, would not exit the car to go to her appointment because of the pain and We had to reschedule the appointment. Upon returning, there were two nurses who helped her using the sliding board, which I suggested. FM 1 further stated Resident 3 requested a Hoyer lift but was told can't put the harness in the car. During an interview on 11/15/2023 at 12:15 PM, CNA 3 stated she was instructed to transfer Resident 3 with a mechanical lift upon hire on 9/21/2023. CNA 3 stated when she was first hired on 9/21/2023 she asked how to transfer Resident 3 and was told to use a mechanical lift. CNA 3 further stated, If I don't have a lift, I wouldn't transfer because per her care plan you have to use a mechanical lift. So, a mechanical lift would be the safest choice for her. During a phone interview on 11/15/2023 at 12:48 PM, Resident 3's primary doctor (PMD) stated that it was ultimately determined Resident 3 did not have a fracture and she was weight bearing as tolerated. During a concurrent interview and record review of Resident 3's medical chart on 11/15/2023 at 1:34 PM, the Minimum Data Set Coordinator (MDSC) stated on 9/28/2023, Resident 3 complained of worsening right ankle and lower leg pain after she twisted her lower leg upon transfer to her car per the nursing progress note dated 9/28/2023 at 8:25 PM. The physician ordered an x-ray of her right ankle and to rest, elevate and apply a cold pack to her right ankle. Thr MDSC also stated Resident 3 received Norco for her pain. The first x-ray result on 10/1/2023 indicated Resident 3 had a nondisplaced tibia fracture. The MDSC further stated a second physician read the x-ray, who determined there was no obvious fracture but mild arthritic changes. Resident 3's physician then ordered Resident 3 to be non-weight bearing on her right leg and to have an orthopedic consult. On 10/2/2023, the PMD ordered the facility to transfer Resident 3 to GACH 1 to evaluate her right ankle pain and determine if the resident had a fracture versus arthritic pain. The MDSC stated Resident 3 was required to be transferred via Hoyer lift for her safety. Upon review of Resident 3's care plans, the MDSC stated Resident 3's requirement for a 2- person, mechanical lift transfer was not care planned. The intervention should have been transferred in order for staff to know the most appropriate and safest way to transfer Resident 3 and to prevent Resident 3 from suffering injury, pain or discomfort. During an interview on 11/15/2023 2:21 PM, Registered Nurse Supervisor 1 (RN 1) stated prior to the incident Resident 3 was a two-person transfer prior to the incident on 9/28/2023. The restorative nurse aide assisted her to the car alone but should have gotten help to transfer the resident in order to prevent Resident 3 from having pain and for the safety of the resident. During an interview on 11/16/2023 at 11:05 AM, the Director of Nursing (DON) stated the CNA transferred Resident 3 to a car for her appointment. After the resident came back, she complained of pain due to the incident when she was transferred to the car. FM 1 reported the wheelchair was quite far from the car. CNA 1 transferred the resident by herself to the car and could not use the mechanical lift. CNA 1 also did not use the sliding board. The DON further stated Resident 3 was a two-person transfer, per the MDS. CNA 1 should have used the sliding board from the wheelchair to the car. Resident 3's safety was placed at risk by not using the sliding board. The resident's left AKA made her more at risk for injury during the transfer. A review of the facility policy titled, Safety and Supervision of Residents, revised on 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents were facility-wide priorities. The same policy indicated the Interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive device. The facility will implement interventions to reduce accident risks and hazards which will include ensuring that interventions were implemented. A review of the facility policy titled, Safe Lifting and Movement of Residents, revised 7/2017, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. It also indicated Nursing staff, in conjunction with the rehabilitation staff, shall assess individual. residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. A further review indicated staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 43851 b. A review of Resident 31's Admission Record indicated the facility originally admitted the resident on 8/2/2019 and readmitted the resident on 7/25/2021 with diagnoses including age-related osteoporosis (a disease that weakens bones), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia (loss of the ability to understand or express speech) following a cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), benign prostatic hyperplasia (enlarged prostate), and a history of falling. The Admission Record indicated Resident 31's emergency contact was Family Member (FM) 3. A review of Resident 31's Care Plan initiated on 7/25/2021 and revised on 11/13/2023, indicated the resident was high risk for falls due to a diagnosis of dementia, poor safety judgement, history of multiple falls, use of antidepressant medication, and use of blood pressure medication. The care plan goals indicated Resident 31 will be free of falls through the review date; and the resident's risk for fall will be minimized through intervention through the review date. The care plan interventions indicated to monitor Resident 31 for episodes of restlessness due to the need for incontinence (lack of voluntary control over urination or defecation) care; to monitor the resident's behavior of trying to get out of bed unassisted, and to consider further interventions when the resident started exhibiting behavior again. A review of Resident 31's Morse Fall Scale (an assessment tool that predicts the likelihood a resident will fall) dated 9/14/2023, indicated the resident was at high risk for falling with a score of 75. The Morse Fall Scale indicated Resident 31 had a history of falling, had more than one diagnosis on the chart, did not use ambulatory aids due to bedrest, used wheelchair and nurse assistance, and had impaired gait (difficulty rising from chair, uses chair arms to get up, bounces to rise, keeps head down when walking, watches the ground, grasps furniture, person or aid when ambulating, cannot walk unassisted).The Morse Fall Scale further indicated Resident 31 overestimated or forgot the limits of their ability to ambulate safely. A review of the Physician's Order dated 9/14/2023, indicated Resident 31 was to have a low bed with floor mats to prevent injury secondary to the resident trying to get out of bed unassisted. A review of the MDS dated [DATE], indicated Resident 31 had severely impaired cognition (never/rarely made decisions), was totally dependent and required one-person physical assistance for transferring, locomotion (movement) on and off the unit, and personal hygiene. The MDS indicated Resident 31 required extensive assistance and two-person physical assistance for bed mobility and toilet use. The MDS indicated Resident 31 required extensive assistance and one-person physical assistance for dressing and eating. The MDS indicated Resident 31 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position and with surface-to-surface transferring. The MDS indicated Resident 31 normally used a wheelchair and was always incontinent of urine and bowel. A review of the Physician's Order dated 9/25/2023, indicated Resident 31 may have a tab alarm on the bed and wheelchair to alert staff, remind resident, and to prevent unassisted ambulation. A review of Resident 31's Order Summary Report indicated there were no orders to monitor Resident 31 for episodes of restlessness or behavior of trying to get out of bed unassisted. A review of Resident 31' Medication Administration Record (MAR) for 11/1/2023 to 11/30/2023, indicated there was no documentation for the monitoring of episodes of restlessness due to the need for incontinence care, or for the monitoring of the resident's behavior of trying to get out of bed unassisted. A review of the Situation Background Assessment and Request (SBAR) Communication Form dated 11/11/2023, indicated at 6:19 PM certified nursing assistant (CNA) heard a tab alarm, rushed to check, found Resident 31 lying on the floor by the hallway, and called for help. The SBAR indicated the Registered Nurse (RN) went to check Resident 31 and found the resident leaning on his left side with his face towards the floor. The SBAR indicated a neuro assessment was done, Resident 31 was alert and responsive, a skin assessment was done, and the resident was noted with a skin tear to the nasal bridge, lump on the forehead, and skin tear to the right hand. The SBAR indicated Resident 31 was able to move all extremities but was noted with discomfort at the left upper extremity upon movement. The SBAR further indicated Resident 31's primary clinician was notified on 11/11/2023 at 6:23 PM with recommendations to transfer Resident 31 to the General Acute Care Hospital (GACH) for evaluation. The SBAR further indicated Resident 31's FM 3 was notified on 11/11/2023 at 6:35 PM. A review of the Physician's Order dated 11/11/2023 indicated may transfer Resident 31 to GACH 1 ED for evaluation related to status post fall. A review of GACH 1 records indicated Resident 31 arrived to GACH 1's Emergency Department (ED) via ambulance on 11/11/2023 at 8:05 PM with a chief complaint of a head injury. A review of GACH 1's ED Care Timeline indicated on 11/11/2023 at 8:27 PM, Resident 31 was brought in by ambulance from the facility complaining of a fall with a hematoma (an abnormal pooling of blood in the body under the skin that results from a broken or ruptured blood vessel) on the forehead, laceration (a deep cut or tear on the skin) on the nose, and left hand and shoulder pain. A review of GACH 1 ED Provider Notes dated 11/11/2023 at 8:53 PM, indicated Resident 31 was sent to GACH 1 from the facility to rule out head bleed and left shoulder fracture (break in the bone). The ED Provider Note indicated findings that Resident 31 had a midline frontal scalp edema (swelling caused by too much fluid trapped in the body's tissues) and hematoma. A review of Resident 31's Imaging Report dated 11/11/2023 at 9:52 PM, indicated Resident 31 had a Computed Tomography (CT, an imaging exam that takes pictures of the inside of the body) scan of the head without contrast (refers to a substance taken by mouth or injected into a vein that causes the particular organ under study to be seen more clearly). The CT scan's impression (summary of findings) indicated Resident 31 had frontal scalp soft tissue injury (when trauma or overuse occurs to muscles, tendons or ligaments) but no clavicle fracture (broken collar bone). A review of Resident 31's Imaging Report dated 11/11/2023 at 10 PM, indicated the resident had a CT scan of the facial bones without contrast. The CT scan's impression indicated Resident 31 had no acute maxillofacial (portion of the face from the upper jaw downwards) fracture. A review of Resident 31's Imaging Report dated 11/11/2023 at 10:42 PM, indicated the resident had a x-ray (an imaging procedure that takes pictures of the inside of the body using radiation) of the left shoulder. The x-ray's impression indicated there was no acute fracture identified. A review of GACH 1's After Visit Summary dated 11/11/2023, indicated Resident 31 had diagnoses of a head injury, face abrasion (type of open wound that's caused by the skin rubbing against a rough surface), and face contusion (bruise, when small blood vessels break open and leak blood into the nearby area). A Review of GACH 1's ED Care Timeline, indicated on 11/12/2023 at 1:09 AM Resident 31 was transferred back to the facility. A review of Resident 31's Progress Note dated 11/12/2023 at 2:11 AM, indicated the resident returned to the facility from GACH 1 with a primary diagnosis of head injury, face abrasion and face contusion. A review of a second Progress Note dated 11/12/23 at 2:11 AM, indicated Resident 31 was noted with a bump and skin discoloration on the forehead, open skin and skin discoloration on the nose bridge, skin discoloration at the right cheek, right eyebrow abrasion, and left back hand skin discoloration upon returning to the facility. During an observation on 11/13/2023 at 8:50 AM, Resident 31 was observed lying in bed. Resident 31 was observed with a bruise, maroon in color, and an elevated bump to the middle of his forehead. Resident 31 was also observed with a laceration on his nose. Resident 31 was observed with a bed alarm and floor mats to the left and right side of the bed. A wheelchair with a chair alarm was observed at bedside. During a concurrent interview, when asked about the injuries, Resident 31 did not answer. During an interview on 11/14/2023 at 2:38 PM, Physical Therapist Assistant (PTA) stated Resident 31 was often restless. The PTA stated Resident 31 was confused and was not able to stand on his own. PTA stated Resident 31's cognition was on and off. The PTA further stated that Resident 31 could not remember to use the call light for assistance after being instructed to do so. During an interview on 11/14/2023 at 3:03 PM, Registered Nurse (RN) 2 stated on 11/11/2023 she heard CNA 7 calling for help and then saw Resident 31 was already on the floor. RN 2 stated Resident 31 was leaning on his left side with their face towards the floor. RN 2 stated she assessed Resident 31 and noted the resident with a bump on the forehead, tear on the nasal bridge, and mildly bleeding skin on the right hand. RN 2 stated Resident 31 was gesturing that his left shoulder was uncomfortable. RN 2 stated she asked Resident 31 if he had any pain, and the resident was gesturing to his left shoulder. RN 2 stated Resident 31 was responsive, alert, and did not have any loss of consciousness. RN 2 stated Resident 31 was transferred back to the wheelchair with a three-person assist and then transferred back to bed. RN 2 stated Resident 31's physician was notified right away and stated to transfer the resident since there was injury. RN 2 stated Resident 31 was transferred to GACH 1 after an hour. RN 2 stated Resident 31 was normally alert and oriented to his name. RN 2 stated Resident 31 was usually confused and tried to get up on their own. RN 2 stated Resident 31 was not really verbal and did not take instruction or education well. RN 2 stated Resident 31 had a history of falls and utilized a tab alarm while in bed or in a wheelchair. RN 2 stated Resident 31 required monitoring and indicated the CNAs were notified to monitor Resident 31 every 15 minutes to check the resident was in bed. RN 2 stated when Resident 31 fell on [DATE] the resident fell from the wheelchair and indicated a tab alarm was being used at the time. During an interview on 11/14/2023 at 9:04 AM, the covering Director of Rehab (DOR) stated Resident 31 had dementia and required nursing to monitor him at all times. The DOR stated Resident 31 needed continuous monitoring to prevent falls. The DOR stated Resident 31 was forgetful and tried to get out of bed. The DOR stated Resident 31 did not know to call for assistance. During a telephone interview on 11/15/2023 at 10:20 AM, FM 3 stated they did not feel the facility's interventions to prevent falls for Resident 31 were working. FM 3 stated Resident 31 had fallen in the facility at least two times. FM 3 stated previously Resident 31 was found lying on the floor and then later complained of pain on the hip. FM 3 stated, I understand falls happen, but they have dementia and needs to be watched more carefully. During an interview on 11/15/2023 at 10:25 AM, CNA 4 stated she was Resident 31's CNA and was familiar with the care the resident needs. CNA 4 stated Resident 31 needed entire assistance and indicated the resident could not do anything on his own. CNA 4 stated sometimes Resident 31 tried to get out of bed CNA 4 indicated the resident was very anxious and was trying to sit on the edge of the bed. CNA 4 stated Resident 31 was confused, could not stand up by himself, and did not walk. CNA 4 stated Resident 31 required monitoring because he was not alert enough to use the call light; and indicated the resident tried to do something but would not use the call light. During a concurrent interview and record review on 11/15/2023 at 10:38 AM, Resident 31's Order Summary Report, Risk for Falls Care Plan, and Medication Administrator Record (MAR) for 11/2023 were reviewed with Licensed Vocational Nurse (LVN) 1. LVN 1 stated he was taking care of Resident 31 and the resident was confused most of the time and tried to get out of the wheelchair and bed. LVN 1 stated Resident 31 could not walk, and used the wheelchair to get around. LVN 1 stated Resident 31 had risk factors for falls because the resident was confused and tried to get out of the wheelchair and bed. LVN 1 verified Resident 31's Risk for Falls Care Plan had interventions to monitor Resident 31 for episodes of restlessness due to the need for incontinence care; to monitor the resi [TRUNCATED]

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was cognitively impaired (trouble remembering, learning new things, concentrating,), identified as a high fall risk, and had a history of falls, the facility failed to: - Identify interventions related to Resident 1's specific risks and causes to try and prevent the resident from falling, per facility policy Falls and Fall Risk, Managing, -Ensure the interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meets to assess the appropriate level and number of staff required to supervise Resident 1 and identify interventions and means of mitigating the risk of fall for Resident 1. These deficient practices resulted in Resident 1 having an unwitnessed fall on 7/6/2023 and 8/3/2023 and developed an acute to subacute right intertrochanteric femoral fracture with mild posterior displacement (broken right hip) and required surgery to repair the right hip fracture. Findings: A review of Resident 1's Admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition where the body cannot pump blood well enough to give the body a normal body supply), end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean the body's blood when the kidneys are not able to), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and long term use of anticoagulants (medication that helps prevent blood clots). A review of Resident 1's Care Plan initiated 5/23/2023 indicated, the resident was at risk for falls due to episodes of forgetfulness, trying to get up by herself, and not using the call light. The Care Plan interventions indicated to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The care plan interventions indicated Resident 1 needed prompt response to all requests for assistance and to ensure Resident 1 was wearing appropriate footwear (non-skid) / socks when ambulating or mobilizing in the wheelchair, follow fall protocol, and a safe environment with even floors free from spills and or clutter, adequate glare-free night light, a working and reachable call light, the bed in low position at night, and having personal items within reach. A review of the Morse Fall Scale form (an assessment tool used to predict the resident's potential for experiencing a fall) dated 6/1/2023, indicated Resident 1 scored a 65, as a score of 45 or greater indicated a high risk for falls. The Morse Fall Scale form indicated Resident 1 had a history of falling and exhibited a weak gait (resident may shuffle and steps were short). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 6/7/2023, indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required), required extensive assistance and one-person physical assistance for bed mobility, transferring, locomotion (movement) on/off unit, dressing, and toilet use. The MDS indicated Resident 1 required limited assistance and one-person physical assistance for personal hygiene; and supervision and set up help for eating. The MDS further indicated Resident 1 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, and surface-to-surface transferring. The MDS further indicated Resident 1 normally used a walker and wheelchair; and was frequently incontinent (having no voluntary control) of urine and always incontinent of bowel. According to a review of Resident 1's Morse Fall Scale dated 6/27/2023, the resident scored 85, as a score of 45 or greater indicated a high risk for falls. The Morse Fall Scale form indicated Resident 1 had history of falling, exhibited a weak gait, and the resident overestimated or would forget her limits. A review of Resident 1's Change of Condition (COC) documentation dated 7/6/2023 at 4:30 PM, indicated Resident 1 claimed she had a fall but could not specify the day and location. The COC indicated Resident 1 complained of pain to the right side of her face with noted maroon/purplish discoloration of the periorbital (skin surrounding the eye) area of the right eye and mid-forehead. The COC indicated Resident 1's clinician was notified with recommendations for an x-ray of the skull, monitor discoloration, and continue neuro checks per facility protocol. A review of Resident 1's care plan initiated 7/6/2023, indicated Resident 1 claimed she had a fall and the interventions were for Resident 1 to have a tab alarm in bed/wheelchair to alert staff of the resident getting out of bed unassisted, neurological assessment per facility protocol for 72 hours, and a stat x-ray to skull. A review of the Physician's Order dated 7/6/2023, indicated Resident 1 was to have a low bed with floor mats to prevent injury secondary to the resident trying to get out of bed unassisted. According to a review of Resident 1's x-ray of the skull results signed 7/7/2023 at 1:41 PM, it was an unremarkable examination. A review of Resident 1's care plan initiated 7/25/2023, indicated the resident was trying to get out of bed or chair without assistance and had episodes of forgetfulness. The care plan interventions indicated to frequently cue Resident 1, monitor the resident for episodes of getting out/up and redirect behavior, move the resident to a room closer to the station to provide easy visibility/cueing, ensure the tab alarm was applied and functioning well, to keep the bed in lowest position at all times and ensure the floor mats were in place. A review of Resident 1's COC documentation dated 8/3/2023 at 2:45 PM, indicated the resident had an unwitnessed fall and denied pain. A review of Resident 1's Pain assessment dated [DATE] at 3:06 PM, indicated Resident 1 denied pain and upon assessment could move all extremities with no complaints of pain. A review of Resident 1's COC documentation dated 8/3/2023 at 5:48 PM, indicated Resident 1 had an episode of screaming and yelling with complaints of severe throbbing pain to the right hip, right thigh, and right heel. The COC indicated Acetaminophen (pain medication) was administered to Resident 1 but was not effective in relieving the resident's pain. A review of the Physician's Order dated 8/3/2023, indicated to transfer Resident 1 to GACH 1 to rule out limb threatening ischemia (inadequate blood supply) to the right lower extremity. According to a review of GACH 1 Computed Tomography Angiogram (CT scan, detailed images of the body that uses a dye to create pictures of blood vessels) of the lower extremity dated 8/3/2023 at 11:16 PM, Resident 1 had an acute to subacute right intertrochanteric femoral fracture with mild posterior displacement (broken right hip). A review of GACH 1 Physician Progress Note indicated on 8/7/2023 Resident 1 received right hip fracture repair with intramedullary nail (a surgical rod forced into a long bone of the extremities that acts as an immobilization device to hold the two ends of the fractured long bone in position) surgery. During an observation on 8/17/2023 at 2:57 PM, Resident 1 was lying on her back in bed with the bed position low and floor mats to the left and right side of the bed. During a concurrent interview, Resident 1 stated she was in the hospital last week because she had an operation on both hips. During an interview on 8/17/2023 at 3:58 PM, Certified Nursing Assistant (CNA) 1 stated Resident 1 frequently tried to get out of bed and had a bed alarm, but sometimes when staff check the resident, she was already sitting at the side of the bed. CNA 1 stated Resident 1 needed assistance with walking and was confused most of the time. A review of the facility's Policy and Procedure titled, Care Plan, Comprehensive Person-Centered, revised 12/2016, indicated the interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. During an interview on 8/17/2023 at 4:30 PM, the Director of Nursing (DON) stated there was no IDT meeting held for Resident's 1 COC on 8/3/2023. During an interview on 8/22/2023 at 2:14 PM, Registered Nurse Supervisor (RNS) 3 stated she was working on 8/3/2023 when Resident 1 fell . RNS 3 stated Resident 1 was found on the floor by Licensed Vocational Nurse (LVN) 2. RNS 3 stated Resident 1 did not like to use the call light and had very impulsive behavior. RNS 3 stated Resident 1 did not have a sitter but needed one to prevent falls. RNS 3 stated the current solution was to place Resident 1 near the nurse's station. During an interview on 8/22/2023 at 2:22 PM, LVN 2 stated he was working on 8/3/2023 when he heard Resident 1's bed alarm again and went and helped her back to bed. LVN 2 stated Resident 1 was usually alert with episodes of confusion, tried to get out of bed all the time, was impulsive, and did not use the call light. On 8/22/2023 at 2:45 PM, during an interview, CNA 2 stated she remembered Resident 1 coming back from dialysis on 8/3/2023 and Resident 1 tried to get out of bed. CNA 2 stated she helped Resident 1 back to bed a couple of times that day. CNA 2 stated Resident 1 never used the call light, and she would help Resident 1 to the chair. CNA 2 stated Resident 1 did not have a sitter but should have one because she always tried to get out of bed. During a telephone interview on 8/22/2023 at 4:20 PM, Resident 1's Family Member (FM) stated the resident had a history of falls and was always trying to get out of bed. The FM stated she was informed of Resident 1's fall on 8/3/2023 but stated she had not had an IDT meeting with the facility regarding Resident 1's plan of care after the resident fell on [DATE] or when she was readmitted to the facility. A review of Resident 1's Resident Care Conference documentation indicated there were no resident care conferences / IDT meetings documented for Resident 1's COC regarding falls on 7/6/2023 and 8/3/2023. During an interview on 8/23/2023 at 9 AM, the Medical Records (MR) staff stated the only IDT meeting for Resident 1 was dated for 6/9/2023. During an interview on 8/23/2023 at 9:04 AM, Registered Nurse Supervisor (RNS) 3 stated IDT meetings were usually done after an incident like a fall, or a complaint. During a concurrent interview and record review on 8/23/2023 at 9:08 AM, Resident 1's Resident Care Conference documentation was reviewed with Social Services (SS). SS stated IDT meetings were done quarterly, if the resident or family members had issues, on admission if there were concerns, and with a change of condition. SS stated that he was part of the IDT meetings and an IDT meeting for Resident 1 was not held after her COC on 7/6/2023 or 8/3/2023. SS stated according to the facility's policy an IDT meeting should have been held with Resident 1's family after the resident had a change of condition. SS stated the purpose of an IDT meeting was to discuss the resident's plan of care, the family's concerns, and to give updates to family members on the plan of care. SS stated if an IDT was not held there was a potential for the resident concerns and plan of care to not be addressed. During a concurrent interview and record review on 8/23/2023 at 9:20 AM, Resident 1's Resident Care Conference documentation was reviewed with Registered Nurse Supervisor (RNS) 2. RNS 2 stated not conducting an IDT meeting can lead to the resident not receiving updated care after a change in condition. RNS 2 stated Resident 1 needs to be monitored closely due to the resident's impulsive behavior and attempts to get out of bed to keep the resident safe from falls. A review of the facility's Policy and Procedure titled, Falls and Fall Risk, Managing, revised 3/2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try to minimize complications from falling .Resident conditions that may contribute to the risk of falls include fever, infection, delirium and other cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypotension, functional impairments, visual deficits, and incontinence .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarm will be monitored for efficacy and staff will respond to alarms in a timely manner .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue to change the current interventions.

Based on interview and record review, the facility failed to ensure one of three sampled residents was free from verbal abuse, when Licensed Vocational Nurse 1 (LVN1) yelled and spoke loudly to Resident 1. This deficient practice resulted in Resident 1 suffered emotional distress which affected her psychosocial well-being resulting in Resident 1 losing sleep, crying, feeling fearful and unsafe, and feeling like a child. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty or discomfort swallowing) following cerebral infarction (damage to the brain due to a loss of oxygen to the area), and a gastrostomy (a tube inserted through the wall of the abdomen to the stomach, which may be used for feeding). A review of the physician`s history and physical dated 10/19/22, indicated Resident 1 had the capacity to make decisions. A review of Resident 1's most recent Quarterly Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/9/23, indicated Resident 1 had intact cognition evidenced by consistent and reasonable decisions. The MDS further indicated Resident 1 was totally dependent on staff for toilet use, and eating, and required extensive assistance with one-person physical assistance for dressing, bed mobility, and personal hygiene. A review of the staff assignment sheet dated 4/29/23 for 11 PM to 7 AM shift, indicated LVN1 was assigned to Resident 1. During an interview on 5/10/23 at 10:24 AM, Resident 1 stated LVN1 yelled at her not only once but multiple times. Resident 1 stated, On 4/30/23 at around 2 am when LVN1 yelled at me, I told him don't yell at me, I am not your child. Resident 1 stated LVN1 talks loudly all the time, but he yelled at me on 4/30/23. He told me I don't like you and I told him I am going to report you. Resident 1 was observed crying. Resident 1 stated That night I told Registered Nurse Supervisor 1 (RN1) that LVN1 yelled at me, and I do not want him to come back. Why would I want a person who does not like me to take care of me. I did not want the registry (a list of nurses who are legally licensed and trained to practice nursing) CNAs to come back either. Resident 1 further stated Next day I told LVN2 about the incident. Resident 1 was observed crying again. Resident 1 stated I even told my family about the way LVN1 treated me. From day one of my stay in the facility, LVN1 did not like me. When he was assigned to me at nights, I did not sleep. I had to stay awake and watch everything that he was doing. Resident 1 stated I was scared to tell the staff that I do not want LVN1 to take care of me. Resident 1 stated she is alright now. She stated she has better sleep at night knowing LVN1 is no longer taking care of her. A review of the facility's written Investigation Report dated 5/4/2023, indicated Resident 1 reported to LVN2 regarding the alleged verbal abuse towards her by LVN1 on 4/30/2023 at 9:45 PM. Resident 1 reported that On 4/30/2023 around 2:30 AM, two Certified Nursing Assistants (CNA) from the registry (staff personnel provided by a placement service on a temporary or on a day-to day basis) were cleaning me. The CNA that was helping my nurse took the pillow from underneath my left arm. I asked my CNA to return my pillow, but she said I did not have a pillow there for her to return. Then, the CNA left and came back with LVN1. LVN1 started yelling at me and saying, I listened to the way you treat my CNAs. Resident 1 stated LVN1 does not like me, and I am not his child. This was not the first time he yelled at me. The investigation report further indicated that Resident 1`s roommate verified that the incident Resident 1 reported, did occur and LVN1 did in fact yell at her. The facility`s investigation report indicated that several residents stated LVN1 raises his voice, yells at other residents, and gets agitated easily. The facility`s conclusion of the allegation of verbal abuse by LVN1 indicated that the verbal abuse did occur, and the facility will not tolerate any type of verbal abuse towards their residents. On 5/4/2023, LVN1 was terminated. During an interview on 5/10/23 at 9:40 AM, The Administrator (ADM) stated the alleged abuse incident happened on 4/30/2023 at around 2:30 AM. The ADM stated that Resident 1 was being changed by two registry CNAs and she requested her left arm pillow to be returned underneath her arm. One of the CNAs stated there was no pillow originally and Resident 1 insisted there was. Thereafter, CNA left the room and came back with LVN1. The ADM stated based on Resident 1`s report, LVN1 yelled at her and treated her like a child. The ADM sated LVN1 generally speaks with a loud voice. The ADM further stated there have been other incidents that facility staff members have had issues with LVN1`s speaking loudly. The ADM stated LVN1 talks loudly and in a commanding way, and the Director of Nursing (DON) and I had previous conversations regarding this matter with him. The ADM stated on 4/30/23 at around 9:45 PM, Resident 1 reported to LVN2 that LVN1 yelled at her. The ADM stated LVN2 called me that night. The ADM stated, I came to the facility on [DATE] around 6 AM and that's when I had a conversation with LVN1, and I told him that I need to start an investigation regarding this incident, and I suspended him for three days. During an interview on 5/10/2023 at 12:04 PM, LVN2 stated Resident 1 is very alert, and has slurred speech (not being able to pronounce each word clearly). LVN 2 stated I worked on Sunday 4/30/2023 during the 3PM-11PM shift and I was assigned to Resident 1. At around 9:45 PM, Resident 1 stated that the night before she was having a disagreement about a pillow with the CNAs. She also told me that LVN1 yelled at her because of the disagreement with the CNAs. LVN2 stated LVN1 is a big guy, normally he has a big tone, he could get loud. LVN2 stated Resident 1 was crying when she was telling me about the incident. LVN2 stated I reported the alleged verbal abuse incident to the Administrator that night around 10 PM. LVN2 stated Resident 1 was emotionally affected because of LVN1 yelling at her. During an interview on 5/10/23 at 12:48 PM, the DON stated, LVN1 is tall, and his voice is husky and loud and some residents get intimidated because of his voice. The DON stated there are some residents who do not like LVN1 because of his voice. The DON stated The ADM and I talked to LVN1 about his voice. We told him he needs to lower his voice. We are nurses and we must really adjust ourselves, we cannot say this is my voice. The DON stated LVN1 received previous in-services regarding customer service, and elder abuse. During an interview on 5/10/2023 at 1:10 PM, the Director of Staff Development (DSD) stated LVN1 was terminated. DSD stated Sometimes some people think LVN1 was mad or angry but that was the way he talks. The DSD stated, The management decided to let LVN1 go, because residents complain that LVN1 treats them like a child. During an interview on 5/11/23 at 11:17 AM, Family 1 stated Resident 1 reported to her that LVN1 is not attending to her needs. Family 1 stated Resident 1 was unhappy with the way LVN1 talked to her. Family 1 stated Resident 1 reported to her that LVN1 raised his voice at her, and she felt uncomfortable. Family 1 stated Resident 1 was very emotional and very tearful with me when she told me about the incident that happened on 4/30/23. She could barely get the words out of her mouth because every time she was trying to explain, she got more and more distraught. Family 1 stated Resident 1 did complain about not being able to sleep occasionally when LVN1 was taking care of her. Family 1 stated whenever LVN1 would scream at her or he would not provide her requested assistance, she was not able to sleep well. Family 1 stated It is hard for Resident 1 to let it go; it is hard for her to recover from this anxiety that she was going through. Family 1 stated part of this is because of Resident 1`s condition, from a total independent person for all her life to a total dependent person. Family 1 stated If you wanted to understand Resident 1, you are able to. LVN1 did not want to understand Resident 1. I hate to say if it was a cultural thing, but you have to want to understand and want to help people. During a telephone interview on 5/12/23 at 10:48 AM, CNA2 stated I remember on 4/30/23, I was working in the facility during the 11PM-7AM shift. RN1 switched my assignment and assigned Resident 1 to me because Resident 1 was not happy with her previous CNA. I remember that when I changed Resident 1, I called LVN1 to assist me to pull her up. I saw Resident 1 turn her face away from LVN1 when he was at her bedside. I asked her why you turned your head, she said LVN1 doesn't like me. During a telephone interview on 5/12/23 at 11 AM, CNA 4 stated she worked in the facility on 4/29/23 during the 11PM-7AM shift, and she was assigned to Resident 1. CNA4 stated At around 2 AM, when we were changing Resident1, Resident 1 asked me to put the pillow back under her left arm. I told her that there was no pillow there, but I can get her one. Resident 1 was not satisfied with the way we placed the pillow under her left arm. I tried different ways to assist her, but she was not satisfied. We decided to ask LVN1 to help us understand Resident 1. CNA4 stated LVN1 came to Resident 1`s room and spoke to her in a strict manor, his voice was high tone, commanding and demanding, as if he was talking to a child. LVN1 told Resident 1 I do not like the way you treat my CNAs. CNA4 stated a charge nurse should never talk to any resident the way LVN1 talked to Resident 1. CNA4 further stated she did not like the way LVN1 spoke to Resident 1. CNA4 stated LVN1 instructed me to leave the room. CNA4 stated when I returned to the room, Resident 1 was not talking anymore. She was emotionally affected by the way LVN1 talked to her. She just told me that she does not want LVN1 to come back to her room. During an interview on 5/12/23 at 12 PM, the ADM stated LVN1 quit on his own. The ADM stated on 5/4/23, when LVN1 came to the facility, we were going to discuss the incident with him, but he immediately stated, I do not want to talk about this, I already have a job and I just need to go, I have to go. LVN1 had a loud commanding voice. LVN1 talking to Resident 1 in a loud commanding voice was not right. We do not talk to the residents like that. My plan was to talk to LVN1 and address this issue. The ADM stated, I do not know what the definition for verbal abuse is, but I just want good customer service for our residents, and I was not happy with the way LVN1 spoke to Resident 1. The ADM stated, I did not know that other residents also had issues with the way LVN1 talks to them until we investigated Resident 1`s complaint. A review of the facility's Elder Abuse In-service Records indicated LVN1 received Elder Abuse training on 2/7/2023. A review of LVN1`s Annual Employee Performance dated 2/9/2023, conducted by the facility`s DON indicated LVN1 was advised to speak calmly, respect the residents, and lower the tone of his voice to improve his performance. A review of the facility`s policy and procedures titled Abuse Prevention Program, revised August 2006, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment (A physical punishment used as a means to correct or control behavior which includes, but is not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object), and involuntary seclusion (Separation of a resident from other residents or from her/his room or confinement to her/his room [with or without roommates] against the resident's will, or the will of the resident representative). Our facility is committed to protecting our residents from abuse by anyone, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, or any other individuals. Our abuse prevention program provides policies and procedures that govern, as a minimum mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting abuse, stress management, dealing with violent behavior or catastrophic reaction.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remain free of accident hazards and residents receive the needed supervision for one of four sampled residents (Resident 1). Resident 1, who had behaviors of wandering, per the comprehensive assessment, was not re-assessed quarterly for wandering and elopement risk (move about without a definite destination or purpose, wandering can be dangerous when the person goes in areas with unsafe conditions. The most dangerous form of wandering is elopement in which the confused person leaves an area and does not return); the plan of care interventions were not implemented to reduce hazards (a wander device) and the plan of care was not updated / modified for effectiveness. These deficient practices resulted in Resident 1's elopement from the facility, falling down a stairway in a wheelchair, sustaining life threatening injuries, requiring Resident 1 to be transported to a general acute care hospital (GACH), where she was found to have a forehead hematoma (solid swelling of clotted blood within the tissues), multiple left-sided posterolateral (side towards the back) fractures involving the third through eighth ribs, extensive subcutaneous [MEDICAL CONDITION] (gas or air under the skin) along the bilateral chest walls and lower cervical (neck) soft tissues. Resident 1 became unresponsive and subsequently died approximately two hours after the fall. Findings: On [DATE], an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 falling down the stairs while in her wheelchair, resulting in death. A review of the Transfer/Discharge Report indicated Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident plan of care, with the Social Worker, titled Wandering dated [DATE], indicated Resident 1 had an alteration in safety related to wandering / exit seeking behavior. The plan of care goal indicated Resident 1 would not have any injuries related to wandering / exit seeking behaviors daily. The plan of care interventions indicated verbal and tactile cues to redirect Resident 1's attention as needed, to keep wandering identification form current, attempt to determine causal factors when Resident 1 was exit seeking, and involve in diversional activities as appropriate. The plan of care interventions indicated safety device (wander device - a signaling device that will alarm when resident goes through an exit door to alert the staff of a resident's elopement attempt). The plan of care indicated to attempt to identify the reason Resident 1 wanted to leave and then try to meet that need, i.e., toileting, hunger, pain. A review of the Minimum Data Set assessments (MDS - an assessment and care-screening tool), dated [DATE], [DATE], and [DATE], and concurrent interview with the Social Worker (SW), the SW stated Resident 1 had behaviors of wandering occurring one to three days for presence and frequency, indicated on the MDS assessments. The MDS indicated a zero for 'No' when asked did the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside of the facility). A review of the Initial History and Physical, dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. According to the facility's Resident Assessment Instrument Manual (RAI, which includes the MDS), version 1.16, dated (MONTH) (YEAR), reviewed with the Social Worker, Wandering was defined as the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The resident may have a purpose such as searching to find something, but he or she persists without knowing the exact direction or location of the object, person or place. A review of the Progress Notes, dated [DATE], indicated Resident 1 was up in the wheelchair outside of her room. She was alert and verbally responsive, with confusion and disorientation. The Progress Note indicated Resident 1 pulled the fire alarm trigger by accident. The Progress Note did not indicate the Wandering care plan was updated or modified. A review of the plan of care titled, The Resident Tried to pull the Alarm System, dated [DATE], indicated the interventions were to monitor Resident 1's whereabouts every shift and to monitor and record behavior to determine if problems seems to be related to external causes. The plan of care goal target date indicated [DATE]. A review of clinical record indicated there was no documentation regarding monitoring Resident 1's whereabouts every shift. A review of the Progress Notes, dated [DATE], indicated Resident 1 had a fall in her room. Resident 1 was unable to recall what happened due to confusion and wandering behavior. The Progress Note indicated Resident 1 was fully disoriented to reality. The Progress Note did not indicate the Wandering plan of care or the Alarm System plan of care was updated. According to the MDS Response Import form reviewed with the Social Worker, it was documented Resident 1 had a behavior of wandering on [DATE], at 12:30 p.m. A review of the Minimum Data Set (MDS - an assessment and care-screening tool), dated [DATE], indicated Resident 1 was rarely or never understood. Resident 1 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 required supervision with locomotion (movement between locations). The MDS further indicated, if in wheelchair, self-sufficiency once in chair. A review of the facility's MDS audit report with the Social Worker indicated on [DATE] at 3:12 p.m. and 3:14 p.m., the SW documented Resident 1 had behaviors of wandering occurring one to three days for presence and frequency. A review of the Progress Notes, dated [DATE], indicated Resident 1 was reported to have a fall incident at the assisted living side (two months after the prior fall) at 1:40 p.m. Resident 1 was found in prone position (body lying face down) near stairs of the assisted living. The Progress Noted indicated bruising and hematoma on forehead was noted. According to the physician's orders [REDACTED]. A review of the GACH report, dated [DATE], indicated Resident 1 was admitted at 2:23 p.m. A review of the GACH Trauma history and physical examination [REDACTED]. The GACH Trauma history and physical examination [REDACTED] Resident 1's [DIAGNOSES REDACTED]. 1 cm right hand laceration. 1 cm left wrist abrasion (superficial damage to the skin). Multiple left-sided posterolateral (side towards the back) fractures involving the third through eighth ribs. Extensive subcutaneous [MEDICAL CONDITION] (gas or air under the skin) along the bilateral chest walls and lower cervical (neck) soft tissues. A review of the GACH Trauma history and physical examination [REDACTED]. The GACH Trauma history and physical examination [REDACTED]. A review of the GACH Emergency Department Notes, dated [DATE], indicated Resident 1 became unresponsive. Upon assessment Resident 1 was found not to have a pulse, pupils were nonreactive and fixed, respiratory rate of zero, unreadable end-tidal carbon [MEDICATION NAME] (CO 2 - exhaled breath). Time of death was subsequently called at 4:13 p.m. A review of the death certificate, dated [DATE], indicated Resident 1's cause of death was [MEDICATION NAME] force traumatic injuries. The death certificate indicated the place of injury was the skilled facility and occurred as the result of history of fall on stairs. On [DATE], at 8:15 a.m., the facility was toured with the Administrator who stated the whereabouts of Resident 1 between 8:30 a.m. and 12:15 p.m., were unknown. The Administrator stated Resident 1 had bad short-term memory. The Administrator stated, She self-propels around the facility, visiting with staff and residents, back to her room. During an interview, on [DATE], at 9:19 a.m., Hallway B was observed with the Activities Director (AD). The AD stated at approximately 1:35 p.m., she was assisting residents out of the dining room after lunch. At approximately 1:35 p.m., AD stated she assisted Resident 1 out of the dining room, placing her next to the door of a room in Hallway B. This door was approximately 10 feet from the dining room. The AD stated, Resident 1 Goes around the facility from resident-to-resident saying hi. The AD asserted this was not a sign and symptom of wandering. The AD stated Resident 1 would ask about her family and their whereabouts. The AD could not verbalize whether Resident 1's inquiries on her family was a possible sign and symptom of wanting to elope from the facility. On [DATE], at 9:23 a.m., Hallway B was observed with the Administrator. There was a video surveillance camera outside of the dining room pointing away from the dining room, which observed Hallway B. During a concurrent interview, the Administrator stated this video surveillance camera has not worked in a while. The Administrator stated after entering the dining room through the double doors, there was a door leading from the facility to the Assisted Living (AL). The AL was approximately 25 feet to the left when entering the dining room. On [DATE], at 10:01 a.m., Certified Nurse Assistant 5 (CNA 5) was interviewed. CNA 5 stated Resident 1 was confused, but for the most part, she was alert. CNA 5 stated when Resident 1 missed her family, she would ask and look for them. CNA 5 could not verbalize whether this was a possible sign and symptom of wandering or wanting to elope from the facility. CNA 5 stated Resident 1 liked to talk to everyone and self-propelled in the hallway, usually to the dining room. During an interview, on [DATE], at 10:06 a.m., CNA 3 stated Resident 1 For the most part she is alert. Sometimes less or more. Depends on the day. CNA 3 stated Resident 1 missed her family and would ask about them. On [DATE], at 10:40 a.m., the Assisted Living Medical Technician (ALMT) was interviewed and stated on the day where Resident 1 had fallen down a flight of stairs, he was in the nursing office directly under the stairway. The ALMT heard some tumbling, slower tumbling. There was approximately one second pause, then faster tumbling. Boom, boom, boom. When the ALMT responded, Resident 1, along with her wheelchair, was on the floor at the base of the stairs. From the hallway of the lower-level of the Assisted Living, the door into the stairway opened outward and towards the right. Resident 1 and the wheelchair were blocking the door. The door could only open, at most, an inch. The ALMT stated he could not force the door open. Resident 1 was not saying much at the time. A few seconds later, Resident 1 started screaming. When ALMT reached Resident 1 at the base of the stairs, he described Resident 1 as being face-down with her legs pointing towards the stairs. Resident 1's head was pointed towards the door. The wheelchair was over her head. The ALMT stated Resident 1 was yelling, Help, get me out of here. She was crying. Due to the limited space in the stairway, the ALMT and RN 1 rolled Resident 1 onto a sheet and slid the resident into the hallway of the lower level of the AL. The ALMT stated Resident 1 had a laceration to the middle-right of her forehead. The laceration was bleeding enough to obscure the dimensions. When Resident 1 was turned to her side to check her back, Resident 1 had a bruised, darkish discoloration to her left posterior chest wall. Resident 1 was on her right-side, but asked to be on her back. When Resident 1 was on her back, she stated it hurt. During an observation, on [DATE], at 10:45 a.m., the stairway where Resident 1 had fallen down were 14 steps in the stairway, which lead to the lower level of the AL. The distance from the top level of the AL to the lower level was approximately 126 inches or 10.5 feet. The area at the base of the stairs was approximately four (4) feet by six (6) feet. During an observation with the Maintenance Supervisor, on [DATE], at 10:59 a.m., the wander device alarm check was conducted at the door between the skilled facility and the AL which was functioning. During an interview, on [DATE], at 11:41 a.m., the Administrator stated and confirmed Resident 1 had an incident where she pulled the fire alarm. The Administrator confirmed there was no documented evidence the facility determined the cause for Resident 1 pulling the fire alarm, per the plan of care. On [DATE], at 12:25 p.m., the MDS Director (MDSD) was interviewed. The MDSD stated, for long-term care residents, the facility did not utilize a specific tool to assess for wandering or elopement. The facility did not assess for a resident's risk for wandering or elopement. There was no tool used to assess for a resident's risk for wandering or elopement. On [DATE], at 12:30 p.m., the Director of Nursing (DON) and the Administrator were interviewed. During a concurrent review of the undated policy, titled Wandering Resident, and the policy, titled Wandering, Unsafe Resident, revised (MONTH) 2014, the DON and Administrator confirmed there was no criteria used to assess a resident for the risk of wandering or elopement. The DON stated a resident was at risk for wandering and elopement if they make an attempt to elope or have a history of wandering or elopement. The Administrator stated all doors leading in and out of the facility were monitored (visually by staff) 24-hours-a-day. It's impossible, for Resident 1 to have made an attempt to elope from the facility unnoticed. The Administrator and DON stated the facility did not assess for a resident's risk for wandering or elopement. The Administrator and DON acknowledged that it was important to identify a resident's risk for wandering or elopement. The DON stated resident-specific care plans were important because they direct the staff in the implementation of interventions to meet the goals of the resident. During an interview, on [DATE], at 9:42 a.m., the Social Worker (SW) stated and confirmed there was no documented evidence Resident 1's behaviors of wandering were addressed, per the plan of care. There was no documented evidence the facility, in accordance with the IDT, updated and implemented care plans in regards to wandering or elopement for Resident 1. The SW stated Resident 1's behavior of going around in the hallway and asking for her children fits the definition of wandering. A review of the policy titled, Wandering, Unsafe Resident, revised (MONTH) 2014, indicated the staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. A review of the policy titled, Social Services, revised (MONTH) 2010, indicated our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. Factors that have a potentially negative effect on psychosocial well-being include behavioral problems. A review of the policy titled, Safety and Supervision of Residents, revised (MONTH) (YEAR), indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI review of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. The IDT care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risk for individual residents.

Based on observation, interview, and record review, the facility failed to observe infection control measures and precautions to prevent the spread of scabies (a condition of very itchy skin caused by tiny mites (human skin parasite) that burrow into the skin) for two of two residents (1, 2) by failing to: 1. Maintain an Infection Control Program to identify and prevent the spread of infection when cases of scabies were not diagnosed or adequately and timely treated. Resident 2 had symptoms of severe itching and rashes on February 8, 2014, and was diagnosed with [REDACTED]. 2. Monitor and assess the resident's skin for the effectiveness of the treatment after Resident 1 was [MEDICATION NAME] (preventive measure) treated for scabies on April 4 and June 11, 2014. 3. Ensure Resident 1 who was diagnosed with [REDACTED]. 4. Ensure that the facility had appropriate infection control committee as required, implemented its policies and procedures and have supplies to enable and allow healthcare personnel to provide safe care. 5. Implement its infection control policy and procedure that included the use of personal protective equipment (gowns, gloves), timely contact isolation, patient/family teaching, terminal disinfection (the act of destroying disease causing organisms), and conducting infection control surveillance (tracking the people residents, employees, family members, visitors) to identify resident, facility staff members who were exposed to scabies and to develop a plan of care accordingly. 6. To systematically assess personnel adherence to correct infection prevention practices. Assessment of adherence should be conducted by direct observation of healthcare personnel during the performance of their duties. These deficient practices had cause the spread of infection to Resident 2 and family member and had a potential to spread this highly communicable disease infection to other residents, staff members and visitors. An Immediate Jeopardy (IJ) situation was called on July 18, 2014, at 6:50 p.m.; the Administrator and Director of Nurses were informed. A written plan of correction for the IJ situation was accepted on July 19, 2014 and the IJ was abated. Findings: On July 2, 2014, the Department received a complaint that alleged Resident 1, Family Member 1 (FM 1 Resident 1's daughter) and her partner contracted scabies while in the facility. The first person who had the scabies was Resident 2 who was a roommate of Resident 1. On July 16, 2014, at 1 p.m., during a telephone interview, FM 1 stated Resident 1 (her mother) was a roommate of Resident 2 who was diagnosed to have scabies. FM 1 stated the facility assessed Resident 1's risk of contracting scabies since she was exposed to the scabies while she shared room with Resident 2. However, the facility did not inform FM 1 about the measures she needed to take to prevent herself from contracting scabies since she too was exposed and had direct contact with both Residents 1 and 2 during her extended daily visits. FM 1 further stated that a few days after Resident 2 was transferred to another room, Resident 1 started with skin eruption and during her visits, she observed Resident 1 itching and scratching her skin until she developed linear skin red marks. FM 1 assisted Resident 1 to scratch parts of her body she was unable to reach. According to FM1, the facility did not do anything about the resident's itching all over her body and complaints of severe pain in the neck and body. FM 1 had to take Resident 1 to an outside physician on June 12, 2014. Resident 1 was diagnosed with [REDACTED]. During the interview, FM 1 stated the facility did not provide her information about scabies and the need to seek [MEDICATION NAME] treatment for her and her partner since they were exposed to scabies. As a result, FM1 and her partner also contracted the scabies. During an observation on July 17, 2014, at 6:26 p.m., Resident 1 was sleeping in bed. There was no sign posted to alert the staff and the public of contact isolation. There were no personal protective devices and equipment such as gown, gloves, shoe covers, and there was no disposable stethoscope or designated blood pressure machine in the resident's room or by the resident's door. In addition, the resident's linens were not bagged and separated from other residents. The resident had two other roommates. A review of the admission record revealed Resident 2 (roommate of Resident 1 for 28 days) was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 2's nurses' progress notes dated February 8, 2014, indicated the resident was received in her room by her bedside and had been scratching hard her arms and chest off and on. The resident stated "Do something I am so miserable with this itching all over me." The physician was notified who returned the call with an order for [REDACTED]. On February 12, 2014, the resident was noted with crusty dry skin on both hands. On February 13, 2014, Resident 2's daughter visited and was concerned about her hands which were noted with whitish crusting formations in between the fingers of both hands. On February 21, 2014, Resident 2 was noted with boil (localized skin infection) on the right forearm about one by one centimeter in size. On February 22, 2014, the resident was assisted to bed before dinner per request. The physician was made aware that the crusting in between her fingers was not responding to current treatment. On February 23, 2014, Resident 2 was up in a wheelchair as tolerated and was assisted to the dining room for group activities of choice. A review of Resident 2's clinical record indicated the resident was transferred out to the acute care hospital on February 26, 2014, and was readmitted on [DATE] with scattered dry rash on the right upper waist. A review of Resident 2's care plan for pruritus (itching) all over her skin related to rashes manifested by extreme itching dated March 1, 2014, indicated the goal was to have a relief from itching for one month. The approaches included were medication regimen as ordered, [MEDICATION NAME] cream, shower and or bath as scheduled, monitor skin, advised resident not to scratch vigorously using her brush or wood scratcher, and to keep her fingernails trimmed. A review of the Progress Note for Resident 2 from a dermatology visit dated April 4, 2014, indicated the resident had itchy rash and crust; worse in the last few months but was itchy for years. Scabies preparation was positive for mites, eggs, and feces. Crusted scabies was discussed with another physician and ordered Ivermectin (used to treat other parasitic infections, including scabies), [MEDICATION NAME] (topical scabicidal agent) cream to toes and between fungus and toes for eight to 12 hours and wash off, then clean linens and undergarments. Place non-washable items in plastic bag for one week. Resident's family will be treated. Treatment of healthcare workers as indicated. Watch for persistence or recurrence. A review of Resident 2's care plan for actual tissue integrity impairment, crusted scabies dated April 7, 2014, indicated a goal for negative scrapings after treatment for two weeks. The approaches included were for nurses to keep the physician informed and follow the medical plan for treatment, follow up on employees' treatment to prevent spread, reinforce personal protective equipment and good hand washing. Contact isolation while on treatments, follow up with dermatology consult in two weeks, and to report changes. A review of the Progress Note for Resident 2's dermatology follow-up dated April 25, 2014, indicated there was no evidence of scabies. Scabies was negative and continue to monitor for signs and symptoms of recurrence. There was no evidence that 3 negative scrapings were done in accordance with the facility's guideline. According to the facility's guideline using the Prevention And Control Of Scabies In California Long-Term Care Facilities by California Department of Public Health Division of Communicable Disease Control in consultation with Licensing and Certification dated March 2008, indicated that for crusted or keratotic scabies to place symptomatic resident on contact isolation precautions in a private room until at least three negative skin scrapings have been documented. This may take from seven to 30 days or longer, depending on the severity of the infestation. According to the admission record, Resident 1 was originally admitted on [DATE], was discharged home on October 19, 2012, and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a comprehensive assessment tool) dated March 14, 2014, indicated the resident's cognitive patterns were moderately impaired, required extensive assistance from staff members for bed mobility, transfer, walking in the room and corridor, locomotion on and off the unit, dressing, toilet use, and bathing. The resident used walker and wheelchair for mobility devices and was always continent of bowel and bladder. The resident did not have any other ulcers, wounds, and skin problems. Under special treatments, procedures, and programs, it did not indicate that the resident was on isolation or quarantine for active infectious diseases. A review of the physician's orders [REDACTED]. 1. [MEDICATION NAME] ([MEDICATION NAME]) five percent cream topical. Apply to skin from head to toe times one to stay in skin in 12 hours then shower in morning for [MEDICATION NAME] dated April 4, 2014. 2. [MEDICATION NAME], apply cream from neck to feet for eight to 12 hours then shower for [MEDICATION NAME] dated June 11, 2014. 3. Apply [MEDICATION NAME] ([MEDICATION NAME]) five percent topical in the morning twice a week, Monday and Thursday until clear. According to the Medication Administration Record (MAR), the above two orders for [MEDICATION NAME] were implemented as ordered. The third order was not implemented since it was later discontinued on June 13, 2014, by the physician and Resident 1 did not receive the full course of the medication. In addition, while the resident received the [MEDICATION NAME] treatment the resident was not placed on contact isolation. A review of the nurses' notes and skin assessment revealed no documentation that the resident had rashes and was itching from April 4, 2014 - June 12, 2014. However, the resident's care plan addressed the issue. Further review of the clinical record revealed a copy of a prescription written by a Physician Assistant when FM 1 brought Resident 1 to an outside physician on June 12, 2014. The prescription indicated to apply [MEDICATION NAME] topical cream every day for seven days, then twice for one month until cured and to ensure linens/clothes are washed with hot water, soap, and appropriate care. There was a note that the prescriptions were faxed to the facility's physician on June 12, 2014, at 6:10 p.m. A review of Resident 1's care plan dated June 12, 2014, indicated rashes from scabies infection manifested by rash complained of itching. The goal was to have no signs and symptoms of infection for one month. The approaches included were to assess skin condition daily and note any changes, and [MEDICATION NAME] cream as ordered and [MEDICATION NAME] (used to treat inflammation of the skin) cream one percent to affected areas. Assist with hygiene and general skin care. Resident 1 was medicated with [MEDICATION NAME] on April 4, 2014, and on June 11, 2014. The facility's plan of care did not include interventions for contact isolation, monitor for the effectiveness of treatment, and the handling of the resident's soiled linens/clothes. In addition, there was no documented evidence that indicated the infection control coordinator and/or the licensed nursing staff assessed personnel adherence to correct infection prevention practices through direct observation of healthcare personnel and housekeeping during the performance of their duties. There was no skin assessment done at the time Resident 1 was administered with [MEDICATION NAME] back in April 2014 and June 11, 2014. The resident received [MEDICATION NAME] cream for [MEDICATION NAME] treatment and was still diagnosed with [REDACTED]. There were no documentation that Resident 1 was placed on contact isolation when [MEDICATION NAME] was administered [MEDICATION NAME], that nursing staff monitored the resident's skin progress and the response to the [MEDICATION NAME] treatment. There was no documented evidence when the resident was cleared of scabies and what other precautionary measures regarding infection control had been taken effect on the resident and for other residents that Resident 1 came in contact with since she was going to the dining/activity room and was receiving rehabilitation services. A review of the physician's Progress Record dated July 19, 2014, indicated daughter and partner were confirmed to have contracted scabies. Daughter claimed she got it from her mom. Per my notes, Resident 1 had a rash in June and at that time was given [MEDICATION NAME] for [MEDICATION NAME] treatment. Scrapings were not performed. Her rash got better. The resident now complained of itching around her neck where she has a papular (small raised bumps) rash. She was seen in the emergency room last night with [DIAGNOSES REDACTED]. On July 18, 2014, at 1:30 p.m., during an interview the Director of Nursing (DON), when asked confirmed that Resident 2 who had scabies was a roommate of Resident 1. According to the DON, one of the daughters (FM1) informed the facility that her mother was itching. The resident went out of the facility on pass with FM 1 on June 12, 2014, and brought a prescription for [MEDICATION NAME] ([MEDICATION NAME]) topical cream for scabies from an outside physician. The DON also stated Resident 1 was treated with [MEDICATION NAME] cream for scabies [MEDICATION NAME]. When asked why the resident was not assessed and examined by her attending physician in the facility, she stated the facility did not believe the resident had scabies. On July 18, 2014, at approximately 1:40 p.m., Resident 1 was observed with dry red pimple-like patches/bumps in the face, abdominal area, below the right breast, and whitish-reddish dry scaly rashes at the right upper back area. The resident was observed scratching her abdominal area and upper back. Resident 1 stated she was itchy. On July 18, 2014, at 1:50 p.m., during an interview with Certified Nursing Assistant 1 (CNA 1), she stated the resident also goes to the activities and dining room. On July 18, 2014, at 3:00 p.m. during an interview with RN 1 when asked why the resident was not placed on contact isolation stated because the resident did not have scabies. Despite the fact that Resident 1 was itching, had rashes, and had a prolonged exposure to Resident 2 who had a confirmed [DIAGNOSES REDACTED]. On July 18, 2014, at 3:05 p.m., during an interview with Certified Nursing Assistant 2 (CNA 2), she stated she had taken cared of Resident 2 and knew that the resident had scabies. They moved her to another room for contact isolation. CNA 2 put on gown, gloves, and mask for Resident 2 but did not put on the gown for Resident 1 as she was not on isolation. On July 18, 2014, at 3:10 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), she stated Resident 2 was originally in a room with other residents and was transferred to a room by herself for isolation. On July 18, 2014, at 3:15 p.m., during an interview with Licensed Vocational Nurse 2 (LVN 2), she stated Resident 2 had chronic rashes and itchiness on and off. The resident was prescribed [MEDICATION NAME] (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various scalp and skin conditions). On July 18, 2014, at 4 p.m., during an interview with the DON, she stated they do not have an infection control log book and everything was in the computer. When asked to provide a list of affected residents, facility staff, family members, and visitors who were exposed to Resident 1, she was unable to provide one. According to the DON, the facility's physician did not agree that the resident had scabies. However, a review of the Physician's Telephone Orders from the facility's physician dated June 12, 2014, indicated for skin treatment was to apply [MEDICATION NAME] 5% topical in the morning twice a week, Monday and Thursday until clear and there was no documentation that indicated the physician did not agree with the [DIAGNOSES REDACTED]. On July 18, 2014, at 4:55 p.m., during an interview with Housekeeper 1 (H 1), he stated that they did not have any residents on isolation that day. He further stated that the room where Residents 1 and 2 resided was not deep (terminal cleaning- method used in healthcare environments to control the spread of infections) cleaned since it was not an isolation room. However, Resident 2 was in that room when she was diagnosed with [REDACTED]. If not in isolation, we do regular cleaning and use Citrus [MEDICATION NAME] (general purpose cleaner). Virex really kills the germs. On July 18, 2014, at 9 p.m., during an observation, Resident 1 was not placed on isolation. According to the facility's guideline using the Prevention And Control Of Scabies In California Long-Term Care Facilities by California Department of Public Health Division of Communicable Disease Control in consultation with Licensing and Certification dated March 2008, indicated in elderly persons, especially those with chronic disease, scabies is generally not diagnosed until cutaneous (skin) lesions and symptoms are apparent. Because of the long incubation period, many exposures may occur before a [DIAGNOSES REDACTED]. Keratotic or crusted scabies occurs when treatment for infestation has been delayed for many months and is characterized by thick, crusted lesions. Imbedded within these crusts are thousands to millions of live mites. Scabies is generally transmitted to health care workers by direct skin-to-skin contact with an infested resident. Activities such as performing physical assessments, bathing, and changing a resident's soiled linen are conducive to transmission because physical contact is often prolonged. Transmission may occur between residents during social or recreational activities. If the infestation is atypical or has progressed to the crusted stage, the environment may also harbor mites and contribute to transmission. Pruritus is a cell-mediated hypersensitivity (allergic) response to the mites, eggs, and feces imbedded in the skin. Skin lesions are generally seen on the hand, wrists, elbows, folds or armpits, female breasts or the male genitals. In long term care facility residents, lesions may be more predominate on the areas of the skin having contact with moist sheets such as the back and buttocks. In typical scabies, the rash is generally characterized as red, raised bumps (papules). Although skin scrapings are generally negative in typical scabies, it is recommended that this procedure be performed on at least one symptomatic case (resident or health care worker). The absence of mites, eggs or fecal pellets on microscopic examination does not guarantee that the resident does not have scabies. However, a positive skin scraping should assist physicians in the development of appropriate therapeutic and [MEDICATION NAME] treatment. On July 19, 2014, at 2:35 p.m., during an interview with the DON, she stated they did not have an infection control committee separately from quality assurance (Q.A.). When asked for the minutes of the meeting or documented evidence done by the infection control committee, she stated that they discussed any infection control issues during the Q. A. meeting. According to the facility's guideline using the Prevention And Control Of Scabies In California Long-Term Care Facilities by California Department of Public Health Division of Communicable Disease Control in consultation with Licensing and Certification dated March 2008, indicated a scabies control program should be developed and approved by the infection control committee. The program should designate a physician such as the medical director who will act as the program coordinator. This physician should be given the authority to notify attending physicians, perform diagnostic procedures such as skin scrapings, and to order [MEDICATION NAME] and therapeutic scabicide treatments on exposed residents. The infection control practitioner should be responsible for identification of contacts of symptomatic case(s), prevention of transmission, treatment of symptomatic cases, treatment of contacts, post-treatment and assessment of treatment failures.