Every finding on record at Gardena Convalescent Center

Based on interview and record review, the facility failed to develop a pain care plan for one out of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 not receiving specific care interventions related to Resident 1's pain.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Unilateral Primary Osteoarthritis of the left hip (a progressive disorder of the joints, caused by a gradual loss of cartilage), left hip artificial joint, and anxiety disorder (a mental health condition defined by intense, excessive, and persistent worry or fear about everyday situations).During a review of Resident 1's physician order, dated 5/18/2026, the physician order indicated to administer Hydrocodone-Acetaminophen (a pain medication) 10-325 milligram (mg, a unit of measurement) one tablet by mouth every four hours as needed for moderate to severe pain.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/24/2026, the MDS indicated Resident 1's cognition (ability to think and process) was intact. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) from staff for toileting hygiene, showering, lower body dressing, sitting to standing, and transfers. The MDS indicated Resident 1 had frequent pain and recently had a hip replacement.During a concurrent interview and record review on 5/29/2026 at 8:48 a.m. with Registered Nurse (RN 1) 1, Resident 1's Care Plan Report, undated, was reviewed. The Care Plan Report did not include a care plan for Resident 1's left hip pain. RN 1 stated there were no care plans for Resident 1's pain. RN 1 stated care plans should be initiated within 3 days of admission. RN 1 stated the care plan was a means of communication for all staff caring for the residents and it was important to have a care plan for everyone to see, follow, and be consistent in the residents' care. During an interview on 5/29/2026 at 9:06 a.m. with Resident 1, Resident 1 stated she had pain in her left hip after having a left hip replacement surgery. During a review of the facility's policy and procedure (P&P), titled Develop-Implement Comprehensive Care Plans, dated 1/2026, the P&P indicated the facility would develop a person-centered comprehensive care within seven days after the completion of the comprehensive assessment. The P&P indicated care plans should describe the residents' needs and preferences and how the facility would assist in meeting those needs and preferences.

Based on interview and record review, the facility failed to: 1.Ensure 36 out of 36 narcotic destruction log sheets were signed by the Director of Nursing (DON) and the facility's pharmacist consultant. This deficient practice had the potential to result in narcotic diversion (the illegal transfer of prescription drugs, specifically controlled substances like opioids, from their intended, legal purpose to an unauthorized person or for illegal use).Findings:During a concurrent interview and record review, on 3/11/2026 at 10:32 a.m., with the DON, the DON stated there were 34 individual residents-controlled drug record that she did not sign on 1/30/2026 during drug destruction with RPH. The DON stated all discontinued narcotics were kept in a locked drawer inside of her office. The DON stated if a narcotic was discontinued, a licensed nurse would come to her office, and both (DON and license nurse) would count the remaining medications. The DON stated she would do a monthly narcotic destruction with the pharmacy consultant. The DON stated she and the pharmacy consultant would count the narcotics together to ensure the amount of medication on the bubble pack matched the medication on the narcotic destruction log, then destroy them by placing the medications into destruction bin. The DON stated the process of destroying narcotics medications included two signatures on the Controlled or Antibiotic Drug Record, one from the Registered Pharmacy (RPH) and the DON per State and Federal guidelines. The DON stated the risk of not properly accounting for a narcotic, not being able to validate a narcotic could result in narcotic diversion. A review of the facility policy and procedures (P&P), titled Medication Destruction, revised 1/2025, indicated Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous waste and controlled substances and to include the signature(s) of at least two witnesses including a registered nurse and an authorized licensed pharmacy representative.

Based on observation, interview, and record review the facility failed to:1. Ensure food items stored in the kitchen walk in refrigerator were maintained in a safe and sanitary manner by allowing expired hot dog buns and corn tortillas to remain stored and available for use. This deficient practice had the potential to result in residents being served expired food products.During a concurrent observation and interview on 3/10/2026 at 8:40 a.m. with the [NAME] in the kitchen walk in refrigerator observed was an opened bag of [NAME] brand corn tortillas 80 count with an expiration date of 12/21/2025 and 5 bags of [NAME] Deli 16 count hot dog buns with 3 with expiration dates of 1/31/2026 and 2 with expiration dates 2/2/2026. The [NAME] stated the hot dog buns and tortillas should not be in the refrigerated stored with other food they should be thrown out. During an Interview on 3/10/26 at 11:09 a.m. with the Dietary Services Supervisor (DSS), the DSS stated having the expired food could expose residents to foodborne illness and make residents sick. The DSS stated the expired food should not have been in the kitchen. During a review of the facility's policy and procedure (P&P), title, Food Receiving and Storage revised January 2026, the P&P indicated, monitoring refrigerated food, including but not limited to leftovers, so it is used by its used-by date or discarded.

Based on observation, interview, and record review the facility failed to: 1. Label with an opened date and remove expired ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solution for three of three sampled residents (Resident 16, Resident 20, and Resident 72) in Medication cart 1. This deficient practice had the potential to result in prolonged use and loss of strength of the expired inhalation solution and can lead to ineffective treatment of respiratory symptoms for Resident 16, 20 and 72.Findings:During a review of Resident 16's admission Record, the admission Record indicated, Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included pneumonia (an infection/inflammation in the lungs), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 16's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set ([MDS] - a resident assessment tool), dated [DATE], the MDS indicated, Resident 16's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated, Resident 16 required substantial assistance (helper does more than half the effort) from staff with eating, oral hygiene, and upper body dressing. During a review of Resident 16's Order Summary Report (a document containing active orders), dated [DATE], the Order Summary Report indicated, the physician placed a telephone order on [DATE] for Resident 16 to start on ipratropium with albuterol inhalation solution 3 milliliter ([ml] unit of volume) every 4 hours as needed for dyspnea (shortness of breath). During a review of Resident 20's admission Record, admission Record indicated, Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included pneumonia (an infection/inflammation in the lungs),congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 20's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 20 had the capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set ([MDS] - a resident assessment tool), dated [DATE], the MDS indicated, Resident 20 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 20 required set-up assistance (helper assists only prior to or following the activity) from staff with eating and oral hygiene. During a review of Resident 20's Order Summary Report (a document containing active orders), dated [DATE], the Order Summary Report indicated, the physician placed a telephone order on [DATE] for Resident 20 to start on ipratropium with albuterol inhalation solution 3 milliliter ([ml] unit of volume) every 6 hours (12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m.). During a review of Resident 72's admission Record, admission Record indicated, Resident 72 was admitted to the facility on [DATE]. Resident 72's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and atrial fibrillation (irregular heart rate and rhythm). During a review of Resident 72's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 72 had the fluctuating capacity to understand and make decisions. During a review of Resident 72's Order Summary Report (a document containing active orders), dated [DATE], the Order Summary Report indicated, the physician placed a telephone order on [DATE] for Resident 72 to start on ipratropium with albuterol inhalation solution 3 milliliter ([ml] unit of volume) every 4 hours for COPD. During a concurrent observation and interview on [DATE] at 9:56 a.m., with Licensed Vocational Nurse 1 (LVN 1), of the medication cart 1, found three opened ipratropium with albuterol combination inhalation foil pack stored at room temperature. LVN 1 stated Residents 16, 20, and 72 have one opened ipratropium with albuterol combination inhalation foil pack with no label with an opened date. LVN 1 stated Resident 16's one opened ipratropium with albuterol combination inhalation foil pack indicated a pharmacy fill date of [DATE]. LVN 1 stated Resident 20's one opened ipratropium with albuterol combination inhalation foil pack indicated a pharmacy fill date of [DATE]. LVN 1 stated Resident 72's one opened ipratropium with albuterol combination inhalation foil pack indicated a pharmacy fill date of [DATE]. LVN 1 stated all medications should be labeled with an open date so the facility staff would know the expiration date. LVN 1 stated giving expired ipratropium with albuterol combination inhalation solution to Residents 16, 20, and 72 would no longer be effective in treating their respiratory symptoms. LVN 1 stated she will discard immediately the three opened ipratropium with albuterol combination inhalation foil pack.During an interview on [DATE] at 12:11 p.m., with the Director of Nursing (DON), the DON stated it is important to label all medications with an open date so the facility staff would know the life span of the medication (the period during which it remains safe and effective for use, provided it is stored properly). The DON stated giving expired medication would have a possibility of adverse reaction (an unintended effect of a medication that is harmful or unpleasant) to residents.During a review of the manufacturer's product storage and labeling, opened foil packs of ipratropium with albuterol inhalation solutions should be stored at room temperature between 36 and 77 degrees Fahrenheit and used or discarded within two weeks of opening the foil cover.During a review of the facility's policy and procedure (P&P), titled, Labeling of Biologicals and Storage of Biologicals, dated 1/2025, the P&P indicated Drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

Based on observation, interview, and record review, the facility failed to:1.Ensure personal information of residents was protected by not throwing the protected information (PHI - any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) in the trash can without shredding.This failure had the potential to violate residents rights and privacy.During an observation on 3/12/2026 at 1:45 p.m. observed meal tickets in the trash by the dishwashing machine area. The meal tickets contained resident names, room numbers and diet types, texture level, liquid consistency level and likes and dislikes.During an interview on 3/12/2026 at 1:50 p.m. with the Dietary Aide (DA) the DA stated the meal cards have patient information names, diet type, and room number and I should not have been thrown in the trash they should have been shredded or given to the supervisor.During an interview on 3/12/2026 at 1:50 p.m. with the Dietary Service Supervisor (DSS) the DSS stated I have staff put the meal tickets on the side and I take the meal tickets and have them shredded. The meal tickets contain resident names, diet and room numbers, which is all protected information. This information should not be discarded in the trash personal privacy information should not be thrown in the trash can, that could expose resident's personal information.During a review of the facility policy and procedure (P&P) titled, Privacy and Confidentiality dated 1/2025 the P&P indicated the resident has a right to personal privacy and confidentiality of his or her personal and medical records.

Based on interview and record review, the facility failed to: 1. Ensure the quarterly (every 3 months) Minimum Data Set Assessment ([MDS] - a resident assessment tool) for one of one sampled resident (Resident 2) was completed within the required timeframe. This deficient practice could potentially affect the care services of Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), atrial fibrillation (irregular heart rate and rhythm), and hypertension ([HTN] - high blood pressure).During a review of Resident 2's History and Physical (H&P), dated 9/11/2025, the H&P indicated, Resident 2 lacks the capacity to make medical decisions.During a concurrent interview and record review on 3/11/2026 at 12:57 p.m., with the Minimum Data Set Nurse (MDSN), Resident 2's quarterly MDS assessment, dated 2/20/2026, was reviewed. The MDSN stated Resident 2's quarterly MDS assessment was not completed yet. The MDSN stated Resident 2's quarterly MDS assessment should have been completed on 3/6/2026 which is 14 days from 2/20/2026. The MDSN stated all MDS assessment should be completed in a timely manner in order to capture the unnecessary changes of resident's condition. The MDSN stated late completion of MDS assessment would affect the plan of care of the resident.During an interview on 3/12/2026 at 12:15 p.m., with the Director of Nursing (DON), the DON stated MDS assessment should be completed within 14 days from the Assessment Reference Date ([ARD] - the specific date used as the endpoint of the observation period when assessing resident's condition). The DON stated by not completing the MDS in a timely manner, the resident's assessment will not be updated and there is a possibility that the care of the resident would not be met.During a review of the facility's policy and procedure (P&P), titled, Resident Assessment, dated 1/2026, the P&P indicated The facility shall complete MDS assessments within required federal timeframes.

Based on interview and record review, the facility failed to: 1. Ensure the Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 17 sampled residents (Resident 2). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), atrial fibrillation (irregular heart rate and rhythm), and hypertension ([HTN] - high blood pressure).During a review of Resident 2's History and Physical (H&P), dated 9/11/2025, the H&P indicated, Resident 2 lacks the capacity to make medical decisions.During a review of Resident 2's MDS assessment, dated 11/21/2025, the MDS assessment indicated, Resident 2's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated, Resident 2 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, lower body dressing, and personal hygiene.During a review of Resident 2's Joint Mobility Assessment ([JMA] - brief assessment of a resident's range of motion in each joint of both arms and legs), dated 8/29/2025, 9/9/2025, 12/15/2025, and 2/20/2026, were reviewed. The JMA indicated, Resident 2 had no impairment on upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot).During a concurrent interview and record review on 3/11/2026 at 1:04 p.m., with the Minimum Data Set Nurse (MDSN), Resident 2's MDS assessment, dated 11/21/2025, was reviewed. The MDSN stated Resident 2's MDS assessment was completed inaccurately. The MDSN stated there was a wrong entry on MDS section GG0115 (Functional Limitation in Range of Motion ([ROM] - full movement potential of a joint]). The MDSN stated MDS section GG0115 ([B] - lower extremity (hip, knee, ankle, foot) should be coded as 0 (no impairment) not 1 (impairment on one side) because Resident 2 had no functional limitation in range of motion on lower extremities. The MDSN stated the facility transmitted an inaccurate information of Resident 2's actual condition to the CMS. The MDSN stated inaccuracy of MDS assessment would affect facility's quality measures (standardized, data-driven metrics derived from CMS-mandated resident assessments to monitor care quality in nursing homes).During an interview on 3/12/2026 at 8:46 a.m., with the Director of Rehabilitation (DOR), the DOR stated Resident 2 had no contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) and had no limitation in range of motion on upper and lower extremities that impairs her Activities of Daily Living ([ADL's] - activities such as bathing, dressing and toileting a person performs daily) function. The DOR stated Resident 2 had no change on ROM since she was admitted to the facility. The DOR stated Resident 2's MDS assessment on functional limitation in range of motion on lower extremity dated 11/21/2025 was not completed accuratelyDuring an interview on 3/12/2026 at 12:12 p.m., with the Director of Nursing (DON), the DON stated it is important to complete MDS assessment accurately in order to provide the needs of the resident.During a review of the facility's policy and procedure (P&P), titled, Resident Assessment, dated 1/2026, the P&P indicated Initially and periodically, the facility conducts a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity.During a review of the facility's P&P, titled Accuracy of Assessments, dated 1/2026, the P&P indicated, The facility shall maintain supporting source documentation used to substantiate all MDS coding in the resident's medical records.

Based on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for one of one sampled resident (Resident 3) by failing to: 1. Obtain a medical order clearance for tooth extraction (removal of a tooth) for Resident 3 as recommended by the dentist. This deficient practice had the potential to put Resident 3 at risk for oral infection, pain, and weight loss.Findings:During a review of Resident 3's admission Record, the admission Record indicated, Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included pneumonia (an infection/inflammation in the lungs), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's History and Physical (H&P), dated 1/21/2026, the H&P indicated, Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set ([MDS] - a resident assessment tool) assessment, dated 1/26/2026, the MDS assessment indicated, Resident 3 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 3 required substantial assistance (helper does more than half the effort) from staff with eating and oral hygiene.During an interview on 3/10/2026 at 9:54 a.m., with Resident 3, Resident 3 stated she needed a surgery to remove her broken teeth. Resident 3 stated her broken teeth bothers her and she was not able to chew the food properly. Resident 3 stated she's still waiting for the dentist to come to remove her broken teeth.During a concurrent interview and record review on 3/11/2026 at 2:15 p.m., with the Social Service Director (SSD), Dental Visit Summary, dated 12/10/2025, was reviewed. The SSD stated the Dental Visit Summary indicated, Resident 3 had periodic oral evaluation (routine dental examination) and the dentist recommended to obtain medical order. The SSD stated she was not aware of the dentist recommendation, and she does not know what kind medical order the dentist was referring to.During an interview on 3/11/2026 at 2:23 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she did not check the Dental Visit Summary, and she was not aware of the dentist recommendation to obtain medical order for Resident 3.During a concurrent interview and record review on 3/11/2026 at 2:34 p.m., with the Director of Nursing (DON), Resident 3's Dental Notes, dated 12/10/2025, was reviewed. The DON stated the Dental Notes indicated, the dentist recommended to obtain a medical order clearance for Resident 3 for tooth extraction. The DON stated there was no documentation by facility staff indicating Resident 3's physician was notified and obtained a medical order clearance for tooth extraction. The DON stated any recommendations by the dentist should be addressed promptly to prevent delay of care and treatment. The DON stated it is important for Resident 3 to have tooth extraction to minimize oral infection, discomfort, and pain that would diminish her quality of life.During a review of the facility's policy and procedure (P&P), titled, Quality of Care, dated 1/2025, the P&P indicated The interdisciplinary team (IDT) shall provide the necessary care or services to improve and/or attain the resident's highest practicable physical, mental, and/or psychosocial well-being.

Based on observation interview and record review the facility failed to: 1. Ensure one of two sampled residents (Resident 36), assessed as being at risk for elopement (leaving the facility without permission) wore a ROAM Alert device (an electronic safety device worn by a resident that triggers an alarm if the resident attempts to exit the building) ordered by the physician to notify staff of potential elopement. This failure had the potential to allow a resident to leave the facility unsupervised and without staff awareness, placing the resident at risk of harm or injury.During a review of Resident 36's admission Record (face sheet), the face sheet indicated the facility admitted Resident 36 on 7/31/2023 with diagnoses including homelessness, syncope and collapse (a temporary loss of consciousness caused by a sudden decrease in blood flow to the brain resulting in fainting) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool) dated 2/6/2026, the MDS indicated Resident 36's was independent (decisions consistent/ reasonable) in cognitive (ability to think and reason) skills of daily decision making. The MDS indicated Resident 36 was independent in functional abilities including eating and upper body dressing and required the minimal assist from one staff for personal hygiene showering and oral hygiene. An elopement risk note dated 2/6/2026 indicated an elopement risk score value of 1 or higher indicated the resident was an elopement risk. Resident 36 risk elopement score was documented as 4. During a review of Resident 36's History and Physical (H&P) dated 2/23/2025, the H&P indicated Resident 36 had fluctuating capacity to understand and make decisions.During a review of the physician orders dated 3/2/2026 the physician orders indicated ROAM Alert to left wrist elopement risk dated 10/7/2024, and ROAM Alert monitor function right wrist every shift dated 11/28/2025.During a review of the plan of care dated 12/3/2023, the plan of care for elopement risk due to Resident 36 constantly seeking behavior, episodes of packing belongings. The intervention dated 5/9/2024 for the problem was for Resident 36 to wear the Roam alert device on the left wrist due to elopement risk.During observations on 3/10/2026, 3/11/2026 and 3/12/2026 at 8:00 a.m. 11:00 a.m. 2:00 p.m. and 4:00 p.m. Resident 36 was observed without a ROAM Alert device on his wrist.During an interview on 3/12/2026 at 9:43 a.m. with the Director of Nurses (DON), the DON stated the resident being without a ROAM Alert device put Resident 36 at an increased safety risk stating Resident 36 could easily elope without staff knowing and put Resident 36 at risk for injury or harm.During a review of the facility's policy and procedure (P&P) titled, Free of Accident Hazards/Supervision/Devices dated January 2025, the P&P indicated, avoidable accident: when an accident occurred because the facility failed to implement interventions including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk.if not reduce the risk of an accident monitor the effectiveness of the interventions and modify the care plan as necessary in accordance with current professional standards of practice.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 39) who has a Peripherally Inserted Central Catheter ([PICC] - a thin flexible tube that is inserted into a vein in the upper arm above the right side of the heart, used to give intravenous fluids, blood transfusions, and medications) was placed on Enhanced Barrier Precaution ([EBP] - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents and staff.Findings:During a review of Resident 39's admission Record, the admission Record indicated, Resident 39 was admitted to the facility on [DATE]. Resident 39's diagnoses included pneumonia (an infection/inflammation in the lungs), urinary tract infection ([UTI] - an infection in the bladder/urinary tract), and bacteremia (presence of bacteria in your blood).During a review of Resident 39's History and Physical (H&P), dated 3/5/2026, the H&P indicated, Resident 39 had the capacity to understand and make decisions.During a review of Resident 39's Order Summary Report (a document containing active orders), dated 3/10/2026, the Order Summary Report indicated, the physician placed a telephone order on 3/5/2026 for Resident 39 to start on Unasyn (medication to treat infection) 3 grams (([gm] - unit of measurement, used for medication dosage and/or amount) intravenously (into the vein) three times a day (9:00 a.m., 1:00 p.m., and 5:00 p.m.) for UTI for 10 days.During a concurrent observation and interview on 3/10/2026 at 10:21 a.m., with the Infection Preventionist Nurse ([IPN] - a healthcare professional who works to prevent spread of infections in the healthcare setting) in Resident 39's room, Resident 39 had a PICC line on right upper arm. The IPN stated EBP is practiced on residents that have a medical device like a PICC line. The IPN stated Resident 39 was not placed on EBP since he was admitted to the facility on [DATE]. The IPN stated there should be a personal protective equipment ([PPE] - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) supplies outside the room of Resident 39 such as gown, gloves for staff to use to provide care to Resident 39. The IPN stated it was an oversight on her part by not putting Resident 39 on EBP. The IPN stated it is important to place Resident 39 on EBP to prevent the spread of infection to residents and staff.During an interview on 3/12/2026 at 12:09 p.m., with the Director of Nursing (DON), the DON stated residents with medical devices such as central line, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and foley catheter (a thin, flexible tube inserted into the bladder to drain urine) should be placed on EBP immediately to prevent cross contamination and spread of infection.During a review of the facility's policy and procedure (P&P), titled Enhanced Barrier Precautions, revised 1/2025, the P&P indicated, EBP are indicated for residents with indwelling medical device that include central lines.During a review of the facility's P&P, titled Infection and Prevention Control, revised 1/2026, the P&P indicated, The facility staff ensure EBP are used in conjunction with standard precautions and expands the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing.

Based on observation, interview, and record review, the facility failed to:1. Ensure the call light (a device used by a resident to signal his or her need for assistance from a staff) was within reach for one of 17 sampled residents (Resident 39).This failure had the potential for increased risk of falls, delayed response to emergencies, and unmet basic needs for Resident 39. Findings:During a review of Resident 39's admission Record, the admission Record indicated, Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 39's diagnoses included dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and congestive heart failure ([CHF] - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 39's History and Physical (H&P), dated 8/30/2025, the H&P indicated, Resident 39 did not have the capacity to understand and make decisions.During a review of Resident 39's Minimum Data Set Assessment ([MDS] - a resident assessment tool), dated 12/10/2025, the MDS indicated, Resident 39's cognitive (ability to think and reason) skills for daily decision were severely impaired (never/rarely made decisions). The MDS indicated, Resident 39 was totally dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 39's care plan, titled Alteration with Activities of Daily Living ([ADL] - a basic skill needed to carry out tasks of everyday life), revised 1/12/2026, the care plan intervention included to maintain call light within easy reach and answer promptly.During a concurrent observation and interview on 3/10/2026 at 9:45 a.m., with the Infection Preventionist Nurse (IPN) in Resident 39's room, the IPN stated Resident 39's touch pad call light was under her pillows and Resident 39 could not reach her touch pad call light (specialized call light in the form of a pad). The IPN stated call light should be in the residents reach to allow resident to call for help and assistance.During an interview on 3/12/2026 at 12:07 p.m., with the Director of Nursing (DON), the DON stated all staff are responsible in monitoring resident's call light. The DON stated resident's call light should be within their reach at all times so the facility staff could anticipate the needs of the residents. The DON stated the purpose of the call light was to ensure residents can call for help especially during emergency.During a review of the facility's policy and procedure (P&P) titled, Resident Call System, dated 1/2025, the P&P indicated, Resident call system shall be accessible to residents while in their bed.During a review of the facility's P&P titled, Reasonable Accommodations of Needs-Preferences, dated 1/2026, the P&P indicated, Each resident shall have access to the resident call system within reach.

Based on observation, interview and record review, the facility failed to ensure one of four residents (Resident 1), was provided with a safe and hazard-free environment while providing care. This deficient practice had the potential to cause severe injuries to Resident 1 including hospitalization and death.Findings: During a concurrent observation and interview on 7/9/2025 at 12:30 p.m. with Resident 1, in Resident 1's room, Resident 1's right upper cheek was observed slightly swollen and purple in color and the right elbow had a dime size abrasion (scratch). Resident 1 was unable to move right upper and lower extremity. Resident 1's speech was slurred but Resident was able to communicate with simple words. Resident 1 stated she fell in the facility while the nurse was in the room and was sent to the hospital. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarct affecting right dominant side ([stroke], loss of blood flow to a part of the brain), muscle wasting and atrophy (loss of muscle mass and strength,) and abnormalities of gait and mobility (any deviation from a typical walking pattern or the ability to move easily and freely in the environment). During a review of Resident 1's History and Physical (H&P) dated 6/24/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/26/2025, the MDS indicated Resident 1 was dependent with staff with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 1's Change of Condition (COC), dated 7/4/2025, timed 6:20 a.m., the COC indicated Resident 1 was in bed while Certified Nurse Assistant (CNA) 2 was providing ADL care. The COC indicated while CNA 2 was doing peri-care to Resident 1, Resident 1's weight shifted (move or cause to move from one place to another) when Resident 1 was turned to one side which contributed to Resident 1's fall from the bed to the floor. The COC indicated Licensed Vocational Nurses (LVN) 1 went to Resident 1's room and found Resident 1 on the floor in a side-lying position (side unspecified) supported by CNA 2. The COC indicated Resident 1 needed maximum assistance with baseline and dependent on transfers. The COC indicated Resident 1 was assisted by nurses (unspecified) back to bed. The COC indicated Resident 1 had an abrasion on the right elbow, and a periorbital (the area around the eye socket) swelling with purple discoloration on the right eye. During a review of Resident 1's care plan titled, Alteration with ADL functions, dated 7/8/2025, the care plan indicated Resident 1 was dependent with staff's assistance. The interventions indicated maintaining a safe and hazard free environment. The interventions did not specify the type of assistance staff needed to provide Resident 1 while providing ADL care. During an interview on 7/9/2025 at 12:30 p.m. with CNA 1, CNA 1 stated when CNAs are changing the residents, we need to make sure when residents are turned to the side, the residents are able keep that position, otherwise the CNA should find help from another nurse. CNA 1 stated Resident 1 was usually able to stay on her side when turned. CNA 1 stated we need to make sure Resident 1 understood to be still until the CNA is done cleaning her (Resident 1). CNA 1 stated it is the nurse's responsibility to provide residents' safety and prevent any falls. During an interview on 7/9/2025 at 3:31 p.m. with LVN 1, LVN 1 stated Resident 1 was totally dependent on staff with ADL care, turning and repositioning. LVN 1 stated Resident 1 can be assisted by one person, but nurses need to make sure that Resident 1 is at the center of the bed before being turned. LVN 1 stated if a resident is at the edge of the bed when turned, the resident could fall. LVN 1 stated nurses should prioritize residents' safety first, or request assistance. During a concurrent interview and record revied on 7/9/2025 at 4:44 p.m. with LVN 2, LVN 2 stated Resident 1 was paralyzed on her right side. LVN 2 stated Resident 1 was totally dependent on staff for mobility and hygiene care. LVN 2 stated Resident 1 was not able to turn by herself, and the nurses should have taken precautions when Resident 1 was repositioned. LVN 2 stated Resident 1 should not be at the edge of the bed when turned so the resident does not fall. LVN 2 stated staff need to maintain a safe environment for the residents. LVN 2 stated Resident 1's care plan should have specified the number of staff needed when providing ADL care. LVN 2 stated if nurses failed to personalize a resident's care plan, it would place the residents at risk for falls and injuries. During an interview on 7/9/2025 at 5:06 p.m. with the Director of Nursing (DON), the DON stated Resident 1 fell from the bed on 7/4/2025 while receiving care from CNA 1 and sustained an abrasion and contusion in her right eye. The DON stated Resident 1 was totally dependent on staff for care. The DON stated Resident 1's interventions needed when being turned and repositioned should have been specified in the care plan based on Resident 1's diagnosis. The DON stated Resident 1's safety is first. During an interview on 7/16/2025 at 12:20 p.m. with CNA 2, CNA 2 stated Resident 1 was totally dependent with care. CNA 2 stated on 7/4/2025, in the morning (time not specified), she was changing the resident by herself, and Resident 1 was turned to her left side, while being held by her (CNA2) right hand. CNA 2 stated Resident 1's weight shifted (moved) and fell from the bed. CNA 2 stated Resident 1's body was not in the middle of the bed and believed why Resident 2 CNA 2 stated she should have asked for assistance and repositioned her in the middle of bed before turning her to prevent her fall. During a review of the facility's Policy and Procedure (P&P) titled, ADL care provided for Dependent Residents, dated 3/2023, the P&P indicated the facility should conduct periodic assessment of each resident to identify the necessary services with activities of daily living. During a review of the facility's P&P titled, Fall Management Program, dated 1/2025, the P&P indicated the facility should monitor the effectiveness of the interventions and modify the care plan as necessary. During a review of the facility's P&P titled, Patient Safety Plan, dated 1/2025, the P&P indicated ongoing training should be conducted on patient safety practices, including fall prevention.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA 1) had the specific competencies, and skill sets necessary to care for one of four residents (Resident 1), by failing to report Resident 1's alleged fall incident. This deficient practice resulted in a delay in Resident 1's treatment/evaluation. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included nondisplaced fracture of the left tibial spine (a break that has not shifted or separated at the top of the tibia bone in the lower leg near the knee), traumatic subdural hemorrhage without loss of consciousness (a serious condition where blood pools between the brain and its outer protective layer (the dura) after a head injury, potentially causing pressure on the brain), and end stage renal disease ([ESRD], is the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). During a review of Resident 1's History and Physical (H&P), dated 9/3/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/2/2025, the MDS indicated Resident 1 was assessed to have clear comprehension (the action or capability of understanding something). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and maximal assistance for personal hygiene, upper and lower dressing. During an interview on 3/26/2025 at 1:15 p.m. with Resident 1, Resident 1 stated on 3/15/2025, while Certified Nursing Assistant (CNA) 1 was cleaning her, she rolled off the bed and fell to the ground. Resident 1 stated, I think it was an accident. Resident 1 stated CNA 1 picked her up and put her back in the bed. Resident 1 stated she reported to CNA 1 that her head hurt, then CNA 1 left the room. During a review of the facility's CNA job description, dated 10/2021, the job description indicated CNAs were to promptly report any resident changes or concerns, such as injuries or falls, to appropriate licensed nursing personnel. The job description indicated CNAs were to safely lift, reposition, and transport residents, using proper body mechanics or lifting devices, as necessary. During an interview on 3/26/2025 at 2:33 p.m. with CNA 1, CNA 1 stated on 3/15/2025, while cleaning Resident 1 and changing the resident's bed, the resident rolled over and slid off the bed. CNA 1 stated he stopped Resident 1 from falling to the ground. CNA 1 stated after the incident Resident 1 complained of a headache. CNA 1 stated, I went and told the charge nurse that the resident had a headache. I did not tell her about the incident because in my perspective the resident didn't fall, I caught him while he was hanging off the bed and did not touch the ground. CNA 1 stated he should have told the charge nurse about the incident because the resident was hurt. During an interview on 3/26/2025 at 3:48 p.m. with the Director of Staff Development (DSD), the DSD stated CNA 1 was from a registry agency. The DSD stated this was the first time CNA 1 worked at the facility. The DSD stated CNA 1 was placed on a do not return list because of not reporting Resident 1's fall to the charge nurse. The DSD stated not reporting a fall would bring harm to the resident and delay timely medical attention. During an interview on 3/27/2025 at 12:09 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated a CNA should always report a fall or near fall to the charge nurse. LVN 1 stated it was not within the CNAs scope of practice to assess the resident to see if they are injured. LVN 1 stated if a fall or accident was not reported immediately the resident would not get the care they would need in a timely manner. During an interview on 3/27/2025 at 12:35 p.m. with LVN 2, LVN 2 stated on 3/15/2025, when she went to pass the pain medication, she noticed a quarter size discolored, slightly raised bump, on the left side above Resident 1's eye. LVN 2 stated Resident 1 reported that he fell off the bed when CNA 1 was cleaning him. LVN 2 stated she was was never told by CNA 1 the resident fell or nearly fell , only that Resident 1 had a headache. During an interview on 3/27/2025 at 1:05 p.m. with CNA 2, CNA 2 stated if you witness a fall or a near fall you must report it to the charge nurse immediately, so they can assess the resident. CNA 2 stated this was for resident's safety. During an interview on 3/27/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated all staff must report a fall or near fall to the charge nurse or supervisor. The DON stated if it is not reported this would harm the resident, which was a safety issue. During a review of the facility's policy and procedure (P&P), titled Fall Management Program , revised 3/2025, the P&P indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accidental hazards as possible. The P&P indicated a fall is unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. The P&P indicated the facility educates employees at the time of hire, annually and as indicated on the facility policy fall management, included intervention to reduce injury and fall related accidents. During a review of the facility's P&P, titled Patient Safety Plan , revised 3/2024, the P&P indicated any employee having knowledge or observation of accidents, including injuries, infections or other of an unknown source, must report to the department supervisor and the charge nurse, and complete an Incident Report Form must be completed on the shift that the incident occurred.

During an interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 1) had a care plan for non-compliance (when a patient don't follow the rules, regulations, or advice that ' s been set in place) when out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not developing a care plan (a document that summarizes a person ' s health needs, current treatments, and desired outcomes) for Resident 1 ' s non-compliance had the potential to place the resident at risk for injury and not be continuously monitored for diabetes mellitus([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P), dated 1/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 1/22/2025 the MDS indicated, Resident 1 ' s cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 1 required supervision for sitting to stand, chair to bed transfers, and walking. The MDS indicated Resident 1 had a history of a fall prior to admission. The MDS indicated Resident 1 required insulin injections (a hormone that lowers the level of sugar in the blood) seven days a week. During a review of Resident 1's Fall Risk Evaluation, dated 1/19/2025, the Fall Risk Evaluation indicated Resident 1 had one to 2 falls in the past 3 months and was a high fall risk (a person has a significantly increased likelihood of experiencing a fall due to various factors such as poor balance, reduced muscle strength making the more susceptible to losing their footing and falling down). During a review of Resident 1's Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. During a review of Resident 1's Progress Notes, dated 1/22/2025. The Progress notes indicated Resident 1 left the facility out on pass on 1/22/2025 at 12:19 p.m. and returned to the facility on [DATE] at 8:55 a.m. During a concurrent interview and record review on 1/29/2025 at 1:45 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/202/2025 and 1/22/205 were reviewed. The Progress Notes indicated Resident 1 had left the faciity on [DATE] at 1:57 p.m. and did not return to the facility until 1:48 a.m. on 1/21/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/22/2025 at 12:19 p.m. and returned to the facility on [DATE] at 8:55 a.m. The DON stated when a resident goes OOP the facility requests the resident goes out for four to six hours and return to the facility. The DON stated Resident 1 was OOP for 12 hours on dates 1/20/2025 to 1/21/2025 and was OOP for 21 hours on dates 1/22/2025 to 1/23/2025. The DON stated a care plan should have been done to address his non-compliance for not returning within the recommended time. The DON stated the Resident 1 was a high fall risk and had diabetes. During a review of the facility ' s policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, dated 3/2023, the P&P indicated the facility develops a person-centered comprehensive care plans that address the resident ' s medical, physical, mental and psychosocial needs. The P&P indicated care plans shall include the discipline providing care or services, measurable objectives and timeframes in order to evaluate the resident ' s progress toward his/her goal(s). The P&P indicated when a resident ' s choice to decline care or treatment poses a risk to the resident ' s health or safety, the comprehensive care plan must 1. Identify the care or service being decline 2. The risk the declination poses to the resident 3. Attempts to find alternative means to address the identified risk.

Based on interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident1) had a plan in place after being identified as a high risk for falls (a patient has a significantly increased likelihood of experiencing a fall due to various factors like poor balance, muscle weakness, which could potentially cause physical harm if they do fall) for continuous supervision and monitoring while out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not having a plan in place for continuous supervision and monitoring had the potential risk for Resident 1 to fall while out on pass. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P), dated 1/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated assessment tool), dated 1/22/2025 the MDS indicated, Resident 1 ' s cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 1 required supervision for sitting to stand, chair to bed transfers, and walking. The MDS indicated Resident 1 had a history of a fall prior to admission. The MDS indicated Resident 1 required insulin injections (a hormone that lowers the level of sugar in the blood) seven days a week. During a review of Resident 1 ' s Fall Risk Evaluation, dated 1/16/2025, the Fall Risk Evaluation indicated Resident 1 had a history of falls in the past three months and was a high risk for falls. During a review of Resident 1 ' s Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. During a concurrent interview and record review on 1/29/2025 at 12:24 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/20/2025 was reviewed. The Progress notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. The DON stated Resident 1 was OOP for 12 hours on 1/20/2025 and returned 1/21/2025 early morning the next day. The DON stated the recommendation for a resident to be OOP was four to six hours. The DON stated Resident 1 was a high risk for falls and had fallen on 1/18/2025 and prior to admission. The DON stated the staff should have documented the risk factors of safety, supervision, and monitored the resident once the resident didn ' t return within the recommended time. The DON stated once the resident left and was gone for long periods of time the staff is no longer able to monitor the resident which would put him at risk for injury. During a review of facility ' s policy and procedure (P&P) titled, Out on Pass Therapeutic Leave, dated 7/2024, the Out on Pass Therapeutic Leave indicated to provide staff with guidelines to ensure residents ' safety when residents choose to leave the facility for social or personal reasons. The P&P indicated the facility ensures that residents are aware of the risks associated with leaving the facility and are provided with necessary information and support to make informed decisions prior to leaving. During a review of facility ' s policy and procedure (P&P) titled, Fall Management Program, dated 3/2023, the P&P indicated to provide each resident with adequate supervision to minimize the risks associated with falls. The P&P indicated identify environmental hazards and individual resident risk of an accident, including the need for supervision. The P&P indicated monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice.

Based on interview and record review the facility failed to: 1. Ensure one out of three sampled residents (Resident 1) glucose (the process of measuring the amount of sugar in a patient ' s blood) was checked after returning to the facility after being out on pass. This deficient practice of not checking the blood sugar after returning to the facility had the potential for Resident 1 exacerbate (a worsening of a medical condition that increases symptoms and may require hospitalization ) his diabetes (a chronic condition characterized by high blood sugar levels). Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P), dated 1/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 1/22/2025 the MDS indicated, Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 1 required supervision for sitting to stand, chair to bed transfers, and walking. The MDS indicated Resident 1 had a history of a fall prior to admission. The MDS indicated Resident 1 required insulin injections (a hormone that lowers the level of sugar in the blood) seven days a week. During a review of Resident 1's Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning) 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. During a review of Resident 1's Weights and Vital Summary, dated 1/21/2025 the blood sugar was 333 milligram per deciliter ([mg/dl]- is a unit of measurement used in medicine to express the concentration of a substance in a fluid such as blood or urine) at 6:57 a.m. During a concurrent interview and record review on 1/29/2025 at 12:55 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left out on pass at 1:57 p.m. on 1/20/2025 The Progress Notes indicated Resident 1 had returned to the facility at 1:48 a.m. on 1/21/2025. In addition, Resident 1 ' s Weights and Vital Summary, dated 1/21/2025 the blood sugar was 333 at mm/dl at 6:57 a.m. was reviewed. The DON stated the Resident 1 has diabetes. The DON stated when Resident 1 returned to the facility an assessment (a process where a nurse gathers, sorts, and analyzes of patient ' s health information) was done. The DON stated the blood sugar should have been checked when Resident 1 returned at 1:48 a.m. on 1/21/2025 as part of the assessment. The DON stated the blood sugar was not checked for four hours after the resident had returned. The DON stated Resident 1 was hyperglycemic (a condition in which there is too much glucose (sugar) in the blood) or hypoglycemic (a condition in which there is not enough glucose in the blood) which would have placed the resident at risk for falls, alter level of consciousness (a change in a patient ' s normal state of alertness and awareness), other signs and symptoms of diabetes. During a review of the facility ' s policy and procedure (P&P) titled, Diabetes Clinical Protocol, dated 3/2017, the P&P indicated to provide staff with clinical practice guidelines to care for residents with diabetes. The P&P indicated based on the comprehensive assessment, including causes and complications, the physician will order appropriate interventions, which may include treatment of underlying conditions causing impaired glucose tolerance. The P&P indicated monitor as indicated if the individual has returned to the facility after a significant absence. During a review of the facility ' s policy and procedure (P&P) titled, Resident Assessment, dated 3/2023, the P&P indicated the facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident ' s functional capacity. The P&P indicated assessments minimally includes the following special treatments and procedures. The P&P indicated the triggers identifying residents who have or are at risk for developing specific functional problems and require further assessment.

Based on interview and record review, the facility failed to: 1.Ensure four of six sampled residents' (Residents 15, 30, 37, and 38) Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) was completed monthly. This deficient practice placed Residents 15, 30, 37, and 38 at risk of not having medication irregularities identified. Findings: A. During a review of Resident 15's Admission Record, the Admission Record indicated the facility admitted the resident on 12/20/2011 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and end stage renal disease (irreversible kidney failure). During a review of Resident 15's History and Physical (H&P), dated 12/19/2024, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set ([MDS] a resident assessment tool) dated 12/2/2024, the MDS indicated Resident 15's cognition (ability to think and understand) was intact. Resident 15 was dependent on staff with dressing, bathing, and toileting. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). B. During a review of Resident 37's Admission Record, the Admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 37 has moderate cognitive (ability to think and understand) impairment. Resident 37 was dependent on staff with dressing, bathing, and toileting. Resident 37 needed maximal assistance rolling left to right, changing from sitting to lying, and transferring from bed. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). C. During a review of Resident 38's Admission Record, the Admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 38's History and Physical (H&P), dated 12/27/2024, the H&P indicated Resident 38 does not have the capacity to understand and make decisions. During a review of Resident 38's Minimum Data Set ([MDS] a resident assessment tool) dated 1/8/2025, the MDS indicated Resident 38 was dependent on staff with dressing the lower body, bathing, and toileting. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, dated March 2023, the P&P indicated the facility's licensed pharmacist shall review at least monthly, each resident's drug regimen to prevent or minimize adverse consequences related to medication therapy. The P&P indicated the pharmacist must review monthly in order to identify irregularities, clinically significant risks; and/or potential adverse consequences which may result from or be associated with medications. 49604 D. During a review of Resident 30's Admission Record, the Admission Record indicated the facility admitted the resident on 8/16/2020 with diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs), heart disease (a general term that include many types of heart problems ), hypertension (high blood pressure), and muscle weakness (decreased strength in muscles). During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 1/11/2025, indicated Resident 30's cognition and decision-making skills was severely impaired. The MDS indicated the resident required extensive assistance from staff for bed mobility, transfer, dressing, bathing, eating, toilet use, and personal hygiene. During a review of the resident's medical record, indicated there was no documented evidence that the MRR was done for the month of October, November and December 2024. During an interview, on 1/23/2025, at 2:28 p.m., with the Director of Nursing (DON), the DON was unable to provide documented evidence of the MRR report for the months of October 2024, November 2024 and December 2024. The DON stated the practice of the facility was to have MRR done monthly. The DON stated when there was a recommendation from the consultant pharmacist, the DON gives the pharmacist's recommendation to the Registered Nurse (RN) supervisor who faxes the recommendation to the physician, signs and files the recommendation in the resident's chart as evidence this was communicated to the physician. A review of the facility`s policy and procedure, revised on March 2024, titled Drug Regimen Review indicated the facility must ensure that a pharmacist reviews each resident's medical chart every month and perform a drug regimen review, including the following expanded requirements:

Based on interview and record review, the facility failed to develop an individualized person-centered care plan (a document that summarizes a person's health condition, care needs, and current treatments) with measurable objectives, timeframe, and interventions to meet the residents needs for two of two sampled residents (Residents 58 and 167) by failing to: 1. Ensure a care plan for out on pass was develop for Resident 58. 2. Ensure a care plan with interventions for Peripherally Inserted Central Catheter ([PICC] - a thin flexible tube that is inserted into a vein in the upper arm above the right side of the heart, used to give intravenous fluids, blood transfusions, and medications) line was develop for Resident 167. These deficient practices had the potential to negatively affect the delivery of care and services for Residents 58 and 167. Findings: a. During a review of Resident 58's Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated Resident 58 was admitted to the facility on [DATE]. The Admission Record indicated, Resident 58's diagnoses included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated Resident 58 required moderate assistance (helper does less than the effort) from staff with toileting, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of Resident 58's care plan, there was no care plan in place for Resident 58 to go out on pass. During an interview, on 01/24/2025 at 2:17 p.m., with the Director of Nursing (DON), the DON stated care plans were to be initiated upon admission or during a change of condition for a resident. The DON stated Resident 58 did not have a care plan regarding going out on pass. The DON stated the risk of not having a care plan in place could result in inadequate and incompetent care. 47923 b. During a review of Resident 167's Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated Resident 167 was admitted to the facility on [DATE]. The Admission Record indicated, Resident 167's diagnoses included atrial fibrillation (irregular heartbeat), hypertension ([HTN] - high blood pressure), and polyneuropathy (a damage or disease affecting peripheral nerves), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). During a review of Resident 167's Minimum Data Set ([MDS] - a resident assessment tool) dated 1/14/2025, the MDS indicated, Resident 167's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 167 required moderate assistance (helper does less than the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 167 had an Intravenous ([IV] - into or within the vein) access. During a review of Resident 167's Order Summary Report (a document containing active orders), dated 1/23/2025, indicated Resident 167's physician prescribed Ceftriaxone (medication to treat infection) 2 grams ([gm] - metric unit of measurement, used for medication dosage and/or amount) IV daily for right foot osteomyelitis. During a concurrent interview and record review on 1/22/2025 at 3:30 p.m., with Registered Nurse 2 (RN 2), Resident 167's clinical records were reviewed. RN 2 stated Resident 167 had a PICC line on right upper arm and receiving IV medication once a day. RN 2 stated the facility did not formulate an individualized care plan to address Resident 167's PICC line. RN 2 stated Resident 167's PICC line was at risk for complications since facility staff did not develop a care plan that includes care maintenance and interventions. RN 2 stated the purpose of the care plan was to keep track of the progress of the resident and serve as a communication tool among the interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) for resident's continuity of care. During a review of the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, dated 10/2020, the P&P indicated, The facility develops a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interview and record review, the facility failed to: 1. Ensure resident was involved in decision making and notified in change of physician for one of one sampled resident (Resident 52). This failure had violated Resident 52's resident rights to choose her own physician. Findings: During a review of Resident 52's Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated 52 was admitted to the facility on [DATE]. The Admission Record indicated, Resident 52's diagnoses included left hip osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension ([HTN] - high blood pressure), and hyperlipidemia (a condition where there are high levels of fats, or lipids, in the blood). During a review of Resident 52's History and Physical (H&P), dated 12/21/2024, the H&P indicated, Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/27/2024, the MDS indicated, Resident 52 had the ability to express ideas and wants and ability to understood others. The MDS indicated Resident 52's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 52 required substantial assistance (helper does more than the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 52's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 52 had a change of physician order on 1/21/2025 due to insurance coverage. During an interview on 1/22/2025 at 1:34 p.m., with Resident 55, Resident 52 stated she was not aware regarding her change of physician. Resident 52 stated she had the right to be informed and choose her own physician since she would be responsible for the care and treatment of her medical condition while at the facility. During a concurrent interview and record review on 1/22/2025 at 2:44 p.m., with the Director of Nursing (DON), Resident 52's clinical records were reviewed. The DON stated there was no documentation by facility staff indicating Resident 52 was notified regarding her change of physician. The DON stated the facility did not validate with the resident regarding her new physician. The DON stated the change of physician was made due to change of Resident 52's level of care from skilled care (a type of medical care that requires the expertise of a licensed professional , such as a nurse or therapist) to custodial care (non-medical assistance with daily activities for people who need help with personal care). The DON stated no matter what the reason would be for a change of physician, Resident 52 should had given an opportunity to choose her own physician, and the facility violated Resident 52's rights to be informed of her new physician. During a review of the facility's policy and procedure (P&P), titled Choice of Attending Physician, dated 3/2023, the P&P indicated, The facility supports each resident's right to choose his or her attending physician. The P&P indicated the facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. During a review of the facility's P&P, titled Resident Rights, dated 3/2023, the P&P indicated, Residents in long term care facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on interview and record review, the facility failed to: 1. Implement the facility's policy and procedures on reporting an unusual occurrence when Resident 58 left the facility and did not return. This deficient practice had the potential to result in serious harm, injuries and death. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of the facility's out on pass log, Resident 58 signed out on 11/19/2024 at 9:54 a.m. and did not return to the facility. During an interview, on 01/24/2025 at 2:17 p.m., with the Director of Nursing (DON), the DON stated Resident 58 left the faciity on [DATE] and did not return. The DON stated the facility did not inform law enforcement nor CDPH within 24 hours of Resident 58 not returning to the facility. The DON stated the risk of not following the facility's policy and procedures could result in serious harm or death for a resident. A review of the facility's policy and procedures, titled Reporting Unusual Occurrences, revised 03/2023, indicated, Our facility will report the following events to appropriate agencies: Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. and Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was protected from abuse as indicated on the facility's policy and procedure, Abuse Prohibition and Prevention Program. Certified Nurse Assistant (CNA) 1 showered Resident 1 with very hot water and grabbed Resident 1's right hand and bent the resident's fingers backwards. This deficient practice caused Resident 1 to sustain an acute fracture (broken bone) to the right 5th (pinky finger). Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including repeated falls, muscle weakness and multiple fractures of the ribs. During a review of Resident 1's History and Physical (H/P), dated 4/7/2022, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/26/22, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required a one-person assist for bed mobility, locomotion (moving from one place to another), dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 required a two-person assist for transfers. During a review of Resident 1's Emergency Department (ED) Physician's notes dated 10/24/2022, at 10:43 p.m., the notes indicated on Resident 1 was admitted to the ED on 10/24/2022 complaining of pain to the right hand, elbow and bilateral shoulders which began 2 days ago after CNA 1 pulled Resident 1's arm during a shower. The notes indicated Resident 1's X-ray (process of taking pictures of body tissues and structures inside the body) revealed Resident 1 had a fracture to the right pinky finger. The notes indicated Resident 1 complained of pain to the right hand, right elbow, and right shoulder. The notes indicated the affected finger was splinted and Resident 1 was discharged back to the facility. During a review of Resident 1's radiology ([X-ray] process of taking pictures of body tissues and structures inside the body) report dated 10/24/2023, the X-ray report indicated acute right fifth proximal phalanx (bone in the finger) fracture. During a concurrent observation and interview on 10/27/2022 at 11:40 a.m., in Resident 1's room, Resident 1 was noted with a purple and green discoloration at the base of the first knuckle of pinky (small) and ring fingers. Resident 1 was noted with discoloration on the palm of the right hand. Resident 1 stated on 10/22/2022, CNA 1 took her to the shower and did not talk to her at all. Resident 1 stated CNA 1 opened the shower head, sprayed very hot water on her (Resident 1) and CNA 1 started to wash the resident. Resident 1 stated she told CNA 1 the water was too hot, and that she (CNA 1) was burning her. Resident 1 stated CNA 1 kept pouring the very hot water from her feet moving towards her upper body and as the water was reaching Resident 1's face, Resident 1 raised her hands to protect her face from the hot water. Resident 1 stated CNA 1 threw the shower head on the floor and CNA 1 grabbed Resident 1's fingers with her hand placing her weight onto the resident's right hand bending her fingers backward. Resident 1 stated she told CNA 1 that she was breaking her hand, but CNA 1 kept pushing on her fingers with all her weight. Resident 1 stated she kept yelling at CNA 1 to stop but CNA 1 would not stop, until Resident 1 tried to reach out with her left hand and attempted to pull CNA 1's hair then CNA 1 stopped. Resident 1 stated her right hand hurt so bad and she reported the entire incident to CNA 2 and Licensed Vocational Nurse (LVN) 1 during night shift. During an interview with Licensed Vocational Nurse (LVN) 1 on 10/27/2023 at 12:45 p.m. LVN 1 stated she worked on the 3:00 p.m. to 11:00 p.m. shift and on 10/22/2022 at 10:45 p.m., Resident 1 reported that she had swelling, pain and discoloration to her right hand. LVN 1 stated she observed Resident 1's right lower hand swollen, bluish-purple in color and when she touched the area Resident 1 complained of pain. LVN 1 stated Resident 1 informed her CNA 1 hurt her right hand, in the shower. LVN 1 stated she did a change of condition and notified the resident's physician (MD). During an interview with Family Member (FM) 1 on 10/27/2022 at 2:00 p.m., FM 1 stated she received a call from Resident 1 on 10/22/2022 at midnight and Resident 1 reported that CNA 1 poured very hot water on her in the shower and when Resident 1 tried to protect herself, CNA 1 grabbed the resident's hand and pushed Resident 1's fingers backward. FM 1 stated Resident 1 told her she was in a lot of pain and believed CNA 1 was mad at Resident 1 because the resident had previously complained about being left wet by CNA 1. FM 1 stated when she spoke with LVN 4, LVN 4 stated Resident 1 had hit herself. FM 1 saw Resident 1's bruised right fingers and told LVN 4 that it did not look like Resident 1 had hit herself. FM 1 stated she believed Resident 1's statement of being hurt by CNA 1 and requested an x-ray of the resident's fingers. During an interview with CNA 2 on 10/28/2022 at 2:50 p.m. CNA 2 stated 10/22/2022 at 10:30 p.m., Resident 1 reported that CNA 1 had hurt her in the shower. CNA 2 stated she observed Resident 1's right hand was purple. Resident 1 reported she was arguing with CNA 1 about the water being hot. CNA 2 stated that Resident 1 told her that CNA 1 threw the head of the shower on the floor then walked towards her and grabbed her right fingers. CNA 1 pushed Resident 1's fingers back and her (Resident 1) fingers hurt so much. The following day she (CNA 1) was asked to translate for Resident 1. Threw translation, Resident 1 reported that she had asked if CNA 1 was stupid because she was burning her with hot water and CNA 1 only stopped bending Resident 1's fingers when Resident 1 reached for CNA's hair and pulled it. CNA 2 stated Resident 1 was very sensitive and did not like hot water. During a review of the facility's Final Summary report dated 10/28/2022, the report indicated Resident 1 was alert and oriented to the facility staff and was able to make her needs known. The report indicated the facility supported evidence through the resident's reported statement that the quality of care, lack of professionalism and discourtesy occurred at the time of Resident 1's shower by CNA 1. The report indicated Resident 1 was mishandled during care and to protect Resident 1 and other residents, CNA 1 was terminated effective 10/31/2022. During a review of the facility's P/P titled Abuse Prohibition and Prevention Program, dated November 2017, the P/P indicated the facility had policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property. The P/P indicated the facility strives to provide an environment which prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident property . will provide protection of residents from harm during an investigation.

Based on observation, interview, and record review, the facility failed to provide the following care and services to two of 17 sampled residents (Residents 33 and10), who used the sit to stand machine: 1. Assess residents' ability to safely use the sit to stand machine. 2. Thoroughly investigate fall incidents related to sit to stand machine (Resident 33) to reduce the risk of further occurrences. 3. Provide ongoing training of all nursing staff on safe use and safe transfer of residents using the sit to stand machine in accordance with manufacturer's guideline. 4. Ensure licensed nursing staff provided supervision to ensure safety of the residents when using the sit to stand machine. 5. Develop a policy and procedures on the use of the sit to stand machine. 6. Ensure manufacturer's guideline for the sit to stand machine was readily available as a referral source to the staff. These deficient practices had the potential to cause repeated falls and could result in serious injury to the residents. An Immediate Jeopardy (IJ) was called on 1/7/2018 at 12:07 PM after discussing the details with the facility Administrator. The IJ was lifted on 1/7/18 at 4:20 p.m. after the facility provided an acceptable written plan of correction. Findings: a. A review of Resident 33's undated record titled, Face Sheet, indicated Resident 33 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 33's record titled, Rehabilitation Screen, form dated 8/9/16 indicated Resident 33 was observed to have decline in current RNA program (restorative nursing programs, provide specific treatments to restore and maintain the strength, coordination and skills to ambulate and perform functional activities of daily living). The Rehabilitation Screen form also planned for Physical Therapy (PT) and Occupational Therapy (OT) to pick up (take over) the resident for services. A review of Resident 33's record titled, PT Therapist Progress and Updated Plan of Care, dated 9/7/2016 indicated Resident 33 displayed decreased strength and range of motion (ROM) which limited safe transfer and gait. A review of Resident 33's record titled, Occupational Therapy (OT), dated 9/8/16 to 9/29/16, indicated Resident 33 continued to require assistance with activities of daily living (ADLs) due to loss of movement on the left upper extremity (LUE), and impaired dynamic (act of moving) skills in sitting and standing tolerance. The Occupational Therapy indicated Resident 33's functional deficits and underlying impairments included loss of movement on the LUE with contracture (shortening and hardening of muscles and tendons) on the wrist and fingers. During an interview on 1/04/18 at 06:58 PM, Resident 33 stated she fell a month ago from the sit to stand lift machine when two nurses were transferring her from her wheelchair to the bed. Resident 33 stated she fell right through the machine and did not know how it happened. Resident 33 stated she fell on her side. Resident 33 stated someone from rehabilitation came and checked to see if she was alright. On a concurrent observation, there was no manufacturer's guidelines attached to the sit to stand machine as an easy access and referral source during the use of the machine for the staff. During an interview on 1/06/18 at 11:57 AM, and concurrent review of Resident 33's records, Physical Therapist (PT 2) was not able to locate the PT assessment of Resident 33's ability to safely use the sit to stand machine before and after the fall in Resident 33's electronic medical records (EMR). During an interview on 1/06/18 at 11:57 AM, the Director of Staff Development (DSD) stated the company changed hands and had asked the Administrator to search for the records. The DSD stated in order to use the sit to stand machine, the resident must be able to firmly hold the handles of the machine with both hands, and be able to stand and bear weight on both legs. The DSD stated two nurses must always be with the resident when the sit to stand machine was in use. The DSD stated all nursing staff were in-serviced on how to safely transfer residents using the sit to stand machine upon hire. During the same interview, both Quality Assurance Registered Nurse (QARN) and DSD were unable to state if PT had assessed Resident 33 prior to using the sit to stand machine. The DSD stated the two Certified Nurse Assistants (CNAs) who were with Resident 33 when the resident fell from the sit to stand machine were not able to recall if Resident 33 was safely secured to the machine prior to the resident's transfer. During the same interview, in the presence of QARN, Resident 33 stated she was unable to use her left arm, hand, and fingers. Resident 33's left hand and fingers were observed to be contracted; left ankle was rotated outward, and unable to move the left leg. The QARN stated the fall incident happened in (MONTH) (YEAR). During an interview on 1/06/18 at 12:12 PM, PT 2 stated the residents who had fractures (broken bone) on lower extremities, were on weight bearing precautions (non- weight bearing), or had decreased or poor strength on the upper and lower extremities must not be placed on the sit to stand machine. PT 2 stated the residents must first be assessed for safety and ability to stand and maintain standing before the sit and stand machine could be used to transfer. PT 2 stated she never evaluated Resident 33. PT 2 stated to ensure the resident's safety, PT should always document on the resident's medical records when a resident could safely use the sit to stand machine. PT 2 stated she was not aware Resident 33 fell from the sit to stand machine. During an interview on 1/06/18 at 03:12 PM, PT 1 stated the only assessment he made on Resident 33 was when the resident complained of pain or condition change after the fall. PT 1 stated he had checked with medical records and was not able to locate Resident 33's and Resident 10's initial assessment for safe use of the sit to stand machine. PT 1 stated nurses were responsible when they use the sit to stand machine on the residents. During an interview on 1/06/18 at 05:06 PM, the DSD stated both PT 1 and DSD were not able to find any in-services provided to the staff on the safe use of sit to stand machine. During an interview 1/07/18 08:25 AM, CNA 3 stated the first in-service on the sit to stand machine was provided a couple of months ago after Resident 33 fell . CNA 3 stated the nurses were instructed to strap the padding around the back and abdomen and one around both legs on the sit to stand machine before transferring a resident. CNA 3 stated, We strap the residents on the machine so they don't fall and two nurses must be present when using the machine. CNA 3 stated that residents who were able to use the machine were supposed to help stand up, support body weight, and be able to hold the machine rails to help with the transfer. During an interview on 1/07/18 at 08:39 AM, CNA 1 stated an in-service was provided on sit to stand machine when the facility first bought the machine in 2013 and never received another in-service after that. CNA 1 stated two nurses must be with a resident before the sit to stand machine could be used to transfer a resident. CNA 1 stated it was important to strap the resident's abdomen. CNA 1 stated the sit to stand machine only had one strap for the abdomen. CNA 1 stated she only used the abdominal strap when transferring a resident on the machine. CNA 1 stated the resident must be able to hold and get a good grip onto the machine and put weight on their feet for safe transfer. CNA 1 stated the abdominal pads must be safely secured on the sit to stand machine hooks. A review of Resident 33's record titled, Fall Care Plan, dated 8/24/17, indicated Resident 33 was at high risk for fall due to generalized weakness. The fall care plan indicated to perform regular checks, remove clutter from patient environment, place call light within reach, and assist during transfers as needed. The document did not indicate how to safely transfer the resident. A review of Resident 33's record titled, Progress Notes, dated 10/22/17, at 9:45 PM, indicated licensed nurse was summoned to Resident 33's room where the resident was found on the floor lying on the right side. The Progress Notes indicated head to toe assessment completed and the resident had no injuries. A review of Resident 33's record titled, Short Term Care Plan, dated 10/22/17, indicated to check function of sit and stand machine. The care plan indicated to assess Resident 33 for function level before transfer and two person to assist. A review of Resident 33's record titled, In-Service Meeting Minutes, dated 10/23/17, indicated Sit to Stand Machine needs two (2) CNAs at all times. The in-service meeting minutes indicated CNA 2 had attended the in-service. During an observation on 1/07/18, at 09:16 AM, CNA 4 was observed standing outside Resident 33's room and was holding the door closed. CNA 4 stated she was waiting for the sit to stand machine and stated CNA 2 had probably completed transferring Resident 33. CNA 2 was observed alone in the room and Resident 33 was observed seated on a wheelchair. The sit to stand machine was observed next to Resident 33. During an interview on 1/07/18 at 09:30 AM, CNA 2 stated she had transferred Resident 33 by herself using the sit to stand machine. CNA 2 stated Resident 33 was in a hurry to go to church and did not have time for CNA 2 to find for help transfer the resident. CNA 2 stated she knew two nurses were supposed to be present during resident transfer using the sit and stand machine. During an interview on 1/07/18 at 10:50 AM, when asked for the fall incident investigation, the Administrator provided Resident 33's and CNA involved interview statements, an in-service dated 1/15/13, and record titled, EZ Sit-To-Stand Demonstration of Proper Use of This Machine. The Administrator stated, This is all l have. The in-service was provided by a consultant from the Sit-To-Stand Machine Company. There was no indication that licensed nurses attended the in-service meeting. b. On 1/07/18, at 10:09 AM, CNA 4 and Restorative Nurse Assistant (RNA 1) were observed transferring Resident 10 from the bed to the wheelchair using the sit to stand machine. Resident 10's left hand and fingers were contracted and left ankle rotated outward. CNA 4 and RNA 1 placed the back padding on Resident 10's both arms and upper back. The leg straps were observed at the bottom of the sit to stand machine. Resident 10's legs were not strapped in. A review of Resident 10's record titled, Face Sheet, undated, indicated Resident 10 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident 10 was cognitively intact, needed extensive assistance with bed mobility, totally dependent on staff for transfers, and was not able to walk. The MDS indicated Resident 10 had impairment on one side on both upper and lower extremities, and was not steady on surface to surface transfer. During an interview on 1/7/18 at 10:20 AM, both RNA 1 and CNA 4 stated during a resident transfer while using a sit to stand machine, they made sure the bed and machine were in locked position, safety belt applied, placed pillow between the knee and leg rest, and made sure both feet were firmly secured on the sit to stand machine. Both CNA 4 an RNA 1 stated Resident 10's left foot was twisted outward when the resident stood on the machine. CNA 4 and RNA 1 stated it was important to make sure the resident could grab the machine handles and the sling was properly secured on two hooks on either side of the machine. On 1/7/18, at 10:30 AM, during an observation of the machine, CNA 4 and RNA 1 were not able to identify the leg straps until it was pointed out to them. CNA 4 then stated, Oh now l see the straps for the legs. CNA 4 stated she had worked at the facility for three months but had never been trained on how to use the sit to stand machine. RNA 1 stated she had worked at the facility for one year and had never been trained on how to use the sit to stand machine. During an interview on 1/07/18, 11 AM, the QARN, Licensed Vocational Nurse (LVN)1, LVN 2, and LVN 3, all stated only CNAs and RNAs assisted residents with transfer using the sit to stand machine. The QARN stated licensed nurses never supervised or assisted non- licensed nursing staff with resident transfer using the sit to stand machine. During an interview on 1/07/18, at 11:51 AM, RNA 1 stated she did not know what to look for on the sit to stand machine because she never been in-serviced on it. During an interview on 1/07/18, at 12:21 PM, the Administrator stated the facility did not have a policy on the use of the sit to stand machine. The Administrator stated he would develop a sit to stand machine policy and procedures that clearly indicate how to safely transfer residents using the sit to stand machine. A review of the manufacturer's guide titled, EZ Way Smart Stand: Your Total Patient Lift Solution, revised 6/17/14, indicated for safe operation of the EZ Way Smart Stand, operators should watch the training video, read through the manual, complete the competency checklist, and practice on fell ow staff members before use with patients. The document in big and blotted warning sign, indicated for safe operation of the EZ Way Smart Stand, the stand must be used by trained personnel in accordance with operators manual, video, and training checklist to avoid injury to patient. A review of the facility's policy titled, Fall Accident Mitigation and Intervention, revised 10/2017 indicated the facility nursing staff and or the Interdisciplinary Team (IDT) would update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or other event. A review of the facility's document titled, Licensed Vocational Nurse Position Description, dated 12/20/2004, indicated to monitor assigned personnel to ensure they follow established safety regulations in the use of equipment and supplies. The document indicated to participate in the development and implementation of procedures for the safe operation of all supplies and equipment. To ensure all personnel operate nursing service supplies and equipment in a safe manner. A review of the facility's document titled, Registered Nurse (RN) Position Description, dated 12/20/2004, indicated the RN would maintain a safe, comfortable, and therapeutic environment for residents and families in accordance with facility's standards.

Based on observation, interview, and record review, the facility's nursing staff failed to ensure two of 15 sampled residents (Resident 13, and Resident 14) were not videotaped via a cell phone, taunted, laughed while exposed on a videotaped by three certified nursing assistants (CNAs). The videotaped was sent to the administrator of the skilled nursing facility (SNF) by the administrative staff from a general acute care hospital (GACH), after they discovered one of the CNAs, who worked at the GACH, posted the videotaped on a social media site. This deficient practice resulted to violation of residents' dignity, as well as psychological harm, embarrassment, unwanted exposure on the internet and invasion of privacy. Findings: During an Entity Reported Incident (ERI) Investigation (CA 542 and CA 546), it was determined that Resident 13 and Resident 14 both were subjected to humiliating behavior, which was taped and posted on a social media site by at least two, possibly three CNAs who worked for and provided care to the residents on or about January 4, 2016. a. A review of Resident 13's Admission Records indicated she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 14 was discharged from the facility to an assisted living center on January 12, 2016. A Minimum Data Set (MDS, a standardized assessment and care screening tool), dated October 29, 2015, indicated Resident 13's cognitive skills for daily decision-making were moderately impaired. On January 15, 2016, at 11:15 a.m., a video footage, which was on the administrator's cell phone, was reviewed, showing Resident 13 in a hospital gown, bare legs exposed lying in bed on her back. In the background laughter, and voices were heard and CNA 2 was seen briefly on the video tape. CNA 1 continued to taunt the resident and at one point in the video tape squared up in a type of boxer stance with closed fist raised and lunging toward the resident as though he would hit her, while laughing. On January 15, 2016, at 12:02 p.m., during a telephone interview, CNA 1 stated he was assigned to Resident 13 and was trying to put her back to bed. He stated the resident was being combative, which was her usual behavior. CNA 1 stated the resident kicked him, and in a playful manner he touched the resident's leg just like he would play with a kid. He stated he did not know CNA 3 was videotaping what was happening and found out about the video tape the next day when the administrator showed it to them. CNA 1 stated the video tape looks worse than what actually happened and he knows it was inappropriate but it was not meant to be abusive. On January 15, 2016, at 3:19 p.m., during a telephone interview, CNA 2 stated he was passing Resident 14's room, he heard commotion and laughing and went inside and saw CNA 1 and CNA 3 playing around. He stated he was in there for less than a minute and did not witness any abusive behavior. He stated CNA 3 was behind a privacy curtain and he did not know she was videotaping. The video tape shows him in the room but does not show that he left. CNA 2 stated he did not report the incident because he did not witness anything. On January 27, 2016, at 10:53 a.m., during a telephone interview, CNA 3 stated CNA 1 was assigned to Resident 13 but she needed help putting Resident 14 in a chair so she went in Resident 13 rooms where CNA 1 was to ask him for assistance. CNA 3 stated she saw Resident 1 kicked CNA 1 in the groin, swing her arms and legs out at him, which surprised her because she was normally is pretty calm. She stated CNA 1 was blocking the resident's kicks and hits and was trying to get out of her way in a playful manner. CNA 3 stated she videotaped what was going on because the incident looked funny and they were playing around with her. She stated it was nothing abusive that happened, just an inappropriate behavior that escalated into something way more than it actually was. CNA 3 stated CNA 2 was in Resident 13's room when she got there but he left immediately, he was there less than one minute after he entered the room. She stated he was not involved in the playful activity that was going on but was seen on the video tape, which taped him accidentally. b. A review of Resident 14's Admission Records indicated he was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, a standardized assessment and care screening tool), dated January 1, 2016, indicated Resident 14 was unable to answer questions to determine her cognitive status, but was documented with behaviors not directed toward others. Resident 14 was discharged from the facility on January 12, 2016, and was unavailable for interview. On January 15, 2016, at 11:15 a.m., a review of the video footage showed Resident 14 was viewed lying in bed fully dressed. There was no physical contact made with the resident by the CNA 1 or CNA 2, however, CNA 1 could be seen posturing in a defensive manner at and over Resident 14, laughter and cursing could be heard by both male and female voices. On January 15, 2016, at 12:02 p.m., during a telephone interview, CNA 1 stated CNA 3 was assigned to Resident 14 and asked him to help her get him up in a chair, which was why she was in Resident 13's room with him, to ask for assistance. CNA 1 stated when he went to Resident 14's room to help transfer him to a chair the resident jumped at him, and the playfulness that went on with Resident 13 continued with Resident 14. CNA 1 stated there was no physical contact with Resident 14 just a laughing. On January 15, 2016, at 11:30 a.m., during an interview, the administrator stated the administrative staff from a GACH contacted him with an allegation of possible abuse at his facility, as witnessed by her, via video tape that was sent to her by someone. She sent him the video tape and he confirmed the incident was at his facility and persons involved were his employees. The Administrator stated on interview, CNA 1 stated it was just a silly gesture not abusive. CNA 2 stated he was not involved in any abusive activity; he just walked by the room, heard the commotion, went in the room and saw the resident being combative. He stated he did not know anyone was videotaping and he left the room. The administrator stated CNA 3 only wanted to know how he obtained the video. He determined the incident likely occurred on the 3 p.m., - 11 p.m., shift on January 4, 2016. On January 27, 2016, at 10:53 a.m., during a telephone interview, CNA 3 stated Resident 14 is a fall risk, he often call out for help but when she goes to see what he wants he does not want anything. Because he is a fall risk and he calls out all night she wanted to sit him in a chair because she had to take care of other residents and could not keep going to Resident 14's room every time the resident yelled out for help. CNA 1 came with her to Resident 14's room to help her transfer him to a chair and the resident jumped out at CNA 1. CNA 3 stated at that time it was kind of funny that all of the residents seemed to be combative that night. She videotaped Resident 14 because it was a continuation of the playing that had gone on in Resident 13's room. She stated she posted it to a social media site, which she now knows was inappropriate, and apparently someone copied and sent it to the administrator. On January 27, 2016, at 11:55 a.m., during a telephone interview, the administrative staff from the GACH (which reported the incident to the SNF) stated an employee at one of their sister facilities called to report they had witnessed abuse occurring at their GACH via a video tape on a social media site, which was posted by one of their employees, who they named as CNA 3. The administrative staff stated the employee did not want to be involved but wanted to do the right thing; a friend of that employee called her and eventually sent the videotape. After viewing the video tape she determined the incident did not occur at her facility (GACH), the name of a city appeared on the video and the rooms looked like one particular SNF in that city. She reviewed CNA 3's employee file and found she was employed at a SNF in the city posted on the video tape. She contacted the administrator, sent him the video tape and he confirmed it was his building and his employees. She stated the person who she spoke to regarding the video tape told her there was more videos of other incidents but that particular social media site stores footage for a short period of time before it was deleted.

Based on observation, interview, and record review, the facility staff failed to ensure two of 15 sampled residents (Resident 13, and Resident 14), were free from abuse. Residents 13 and 14 were videotaped, via a cell phone; taunted, laughed at and physically assaulted by three certified nursing assistants (CNAs). The videotaped was sent to the administrator of the skilled nursing facility (SNF) by the administrative staff of a general acute care hospital (GACH) after they discovered one of the CNAs, who worked at the GACH, posted the video tape on a social media site. This deficient practice potentially caused the resident's physical as well as psychological harm. Findings: During an Entity Reported Incident (ERI) Investigation (CA 542 and CA 546), it was determined that Resident 13 and Resident 14 both were subjected to abusive behavior by at least two, possibly three CNAs who worked for and provided care to the residents on or about January 4, 2016. a. A review of Resident 13's Admission Records indicated she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 14 was discharged from the facility to an assisted living center on January 12, 2016. A Minimum Data Set (MDS, a resident assessment and care screening tool), dated October 29, 2015, indicated Resident 13's cognitive skills for daily decision-making were moderately impaired. On January 15, 2016, at 11:15 a.m., a video footage, which was on the administrator's phone, was reviewed, showing Resident 13 in a hospital gown, bare legs exposed lying in bed on her back. She was kicking out at CNA 1; CNA 1 slapped the resident with an open hand on her leg. In the background laughter and voices were heard and CNA 2 was seen briefly on the tape. CNA 1 continued to taunt the resident and at one point in the video squared up in a type of boxer stance with closed fist raised and lunging toward the resident as though he would hit the resident, while laughing. On January 15, 2016, at 12:02 p.m., during a telephone interview, CNA 1 stated he was assigned to Resident 13 and was trying to put her back to bed. He stated she was being combative, which was her usual behavior. CNA 1 stated the resident kicked him and in a playful manner he touched her leg just like he would play with a kid. He stated he put his hands up in a self-defense stand, playfully, to let the resident know he was going to defend himself. He stated he did not know CNA 3 was videotaping what was happening and found out about the video tape the next day when the administrator showed the video tape to them. He stated the video tape looks worse than what actually happened and he knows it was inappropriate but it was not meant to be abusive. On January 15, 2016, at 3:19 p.m., during a telephone interview, CNA 2 stated he was passing Resident 14's room, he heard commotion and laughing and went inside and saw CNA 1 and CNA 3 playing around. He stated he was in there for less than a minute and did not witness any abusive behavior. He stated CNA 3 was behind a privacy curtain and he did not know she was videotaping. The video tape shows him in the room but does not show that he left. He did not report the incident because he did not witness anything. On January 27, 2016, at 10:53 a.m., during a telephone interview, CNA 3 stated CNA 1 was assigned to Resident 13 but she needed help putting Resident 14 in a chair so she went in Resident 13 rooms where CNA 1 was to ask him for assistance. She stated she saw the Resident 1 kicked CNA 1 in the groin, swing her arms and legs out at him, which surprised her because she was normally was pretty calm. She stated CNA 1 was blocking the resident's kicks and hits and was trying to get out of her way in a playful manner. She stated she videotaped what was going on because the incident looked funny and they were playing around with her. She stated it was nothing abusive that happened, just an inappropriate behavior that escalated into something way more than it actually was. She stated CNA 2 was in Resident 13's room when she got there but he left immediately, he was there less than one minute after she entered the room. She stated he was not involved in the playful activity that was going on but was seen on the videotaped, which taped him accidentally. b. A review of Resident 14's Admission Records indicated he was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, a resident assessment and care screening tool), dated January 1, 2016, indicated Resident 14 was unable to answer questions to determine his cognitive status but was documented with behaviors not directed toward others. Resident 14 was discharged from the facility on January 12, 2016, and was unavailable for interview. On January 15, 2016, at 11:15 a.m., a review of the video tape showed Resident 14 was viewed lying in bed fully dressed. There was no physical contact made with the resident by the CNA 1 or CNA 2, however, CNA 1 could be seen posturing in a defensive manner at and over Resident 14, laughter and cursing could be heard by both male and female voices. At the end of this video tape CNA 3 was seen full face on the video making a statement about elder abuse (unable to understand all of the verbiage). On January 15, 2016, at 12:02 p.m., during a telephone interview, CNA 1 stated CNA 3 was assigned to Resident 14 and asked him to help her get him up in a chair, which was why she was in Resident 13's room with him, to ask for assistance. He stated when he went to Resident 14's room to help transfer him to a chair the resident jumped at him. CNA 1 stated the playfulness that went on with Resident 13 continued with Resident 14, there was no physical contact with Resident 14 just laughing. On January 15, 2016, at 11:30 a.m., during an interview, the administrator stated the administrative staff of a GACH contacted him with an allegation of possible abuse at his facility, as witnessed by her, via video tape that was sent to her by someone. She sent him the video tape and he confirmed the incident was at his facility and persons involved were his employees. The administrator stated on interview, CNA 1 stated it was just a silly gesture not abusive. CNA 2 stated he was not involved in any abusive activity; he just walked by the room, heard the commotion, went in the room and saw the resident being combative. He stated he did not know anyone was videotaping and he left the room. The administrator stated CNA 3 only wanted to know how he obtained the video tape. He determined the incident likely occurred on the 3 p.m., - 11 p.m., shift on January 4, 2016. On January 27, 2016, at 10:53 a.m., during a telephone interview, CNA 3 stated Resident 14 is a fall risk, he often call out for help but when she goes to see what he wants he does not want anything. Because he is a fall risk and he calls out all night she wanted to sit him in a chair because she had to take care of other residents and could not keep going to his room every time he yelled out for help. CNA 1 came with her to Resident 14's room to help her transfer him to a chair and the resident jumped out at CNA 1. At the time it was kind of funny that all of the residents seemed to be combative that night. She videotaped Resident 14 because it was a continuation of the playing that had gone on in Resident 13's room. She stated she posted it to a social media site, which she now knows was inappropriate, and apparently someone copied and sent it to the administrator. She stated she there was no abuse going on, just inappropriate behavior, which she now regrets. On January 27, 2016, at 11:55 a.m., during a telephone interview, the administrative staff from the GACH (which reported the incident to the SNF) stated an employee at one of their sister facilities called to report they had witnessed abuse occurring at their GACH via a video tape on a social media site, which was posted by one of their employees, who they named as CNA 3. The administrative staff stated the employee did not want to be involved but wanted to do the right thing, a friend of that employee called her and eventually sent the video tape. After viewing the video tape she determined the incident did not occur at her facility (GACH), the name of a city appeared on the video tape and the rooms looked like one particular SNF in that city. She reviewed CNA 3's employee file and found she was employed at a SNF in the city posted on the video tape. She contacted the administrator, sent him the video tape and he confirmed it was his building and his employees. She stated the person who she spoke to regarding the video tape told her there was more videos of other incidents but that particular social media site stores footage for a short period of time before it was deleted.

Based on observation, interview, and record review, the facility failed to ensure a resident (1) who had a [DIAGNOSES REDACTED]. of wandering and risk of elopement (leaving the facility unattended); and failed to update the care plan to include the elopement risk after the incident on April 1, 2013, to prevent another potential accident from occurring. On April 1, 2013, at 3:05 p.m., Resident 1 was found outside the facility lying on the ground at the bottom of the ramp, and had sustained a right humeral fracture (a break in the upper arm bone just under the shoulder joint). She was hospitalized and returned to the facility on [DATE], with multiple bruising on her back and arms, a fractured right arm with right arm immobilizer. Findings: On April 8, 2013, the Department of Public Health received a complaint alleging Resident 1, who had dementia (decreased intellectual functioning such as loss of memory, language, judgment and reasoning), and was a wanderer, was found on the ground outside the facility with a right arm fracture. An unannounced complaint investigation was conducted on April 8, 2013. According to Resident 1's medical records, she was originally admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the Licensed Personnel Progress Notes dated November 7, 2010, indicated Resident 1 made several attempts to leave the facility, was highly agitated and tearful, had repetitive questions and was confused. An elopement risk assessment was not done at that time. There was a care plan for elopement risk completed November 7, 2010, re-evaluated February 2011, with a goal for the resident to remain in a secure environment for 90 days. The approach was to monitor her where-abouts, redirect her, and give medications. The care plan did not address how to redirect the resident or how frequent to monitor her. There was no further update to this care plan after 2011 that could be provided by the director of nursing (DON). The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 18, 2012, indicated the resident was severely cognitively impaired. According to the MDS she required extensive assistance from staff with one person assist for activities of daily living (ADLs), such as transferring, walking, dressing, personal hygiene and toilet use. The MDS also indicated she resident gets around the facility by wheelchair. A review of the Fall Risk Assessment forms from August 2010 through April 2013, indicated Resident 1 was a high risk for falls. The Social Services Quarterly assessment form dated February 26, 2013, had notations that the resident was confused and disoriented, had episodes of wandering, asking for help, and requiring reassurance "that she is o.k." A review of the Licensed Personnel Progress Notes dated April 1, 2013, at 3 p.m., indicated Resident 1 fell from the wheelchair with complaints of right arm pain. The note did not indicate the resident's pain level. The physician was made aware, and ordered to transfer the resident to the general acute care hospital (GACH) emergency room (ER) for an evaluation secondary to a fall. A review of the facility Incident Investigation Summary and Results dated April 2, 2013, regarding the April 1, 2013, incident, indicated that at about 3:05 p.m., the front office staff heard a loud bang and ran to the front of the building where Resident 1 was found lying on the ground at the bottom of the ramp. The resident was alert, confused and was complaining of pain in her right arm. The resident was helped back into her wheelchair and placed back in her bed. A review of the GACH ER Physician History and Physical (H&P) Record dated April 1, 2013, indicated Resident 1 was transferred from the nursing home after a fall. The H & P record indicated Resident 1 ' s right upper extremity had 1+ edema (swelling) all the way to the shoulder and was very tender to touch. Resident 1 was unable to move her right arm. The GACH X-ray Report of the right shoulder dated April 1, 2013, indicated a right humeral neck fracture. A review of the Licensed Personnel Progress Notes dated April 8, 2013, indicated Resident 1 was readmitted to the skilled nursing facility with multiple bruising on her back and arms, a fractured right arm with right arm immobilizer. The Elopement Risk assessment dated [DATE], which was completed the same day of the Department's investigation and five days after the resident had been readmitted from the GACH, indicated Resident 1 was alert, confused and was not capable of making decisions. The assessment indicated Resident 1 had "no history" of elopement attempts, even though she was found unattended and outside of the facility on April 1, 2013. A review of Resident 1's medical records indicated there was no current Elopement Risk Assessment done until April 8, 2013. On April 8, 2013, at 3:25 p.m., an interview was conducted with the social service designee (SSD). When asked to describe Resident 1' s mental status, the SSD stated that the resident was confused and wandered inside the facility all the time. She also stated Resident 1 would wander into the male resident room next to hers. A care plan was not initiated to address the resident's behavior of wandering. On April 16, 2013, at 3:00 p.m., an interview was conducted with a certified nursing assistant (CNA 1). CNA 1 was asked if Resident 1 wandered, and he stated, "Yes." CNA 1 also stated a couple of months ago Resident 1 was seen going outside in the back parking lot by herself. When asked if he reported the incident to anyone he stated, "No." In an interview on April 16, 2013, at 3:41 p.m., CNA 2 stated about a month ago prior to Resident 1 ' s fall incident, the housekeeper told her that Resident 1 was in the back parking lot, so she went and wheeled her back inside. During an interview with the housekeeper at 3:50 p.m., she confirmed that she had seen Resident 1 outside the back parking lot a month ago and asked her to come in, but she refused, therefore she went and told CNA 2. When asked if she told anyone else about this incident she stated, "No." On April 16, 2013, at 3:58 p.m., Resident 1 was observed in the dining room sitting in her wheel chair with an immobilizer to her right arm. She was unable to be interviewed due to her dementia. In an interview on July 30, 2013, at 11:00 a.m., the director of nursing (DON) stated she was the one who completed the Elopement Risk assessment for Resident 1 on April 8, 2013. She also stated that after the resident was found outside, staff should have completed an assessment to include a history of elopement. When asked if Resident 1 had a current care plan for her wandering behavior, the DON was unable to find one in the resident's medical record. There was a care plan titled " High Risk for Fall " , dated April 8, 2013 (after the fall incident), the goal was to minimize risk of injury for 90 days. The approach plan was to have visual checks every 2 hours, call light within reach, assist during all transfers, low bed and alarm, and wander guard (device that alarms to notify staff when the resident is approaching an area) applied to the left hand as physician ordered on April 15, 2013. A review of the facility's policy and procedure titled, "Wandering Resident", and subject titled "Elopement/Missing/Against Medical Advice (AMA)", dated February 14, 2011, indicated the safety and well-being of all residents with a potential for wandering will be ensured at all times. All residents who are at risk for harm because of wandering behavior will have an assessment and care plan that addresses the issue.