Every finding on record at Granite Hills Healthcare & Wellness Centre, LLC

Based on observation, interview, and record review, the facility failed to provide care and services to prevent accidents for one of five sampled residents (Resident 1) who has left sided hemiplegia (paralysis affecting one side of the body) and hemiparesis (one-sided weakness) when the facility failed to develop an individualized care plan that addressed Resident 1's physical limitation and failed to ensure the staff implemented appropriate interventions when certified nursing assistant (CNA 1) left the bedside table positioned on the resident's left-side, rendering necessary items inaccessible and requiring Resident 1 to reach across the body which posed a risk of Resident 1 falling off the bed. These failures resulted in Resident 1 sustaining an unwitnessed fall on 12/6/2025. Resident 1 went to the hospital and was admitted for a forehead laceration and femoral neck fracture (fractured hip).Findings:On 12/30/2025 at 1:00 P.M., an unannounced onsite visit at the facility was conducted for an abbreviated survey related to a facility-reported incident.On 12/30/25 at 1:30 P.M., A review of Resident 1's undated admission Record was conducted. Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis affecting one side of the body) affecting the movement of the left side of his body (hemiparesis).According to Resident 1's Care Plan Report, dated 12/8/2025, under Focus [Problem], Resident 1 was at risk for falls because of impaired mobility, history of CVA [Cerebrovascular Accident-blood flow to the brain was blocked], under Interventions, it was indicated that staff needed to ensure Resident 1 wore nonskid socks, keep environment clutter free, adequate lighting, maintain fall precautions such as low bed and call light within reach, and reorient Resident 1 as needed due to dementia (a loss in mental functioning). The care plan did not indicate putting Resident 1's belongings or items on the right side for easy access ,safety, and fall prevention.According to Resident 1's Hospital Discharge summary, dated [DATE], the Emergency Department physician repaired the superficial forehead laceration with sutures, and Resident 1 was found to have a femoral neck fracture.Resident 1 returned to the facility on [DATE].On 12/30/2025 at 2:00 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 1's roommate called for help, the staff answered the call light and found Resident 1 on the floor. Licensed Nurse (LN 1) assessed Resident 1 and found that Resident 1 had a bump on the forehead. LN 1 called the physician and ordered them to transfer Resident 1 to the hospital. Later, the hospital called the facility and said that Resident 1 had a left femoral neck fracture.The DON further stated that the facility did their investigation and found out that Resident 1's bedside table was on the affected side of Resident 1, which would make it hard for Resident 1 to reach the item, and Resident 1 fell out of bed. The DON further stated that the fall could have been avoided, and corrective actions were implemented, such as in-service training for the staff and a 1:1 CNA education for CNA 1.On 12/30/2025 at 2:35 P.M., Resident 1 was observed sitting in a wheelchair in the activity room and was not available due to attending activitiesOn 12/30/2025 at 3:35 P.M., an interview was conducted with LN 1. LN 1 stated she was giving medications to another resident when CNA 1 called her to check Resident 1. LN 1 entered the room and found that Resident 1 was on the floor between the B- bed and the C- bed. LN 1 explained that Resident 1's room had three beds, and Resident 1's bed was the C-bed away from the door. LN 1 further stated the bedside table was tilted and pushed against the B-bed. LN 1 saw Resident 1's right forehead with a bump and a superficial scrape, which had a moderate amount of blood. Resident 1's physician was made aware and asked the facility to transfer Resident 1 to the hospital. LN 1 further stated that Resident 1 told her that he was reaching for the remote control on the bedside table, felt weak, and then fell onto the floor. LN 1 stated the roommate pressed the call light because Resident 1's bedside table leaned against his right side. LN 1 further stated that CNA 1 arrived to answer the call light and saw Resident 1 laying on the floor, and she was called by CNA 1.On 1/8/2026 at 2:10 P.M., an interview was conducted with CNA 1. CNA 1 stated the last time she saw Resident 1 was before she took her 30-minute lunch break. CNA 1 stated she knew Resident 1 had left-sided weakness, and the bedside table should have been placed on Resident 1's right side of the bed. CNA 1 said she could not recall where the bedside table was located when she left Resident 1 to take a break. CNA 1 further stated that Resident 1's fall was unwitnessed, and Resident 1 was not a good historian. CNA 1 further stated that she came back from her 30-minute lunch break, saw the call light was on, and she went to the room. She did not know how long the call light had been on before she responded. CNA 1 further stated she entered the room, the roommate on B-bed said he did not need help and CNA 1 then approached C-bed. CNA 1 saw Resident 1 on the floor, with blood on the face, and called LN 1. CNA 1 said that she did not know how long the call light had been on, but noticed it was on after she came back from her break. CNA 1 stated she told LN 1 she was going to lunch but not the CNA that is going to cover her section. CNA 1 said she only notified LN 1.According to the facility's policy, dated 8/28/25, titled Fall Management Program, The facility will maintain an environment free of accident hazards, provide adequate supervision and assistive devices to prevent avoidable accidents.

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) was free from significant medication errors when Resident 1 received two medications (solatol- used to treat heart rhythm problems and apixaban- a blood thinner that reduces blood clotting), which were intended for another resident. This failure resulted in the potential to affect Resident 1's health and well-being and placed other residents at risk for medication errors.Findings:During a record review, the admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia (paralysis on one side of the body) following cerebral infarction (a stroke), and epilepsy (a seizure disorder). During a record review, the MDS (Minimum Data Set- an assessment tool) dated 5/19/25 indicated Resident 1 had a BIMS (Brief Interview for Mental Status- a tool to measure cognition) of 14, which indicated intact cognition. During a record review, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses which included atrial fibrillation (irregular heart rhythm) and hypertension (high blood pressure). During a record review, the MDS (Minimum Data Set- an assessment tool) dated 6/17/25 indicated Resident 2 had a BIMS (Brief Interview for Mental Status- a tool to measure cognition) of 14, which indicated intact cognition. On 7/2/25 at 9:50 A.M., an interview was conducted with Resident 1. Resident 1 stated Resident 2 was his roommate. Resident 1 stated a few weeks ago, Licensed Nurse (LN) 1 accidentally gave him two of Resident 2's medications. Resident 1 stated, .my blood pressure got really low and I had to go to the hospital. On 7/2/25 at 11:21 A.M., an interview was conducted with Resident 2. Resident 2 stated on 3/27/25 around 5 P.M. while he was in his room, Licensed Nurse (LN) 1 brought medications into the room. Resident 2 stated LN 1 brought two medication cups, with pills in each cup. Resident 2 stated LN 1 gave one of the cups of medicine to Resident 1, then handed Resident 2 the second cup of medications. Resident 2 stated he did not recognize the medications and asked LN 1 if the pills belonged to him. Resident 2 stated LN 1 mistakenly handed him Resident 1's medications and vice versa. Resident 2 stated, [LN 1] took the meds away from me and went to [Resident 1]. [LN 1] realized what happened, went to grab the meds from [Resident 1] but [Resident 1] already took [the medications]., I'm the one who caught it [the medication error]. Resident 2 stated LN 1 mistakenly handed him Resident 1's medications and vice versa. During a record review on 7/9/25, the IDT (Interdisciplinary Team- a group of people with different areas of expertise) Note dated 3/28/25 indicated, Incident Details: approximately 6-6:30 pm on 03/27/2025 LN administered wrong medication [sic] to another resident. Sotalol and Eliquis was administered.MD gave parameters to send to ER [sic] if SBP [Systolic Blood Pressure-the top number of a blood pressure reading] less than 90 DBP [Diastolic Blood Pressure - the bottom number of a blood pressure reading] less than 60 and HR [Heart Rate] less than 50. At approximately 4:07 am 03/28/2025 resident blood pressure dropped below parameters and was sent 911 to [Hospital].Root Cause: LN failed to use identifiers and to follow the 7 rights of medication administration.During a record review on 7/9/25, Resident 2's Physician's Orders indicated resident was to receive Solatol Hcl Oral Tablet 160 MG twice a day and Eliquis Oral Tablet 5 MG twice a day. On 7/9/25 at 11:45 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the medication error occurred because LN 1 did not use resident identifiers, such as the arm band, birth date, or picture in the Electronic Health Record prior to administering the medications. The DSD stated LN 1 no longer worked at the facility and was unavailable for an interview.On 7/9/25 at 1:20 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated it was her expectation that licensed nurses verify a resident's identify prior to administering medications. The IDON stated it was important to follow the seven rights of medication administration to ensure residents receive the correct medication. The IDON stated it was important to avoid medication errors to protect residents from any adverse reactions to medications that are not intended for them.During a record review on 7/14/25, the facility's policy titled Medication-Errors revised 7/2018 indicated, Medication Error means the administration of medication.To the wrong resident.or.Which is not currently prescribed. During a record review on 7/14/25, the facility's policy titled Medication-Administration revised 1/1/12 indicated, Purpose.To ensure the accurate administration of medications for residents in the facility.No medication will be used for any patient other than the patient for whom it was prescribed.The Licensed Nurse will verify the resident's identity before administering the medication.Nursing Staff will keep in mind the seven rights of medication when administering medication.The seven rights of medication are: i. The right medication. Ii. The right amount. Iii. The right resident. Iv. The right time. V. The right route. Vi. Resident has right to know what the medication does. Vii. Resident has the right to refuse the medication.

Based on observation, interview, and record review, the facility failed to ensure one of four medication carts and narcotic storage boxes was locked, secured, and inaccessible to unauthorized staff, residents and visitors.This failure had the potential for visitors, residents, and unauthorized staff to access medications and narcotics stored in the medication carts.Findings:On 7/2/25 at 10:21 A.M., an observation was conducted in the west station hallway. A medication cart was in front of a resident room. The cart was unattended and was unlocked with the key observed inserted into one of the cart's drawers. On 7/2/25 at 10:28 A.M., a concurrent observation and interview was conducted with Licensed Nurse (LN) 2. LN 2 was observed walking out of a resident's room and opened the top drawer of the medication cart. LN 2 removed the keys from the cart drawer and placed the keys in her pocket. LN 2 stated she left the medication cart unlocked and the keys were in the narcotic storage box. LN 2 stated, I thought I was only going to be in the room for a few seconds. LN 2 stated she should not have left the keys in the narcotic storage drawer, which contained several packages of narcotics. LN 2 stated .we won't know who will go in there especially when there's narcotics in the drawer.On 7/2/25 at 4:25 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated the medication carts and narcotic boxes should always be locked when unattended. The IDON stated, .I tell my nurses, you never know who is around, who could grab a key, grab stuff out of the drawer. People have dementia, they can grab something, narcotics out of the drawer. A review of the facility's policy titled Medication Storage in the Facility revised 01/25 indicated, Medications and biologicals are stored safely, securely, and properly.The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized.

Based on observation, interview and record review, the facility failed to report an injury of unknown origin within 24 hours for one of one sampled resident (Resident 1). This failure resulted in Resident 1's injury of unknown origin to not be reported to the state licensing/certification office, delayed the abuse investigation, and placed residents at risk for abuse. Findings: During a review of Resident 1's Admission Record on 3/13/25, Resident 1 was admitted on [DATE] with diagnoses which included muscle weakness and dementia (a condition which causes memory loss, language, and problem-solving skills). A review of Resident 1's Minimum Data Set (MDS - a care planning and assessment tool), dated 1/2/25 indicated Resident 1 's cognition (ability to think, understand and make daily decisions) was 7, which suggested severe cognitive impairment. On 3/13/25 at 12:36 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated on 3/9/25 around 11 A.M . she observed Resident 1 .having an altercation with his roommate [Resident 2] . LN 1 stated Resident 1 and Resident 2 were, .yelling, getting into each other ' s face . LN 1 stated a room change was necessary because it was not the first incident between the two residents. LN 1stated both residents get verbally aggressive, not sure if there was physical contact between the two residents. On 3/13/25 at 1 P.M., a joint interview and observation of Resident 1 was conducted with Certified Nursing Assistant (CNA) 1 inside Resident 1 ' s room. Resident 1 was lying in bed, on his back. There was a dark purple bruise underneath Resident 1 ' s left eye, which extended down to the cheek. CNA 1 stated, .[Resident 1] is always confused, he ' s always grumpy .He yells at other residents a lot . CNA 1 stated she believes Resident 1 sustained the bruise, .because he got into a fight with [Resident 2] . but she did not see the incident occur. On 3/13/25 at 1:21 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated on 3/10/25, Resident 1 ' s family member was at the facility. The ADON stated while at the facility, the family member informed him that Resident 1 ' s left cheek was black and blue, and he had a cut on his left arm. The ADON further stated he was notified there was a room change and an altercation had occurred on 3/9/25. Additionally, the ADON stated on 3/9/25 staff found Resident 1 outside the facility, attempting to open a side gate. The ADON stated, What we determined was the resident was injured when he was trying to open the gate .he wanders aimlessly . The ADON stated we believed Resident 1 was pinned between the gate and the fence which caused the injury. On 3/13/25 at 1:45 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 ' s family member had been in the facility on 3/10/25 and had reported to her that Resident 1 said he had been punched in the eye. On 3/13/25 at 2:07 P.M., an interview was conducted with CNA 2. CNA 2 stated on 3/9/25 around 5:30 P.M., he heard the activated gate alarm. CNA 2 stated he went outside and found Resident 1 next to the gate. CNA 2 stated he observed Resident 1 sitting in his wheelchair in front of the gate. CNA 2 stated the gate was closed, but he thinks Resident 1 had opened the gate which activated the alarm. CNA 2 stated, .I believe he got [the bruise] from the gate .we didn ' t see a bruise on his face .we didn ' t see the gate hit him. The gate was already closed when we got to him . CNA 2 stated he reported the incident to the charge nurse. During an interview on 3/21/25 at 12:01 P.M. with the Director of Nursing (DON), the DON stated he was aware that Resident 1 was confused and had an altercation with Resident 2. The DON stated, .we determined the bruise was most likely caused by attempting to exit the courtyard gate [not from the altercation with Resident 2] .but it cannot be concluded . The DON confirmed the injury was not reported to the state licensing agency. The DON stated, This should have been reported immediately to the Ombudsman, to California Department of Public Health, to the police . immediately and then we should have started the abuse investigation . The DON further stated, .We have a duty to protect our residents . A review of the facility ' s policy titled Injuries of Unknown Origin-Investigation revised 11/18/15 indicated, .To protect the health and safety of residents by ensuring all unexplained injuries are promptly and thoroughly investigated and addressed .Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing Services and/or other staff person appointed by the Administrator, to ensure that resident safety is not compromised and action is taken whenever possible, to avoid future occurrences . A review of the facility ' s policy titled Reporting Abuse revised 1/8/14 indicated, .III. Reporting Requirements .A. The Facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations .

Based on observation, intervention, and record review, the facility failed to follow safe food practices when: 1. The ceiling above the kitchen tray line area had peeling and bubbling paint; and, 2. Two staff members entered the kitchen without donning (to put on) hair coverings. This failure had the potential for unsanitary products to fall into resident food or onto kitchen equipment. Findings: 1. An observation was conducted of the ceiling within in the kitchen, over the food tray line area on 1/28/25 at 9:20 A.M. The ceiling had an approximately 5 inch by 5 inch area of peeling paint. Pieces of peeling paint were hanging downwards. North on the ceiling, from the peeling paint area was a large section of bubbling paint estimated at 5 inches by 10 inches in size. An interview and record review was conducted with the Certified Dietary Manager (CDM) on 1/28/25 at 9:55 A.M. regarding the kitchen ceiling. The CDM stated the bubbling paint could start to peel and the peeling paint could flake off and fall down into resident food, which could cause harm. The CDM stated she believed she had reported the peeling paint to the maintenance department and she would check her Dietary Maintenance logbook. The CDM provided copies of documented past report she made for repair of the ceiling. The repairs were requested on 8/8/22, 9/1/22, 11/6/23, and 1/14/24. The repairs were never marked off by maintenance as being completed. An interview was conducted with the Director of Maintenance (DM) on 01/28/25 at 2:15 P.M. regarding kitchen repairs. The DM stated he started working at the facility in July 2024. The DM stated he was unaware of the ceiling issues within the kitchen and just learned about it today. An interview was conducted with the Registered Dietician (RD) on 1/29/25 at 10:13 A.M. The RD stated she reported the ceiling issues on her last kitchen audit to the former Administrator. The RD stated repairing the ceiling was very important to protect residents and kitchen equipment from the contamination of peeling paint. The RD stated it was important to have a clean, functioning kitchen. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9 A.M. The DON stated the kitchen ceiling should have been repaired when it was first reported. The DON stated paint could have fallen into resident food, which would be unsanitary. According to the facility's policy, titled Sanitation, dated 2023, .5. The dietary Supervisor will report any equipment needing repair to the maintenance man 14. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by maintenance staff . 2a. An observation and interview was conducted of Kitchen Aide 1 (KA 1) on 1/28/25 at 10:31 A.M. KA 1 was observed re-entering the kitchen area and walking across the kitchen to the handwashing sink. KA 1 was wearing a baseball hat with no hair net. KA 1 had her hair pulled back into a messy bun, with strands of hair hanging down in the back. KA 1 stated she knew she was supposed to have a hair net on and she did not. KA 1 stated her hair could fall into resident food. 2b. An observation and interview was conducted with Dishwasher 1 (DW) on 1/28/25 at 10:33 A.M. The DW was observed entering the kitchen, crossing the kitchen area to speak with the CDM. The DW had on a baseball hat with no hair net. The DW also had a mustache and goatee style beard approximate 1 inch in length that was uncovered. The DW stated he knew he was supposed to have a hair net and beard cover on and he did not. The DW stated his hair could fall onto food and cause cross contamination. An interview and record review was conducted with the CDM on 1/28/25 at 10:48 A.M. The CDM stated she expected all kitchen staff to wear hair and beard guards to prevent cross contamination. The CDM reviewed and provided sanitation/hairnet training, which was provided to KA 1 and DW on 1/22/25. An interview was conducted with the Registered Dietician (RD) on 1/29/25 at 10:13 A.M. The RD stated all kitchen staff were expected to put on hair nets and beard guards before entering the kitchen. The RD stated hair nets, and facial guards were important to prevent hair from falling into food or onto equipment, which would cause cross contamination. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9 A.M. The DON stated he expected all staff to cover head hair and facial hair at all times when in the kitchen, because hair could fall into the residents' food. According to the facility's policy, titled Food Service Employee Hygiene Practices, undated, .1. Food Service Staff are to .use appropriate hair restraints to prevent contamination of food .

Based on observation, interview, and record review, the facility failed to provide and promote a homelike atmosphere for four of 15 resident rooms (11, 19, 21, 22), within the secured unit (a specialized care unit which is locked and limits residents with memory loss and/or mental health issues from exiting the unit without supervision), when reviewed for Resident Rights. This failure had the potential for residents to feel disrespected and undervalued. Findings: 1. An observation was conducted of the secured unit, room [ROOM NUMBER] on 1/27/25 at 3:03 P.M. The room sink was in the middle of the main room. The sink's faucet was covered on both sides and underneath with lime green calcification. An observation and interview regarding room [ROOM NUMBER] was conducted with the Director of Maintenance (DM) on 1/28/25 at 2:34 P.M. The DM stated he started at the facility in July 2024 and had never performed an inspection of the resident rooms on the secured unit. The DM viewed the sink faucet and stated, That's nasty and the whole sink and faucet needs to be replaced. The DM stated the sink did not present a homelike atmosphere. 2. An observation was conducted of the secured unit, room [ROOM NUMBER] on 1/27/25 at 3:50 P.M. Plastic, cord covers on the wall were broken and hanging downwards next to the TV. The bedside dressers for both bed A and bed B had no knobs attached to the two drawers for opening. The dresser of bed B was leaning to the right, with no metal footrest on the front right dresser leg. An observation and interview regarding room [ROOM NUMBER] was conducted with the DM on 1/28/25 at 2:20 P.M. The DM stated bed B's front dresser leg needed to be replaced. The DM stated he did not see any drawer handles, so it made it hard for residents to open their drawers and the plastic cord covering was broken and splintered. The DM asked the resident of bed A if he would want a door handle for his dresser and the resident stated, That would be nice. The DM exited the room and stated the room did not look neat or homelike. 3. An observation was conducted of the secured unit, room [ROOM NUMBER] on 1/27/25 at 3:47 P.M. Both bed A and bed B had no door handles or knobs for opening the two-drawer bedside dresser. A cable wire was seen sticking out of the wall and was not attached to anything on the same wall as the TV. The wall thermostat had no covering and the metal mechanism was exposed. An observation and interview regarding room [ROOM NUMBER] was conducted with the DM on 1/28/25 at 2:10 P.M. The DM stated the residents could not open their dresser drawers without handles or knobs. The DM stated the cable cord was sticking out and should not be there, because it served no purpose and the exposed metal thermostat looked tacky. The DM stated the resident's room did not look functional or homelike. 4. An observation and interview was conducted of the secured unit, room [ROOM NUMBER] on 1/27/25 at 4:20 P.M. with Resident 40 in the room. Resident 40 stated she did not like her room and pointed to the area around her sink, stating it had mold and she believed it was making her sick. The sink was in the main room with lots of bumpy plaster patches on the wall, around and under the sink. Blackened areas were noted on the caulking between the wall and the sink. Resident 40 asked if someone could get rid of, that black stuff. An observation and interview regarding room [ROOM NUMBER] was conducted with the DM on 1/28/25 at 2:50 P.M. The DM stated the plaster repair job on the sink wall was sloppy and unprofessional. The DM stated the sink area looked bad and the whole sink and wall should be replaced. The DM stated the room was not homelike and he would not want his family member to look at a wall like that. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9 A.M. The DON stated he wanted all residents to feel comfortable with a homelike atmosphere in their rooms. The DON stated with dresser handles missing, it did not present a homelike environment. According to the facility's policy titled, Resident Rooms and Environment, dated January 2012, .The Facility provides residents with a safe, clean, comfortable, homelike environment . 1. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order; .

Based on observation, interview, and record review, the facility failed to maintain resident rooms from environmental hazards for six of 15 rooms (12, 13, 17, 19, 20, 21), reviewed for accidents. In addition, the facility failed to provide two-person lifting assistance while transferring one of one resident (Resident 29 ) from a wheelchair to bed using a mechanical lifting device (a hydraulic devices with a sling used for transfers) with one staff, (Two staff always required for mechanical lifts). These failures had the potential for residents to sustain injuries from hazards identified in their rooms and from mechanical lifts or transfers. Findings: 1. An observation was conducted of room [ROOM NUMBER] on the secured unit (a specialized care unit which is locked and limits residents with memory loss or mental health issues from exiting the unit without supervision) on 1/27/25 at 4:02 P.M. A cable wire was protruding from the wall next to the closet area. Plastic cord covers on the wall were brittle and splintered protruding out, away from the wall. An observation and interview was conducted with the Director of Maintenance (DM) of room [ROOM NUMBER] on 1/28/25 at 2:31 P.M. The DM stated he did not know why the cable wire with a center point was sticking out from the wall, since it did not seem to be needed and was not going anywhere. The DM stated the center point was sharp and could hurt someone. The DM inspected the splintered plastic cord covers on the TV wall and stated this was a hazard because someone could walk into it and it was high enough to poke them in the face or eye. The DM stated he was unaware of these hazards and had never inspected the resident rooms within the secured unit. 2. An observation was conducted of room [ROOM NUMBER] in the secured unit on 1/27/25 at 3:57 P.M. A small circular hole was in the middle of the exterior bathroom door. The hole was approximately 2 inch by 2 inches in size and contained splintered wood. An observation and interview was conducted with the DM of room [ROOM NUMBER] on 1/28/25 at 2:28 P.M. The DM stated the hole in the wall was splintered and a resident could cut themselves. The DM stated this should have been reported immediately, so he could have fixed it. 3. An observation was conducted of room [ROOM NUMBER] on 1/27/25 at 8:52 A.M. The bedside dresser of Bed B had a Phillips' screw head protruding from the drawer, where a door handle use to be. An observation and interview was conducted with the DM of room [ROOM NUMBER] on 1/28/25 at 2:26 P.M. The DM observed the protruding screw head when inspecting the dresser and stated, That's a hazard, someone could catch themselves on that and it should be fixed. The maintenance book for the secured unit was viewed on 1/30/25 at 8:46 A.M. A staff member documented repair was required in room [ROOM NUMBER] on 1/14/25 for, Toilet seat loose Rm 17. An observation, interview, and record review was conducted with Licensed Nurse 1 (LN 1) of room [ROOM NUMBER]'s toilet seat on 1/30/25 at 8:51 A.M. The toilet seat slid to the right when touched and was not anchored down. LN 1 stated the toilet seat was a hazard, because someone could fall to the floor if they attempted to sit on it. LN 1 stated she will add the repair to the maintenance book. LN 1 stated the toilet seat was already reported in the maintenance log on 1/14/25, it should have been fixed within a day. LN 1 stated 16 days later for a repair was unacceptable for a potential hazard. 4. An observation was conducted of room [ROOM NUMBER] on 1/27/25 at 12:34 P.M. On the TV wall, approximately 4-5 feet from the floor was an area of peeling paint. The area was estimated to be 6 inches by 4 inches in size with loose paint coming off the wall. An observation and interview was conducted with the DM of room [ROOM NUMBER] on 1/28/24 at 2:22 P.M. The DM stated there should not be peeling paint, where residents had access to it. The DM stated some residents on this unit were confused and could ingest the peeling paint, not knowing it could be harmful to them. 5. An observation was conducted of room [ROOM NUMBER] on 1/27/25 at 3:52 P.M. A long cable cord was protruding from the floor of the TV wall, near the sliding glass door, The cord was approximately 4 feet in length. The cord was pulled up and wrapped around the sliding glass door handle. An observation and interview was conducted with the DM of room [ROOM NUMBER] on 1/28/25 at 2:24 P.M. The DM observed the cable cord protruding from the wall and wrapped around the sliding glass door handle. The DM stated this was a tripping hazard and it could also be a choking hazard if a resident got tangled up in it. 6. An observation was conducted of room [ROOM NUMBER] on 1/27/25 at 3:47 P.M. The exterior edge of the bathroom door, near the doorknob had wood exposed, which was splintered and sharp. An observation and interview was conducted with the DM of room [ROOM NUMBER] on 1/28/25 at 2:15 P.M. The DM stated the edges were sharp and the door needed to be sanded down. The DM stated a resident could hurt themselves on the sharp wood if they grabbed or fell against the door. An interview was conducted wit the Director of Nursing (DON) on 1/30/25 at 9 A.M. The DON stated he expected all resident rooms to be safe and free of environmental hazards. The DON stated the sliding toilet seat was a hazard and should have been fixed immediately to avoid a possible fall. According to the facility's policy, titled Resident Safety, dated April 2021, .VII. Any facility staff member who identifies an unsafe situation, practice or environmental risk factors should immediately notify their supervisor or charge nurse . 39449 7. A record review of the facility's Admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses to include complete weakness on one side of the body and partial weakness of one side of the body following a stroke. On 1/28/25 at 3:46 P.M., an observation and interview was conducted with a Certified Nursing Assistant (CNA) 31. Resident 29 was observed on a wheelchair in his room with one CNA. CNA 31 was observed setting the sling of the mechanical lifting device (an equipment to assist in lifting). CNA 31 was observed transferring Resident 29 from the wheelchair to his bed. Resident 29's transfer using mechanical lifting device was conducted by CNA 31 without another CNA. CNA 31 was observed on one side of the mechanical lifting device while transferring Resident 29. There was no other CNA on the other end of the mechanical lifting device. CNA 31 stated she usually did it by herself. CNA 31 stated she did it by herself when other CNAs were not available. CNA 31 stated she had an in-service training for using a mechanical lifting device with two- person assistance. CNA 31 stated it was important to have two-person assist for mechanical lifting device to prevent any accidents and for safety. On 1/29/25 at 8:57 A.M., an interview was conducted with CNA 32. CNA 32 stated mechanical lifting device required two-person assistance, which meant two CNAs must be present to use the mechanical lifting device. On 1/29/25 at 9:14 A.M., an interview was conducted with CNA 33. CNA 33 stated mechanical lifting device required two-person assistance. On 1/29/25 at 10 A.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated using a mechanical lifting device required two-person assistance which meant two direct care staff like CNAs, licensed nurses or rehabilitation therapy staff would assist using a mechanical lifting device. The DSD stated the facility policy did not indicate two persons are required to use the mechanical lift, but he stated it should be with two-person assistance. A review of Minimum Data Set (MDS- assessment tool) Section GG dated 12/13/2024 indicated Resident 29 had impairment of his upper and lower extremity. Resident 29 was dependent on two or more staff to complete activity. A review of the care plan dated 12/1/21 indicated Resident 29 required mechanical lift with at least two staff assistance for transfers. On 1/29/25 2:41 P.M., an interview and record review was conducted with LN 31. LN 31 stated Resident 29 required a mechanical lifting device with two-person assist, LN 31 stated Resident 29 was a total care and required two person lifting with one staff to operate the sling and another to guide the resident to prevent swinging in the sling or from falling. On 1/29/25 at 3:19 P.M., an interview was conducted with CNA 34. CNA 34 stated a mechanical lifting device required two person, because one person was guiding the resident and the other staff was operating the mechanical lift. On 1/29/25 at 1:31 P.M., an interview and record review was conducted with the DON. The DON stated his expectation was that mechanical lifting of a resident required two person assistance to prevent resident injury. The facility policy titled Transfer of Residents dated 4/27/2023 111 indicated, . Residents who require assistance in transferring may be transferred using . or with a mechanical lift The policy did not provide guidance on the number of staff required when utilizing the mechanical lift.

Based on interview and record review, the facility's Quality Assessment Performance Improvement (QAPI-plan developed by the QAA committee to improve conditions in the facility) failed to identify deficient practices prior to to their recertification survey when: 1) The facility did not provide education to staff related to the management of residents with post-traumatic stress disorder (PTSD- a mental condition that's caused by an extreme event - either being part of it or witnessing it) and, 2) Did not identify and correct environmental hazards which could have caused injury. These failures had the potential to negatively affect residents' health and quality of life. Findings. Cross reference : F-584, F-689, and F699. 1) A joint interview on 1/30/2025 at 2:27 P.M., with the Administrator (ADM) and the Director of Nursing (DON) was conducted. The DON stated there was no education provided to staff regarding PTSD and triggers associated. The DON stated the importance of QAA committee was identifying the trends and to maintain residents health condition, prevent possible decline and to promote the highest standard of care for their residents with PTSD. 2) A joint interview on 1/30/25 at 2:27 P.M.,was conducted with the Administrator (ADM) and the Director of Nursing ( DON). The ADM stated they were aware of maintenance issues but had not identified the environmental hazards found during the federal recertification survey. The ADM stated she was unaware if the facility had a safety committee, but she would now be initiating one. A record review of the facility's policy titled, Quality Assessment and Assurance Activities undated, indicated The QAA committee will review data from areas the facility believes it needs to monitor on a monthly basis to assure systems are being monitored to achieve the highest level of quality for our facility.

Based on observation, interview, and record review, the facility failed to accurately assess, document, and transmit Minimum Data Set (MDS-a clinical assessment tool), information to the Center for Medicare and Medicaid Services (CMS-A federal agency that oversees health insurance) regarding a vision assessment for one of eight residents (Resident 3), reviewed for Resident Assessment. As a result, CMS was uninformed of Resident 3's impaired vision. Cross reference (F-685) Findings: Resident 3 was readmitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a progressive brain disorder that causes nerve cells in the brain to deteriorate, leading to body movement problems), per the facility's Admission Record. An observation and interview was conducted with Resident 3 on 1/27/25 at 12:52 P.M. in his room. Resident 3 was earlier heard telling staff if did not want his lunch tray and to take it away. Resident 3 was observed dressed, lying in bed. Resident 3 stated he did not want his lunch because he could not see it and did not want to eat anything he could not see. Resident 3 yelled, I'm blind and can't see. I keep telling everyone, but no one listens. Resident 3's clinical record was reviewed on 1/28/25: According to care plan, titled Impaired Vision related to Cataracts (a clouding in the lens of the eye, which impairs vision), revised 6/15/24, listed interventions to include, arrange consultation of eye practitioner, and tell resident where you are placing their items. According to the Eye Doctor Consultation report, dated 7/19/24, Resident 3 was diagnosed with bilateral (both eyes) cataracts (a clouding of the eye's natural lens, resulting in vision loss). According to the facility's social service note, dated 8/27/24, a referral to ophthalmologist (physician who specializes in eye and vision care), was documented. There was no additional documentation that an appointment was schedule or a follow up was conducted for an ophthalmology appointment. According to the most recent quarterly MDS, dated [DATE], Section B-1000 listed Resident 3's Vision as Adequate . According to the facility's Registered Dietician (RD) note, dated 1/23/25, Resident 3 said he was having difficulty seeing. An interview and record review was conducted with the Minimum Data Set Nurse (MDSN) on 1/28/25 at 1:42 P.M. The MDSN stated when preparing MDS data for CMS, she reviewed the resident's clinical record, such as the physician assessments, nurse's notes, social service notes, and care plans. The MDSN reviewed Resident 3's quarterly vision assessments, dated 1/16/25, and stated the assessment was inaccurate, because the care plan indicated vision impairment. The MDSN stated because of incorrect coding, CMS was unaware Resident 3 still had impaired vision. The MDSN stated the 1/16/25 quarterly MDS did not give an accurate picture of Resident 3's current visual status. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9 A.M. The DON stated he expected MDS assessments, coding, and transmissions to be accurate, so CMS had a clear picture of what was currently going on with each resident. According to the MDS Resident Assessment Instrument (a guide which gives direction to staff of requirements and for MDS coding), dated October 2019, .B-1000 Steps for Assessment: 1. Ask direct care staff over all shifts if possible about the resident's usual vision patterns during the 7-day look-back period (e.g., is the resident able to see newsprint, menus, greeting cards?). 2. Then ask the resident about his or her visual abilities. 3. Test the accuracy of your findings .

Based on observation, interview, and record review, the facility failed to develop a person-centered care plan to manage combative behavior for one of three residents (Resident 84) reviewed for ADLs (Activities of Daily Living- eating, dressing, showering, grooming and toileting). As a result, there was potential for the resident to not receive individualized care. Findings: According to the Admission Record, Resident 84 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (a stroke), and anxiety disorder. A review of the Minimum Data Set (MDS-an assessment tool) dated 12/16/24 indicated Resident 84 had a BIMS (a tool that measures cognition) of 3 and was cognitively impaired. On 1/28/25 at 4:02 P.M., an observation and interview was conducted with Certified Nursing Assistants (CNA) 13 and 14 in Resident 84's room. CNA 13 was attempting to give Resident 84 a shave while CNA 14 was standing on Resident 84's left side. CNA 14's hand was placed on Resident 84's left arm. Resident 84 was observed moving his head to the left and right. CNA 14 stated, I'm here to make sure [Resident 84] doesn't swing his arm, so that [CNA 13] can give him a shave. CNA 14 stated Resident 84 had a behavior of attempting to hit staff during ADL's. On 1/29/25 at 8:12 A.M. an interview was conducted with CNA 16 in Resident 84's room. CNA 16 stated, .If you do his nails and shave him, he doesn't like that. He'll try to push you away and grab you .he doesn't know what's going on . During an interview with Licensed Nurse (LN) 11 on 1/29/25 at 8:28 A.M., LN 1 stated Resident 84 was confused, but understood Spanish. LN 11 stated, I do something sing-[NAME] .I will say agua, agua and give him a distraction. He'll focus on what I'm saying and listen to my voice so that he is calm .it helps to distract him .to explain things in Spanish even though he's not very alert, it does seem to register when you talk to him in Spanish . A review of Resident 84's records indicated there was no care plan developed to address combative behaviors when receiving care. On 1/30/25 at 12:54 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was important for Resident 84 to have an individualized care plan, especially because he is confused, combative and Spanish speaking. The DON stated, .we can meet the needs [of Resident 84] by having the [individualized] care plan in place, and everybody will know what's required to help him . A review of the facility's policy titled Comprehensive Person-Centered Care Planning dated 11/18 indicated, It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care .to obtain or maintain the highest physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to address a residents' visual impairment in a timely manner for one of two residents (Resident 3), reviewed for Quality of Care. As a result, Resident 3 experience weight loss due to being unable to see his food. Cross Reference (F-641 and F-692) Findings: Resident 3 was readmitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a progressive brain disorder that causes nerve cells in the brain to deteriorate, leading to body movement problems), per the facility's Admission Record. An observation was conducted of Resident 3 on 1/27/24 at 9:58 A.M., in his room. Resident 3 had a covered, untouched breakfast tray sitting on his bedside table. An observation and interview was conducted with Resident 3 on 1/27/25 at 12:52 P.M. in his room. Resident 3 was heard telling staff if did not want his lunch tray and to take it away. An unidentified staff returned Resident 3's lunch tray to the food cart. Resident 3 was observed dressed, lying in bed. Resident 3 stated he did not want his lunch because he could not see it and he did not eat anything he could not see. Resident yelled, I'm blind and can't see. I keep telling everyone, but no one listens. An observation and interview was conducted on 1/28/25 at 10:13 A.M., with Certified Nursing Assistant 1 (CNA 1). Resident 3's uneaten breakfast tray 2 was removed by CNA 1. CNA 1 stated Resident 3 does not usually eat breakfast. Resident 3's clinical record was reviewed on 1/28/25. According to the facility's Minimum Data Set, (MDS-a clinical assessment tool) dated 10/18/24, Resident 3 had a cognitive score of 10, indicating moderately impaired cognition. The care plan, titled Impaired Vision related to Cataracts (a clouding in the lens of the eye, which impairs vision) , revised 6/15/24, listed interventions included: arrange consultation of eye practitioner, and tell resident where you are placing their items. According to the facility's Eye Doctor Consultation, dated 7/19/24, Resident 3 had cataracts in both eyes. According to the facility's Social Service note, dated 8/27/24, Refer to an Ophthalmologist (physician who specializes in eye and vision care). There was no documented evidence Resident 3 was ever referred or seen by an Ophthalmologist, or any follow-up by staff to inquire why he was not seen by the eye specialist. According to the facility's Change of Condition report, dated 1/16/25, Resident 3 had an identified weight loss. According to the facility's Interdisciplinary Team meeting, (IDT-when department heads meet to discuss resident issues and develop interventions to address those issues), titled Weight Variance, dated 1/23/25. There was no documented evidence Resident 3's vision loss was discussed or investigated as to when his last vision exam was. An interview and record review was conducted with the Social Services Director (SSD) on 1/28/25 at 1:54 P.M. The SSD reviewed the eye doctor exam on 7/17/24, and the Ophthalmologist referral dated 8/27/24, The SSD stated she could not find any documentation that Resident 3 ever went to Ophthalmologist for treatment of his cataracts or that a follow-up was conducted to ensure an appointment was made. The SSD stated with no follow-up for Resident 3's vision, his eye sight could have worsened, which would impact his quality of life An interview and record review was conducted with the RD on 1/29/25 at 10:29 A.M. The RD stated during Resident 3's weight variance IDT meeting, she informed the team of Resident 3 complaining of visual problems. The RD stated the vision issue was not explored or investigated, and it should have been. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9 A.M. The DON stated he expected all referrals to be completed and followed up on, so resident needs were addressed. The DON stated Resident 3's vision and eye care was not addressed in a timely matter, which could worsen his vision . According to the facility's policy, titled Referrals to Outside Services, dated December 2013, .I. The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility . The facility did not have a policy specific to Vision Care or Services.

Based on observation, interview, and record review, the facility failed to investigate and analyze the root cause for recent weight loss for one of one resident (Resident 3) reviewed for nutrition. This failure had the potential for Resident 3 to experience additional weight loss. (Cross Reference F-641, F-685, F-842) Findings: Resident 3 was readmitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a progressive brain disorder that causes nerve cells in the brain to deteriorate, leading to body movement problems), per the facility's Admission Record. An observation was conducted of Resident 3 on 1/27/25 at 9:58 A.M., in his room. Resident 3 had a covered, untouched breakfast tray sitting on his bedside table. An observation and interview was conducted with Resident 3 on 1/27/25 at 12:52 P.M. in his room. Resident 3 was heard telling staff if did not want his lunch tray and to take it away. An unidentified staff returned Resident 3's lunch tray to the food cart. Resident 3 was observed dressed, lying in bed. Resident 3 stated he did not want his lunch because he could not see it and he did not eat anything he could not see. Resident 3 yelled, I'm blind and can't see. I keep telling everyone, but no one listens. An observation and interview was conducted on 1/28/25 at 10:13 A.M. with Certified Nursing Assistant 1 (CNA 1). Resident 3's uneaten breakfast tray 2 was removed by CNA 1. CNA 1 stated Resident 3 does not usually eat breakfast. Resident 3's clinical record was reviewed on 1/28/25. According to the physician's order, dated 5/10/24, Resident 3 required a fortified diet, regular texture with regular to thin consistency. According to the facility's Minimum Data Set, (MDS-a clinical assessment tool) dated 10/18/24, Resident 3 had a cognitive score of 10, indicating moderately impaired cognition. The care plan, titled Impaired Vision related to Cataracts, revised 6/15/24, listed interventions included: arrange consultation of eye practitioner, and tell resident where you are placing their items. According to the facility's Change of Condition report, dated 1/16/25, Resident 3 had an identified weight loss. The facility's Weight Summary was reviewed for Resident 3. Recorded weight on 7/5/24 was 170.5 pounds. Recorded weight on 1/16/25 was 156.5 pounds. The facility's Task for food percentages consumed was reviewed: Staff documented food percentage consumed by Resident 3 on 1/27/25, was 75-100% for breakfast and lunch, which was incorrect. (Observation was no breakfast and or lunch was consumed). According to the Registered Dietician (RD) note dated 1/23/25, Resident 3 experienced a 13.7% weight loss in 6 months. Resident 3 told the RD he was having trouble seeing, but agreed to try Ensure (a nutritional supplement drink designed to help with nutritional needs), with his lunch and dinner. According to the facility's Interdisciplinary Team meeting, (IDT-when department heads meet to discuss resident issues and develop interventions to address those issues), titled Weight Variance, dated 1/23/25. There was no documented evidence Resident 3's vision loss was discussed or investigated as to when his last vision exam was. The recommended interventions were finger foods and supply Ensure with lunch and dinner. The care plan, titled Nutritional problem, revised 1/23/25, included interventions of Ensure with lunch and dinner, provide finger food, and offer snack. A note was added by RD stating resident drinks 2-3 soda's a day and was at risk for weight fluctuation. Resident 3 agreed to be re-weighted by CNA 2 on 1/28/25 at 2:43 P.M., if he was provided a soda. Resident 3's weight was documented as 160.3 An interview was conducted with Licensed Nurse 1 (LN 1) on 1/29/25 at 8:16 A.M. LN 1 stated Resident 3 refused to do things unless he was provided a soda and he would drink 20 sodas a day if staff allowed it. LN 1 stated sometimes Resident 3 will refuse to eat, unless he was provided a soda. There was no documented care plan related to soda consumption or bargaining for a soda. An observation and interview was conducted of Resident 3 in his room on 1/29/25 at 8:29 A.M. Resident 3's breakfast tray remained untouched with no finger food present. The breakfast tray consisted of a bowl of dry cereal, an unopened carton of milk, a cellophane covered bowl of canned fruit, and an unopened container of cherry yogurt. Resident 3 stated he could not see his food, so he was not going to eat it. Resident 3 asked for a banana instead, which was provided. An interview and record review was conducted with the RD on 1/29/25 at 10:29 A.M. The RD stated during Resident 3's weight variance IDT meeting, on 1/23/25, she informed the team of Resident 3 complaining of visual problems and was informed by the rest of the team of Resident 3's desire for sodas. The RD stated the vision issue was not explored or investigated, and it should have been. The RD stated she was unaware of the soda addiction until the IDT meeting, and no one discussed using the soda as an incentive to encourage eating. The RD stated they had not discussed one to one assistance with eating either. The RD stated she could have been more forceful in IDT to explore the issues and think of better interventions. The RD stated all staff needed to get behind the plan to correct the issue and she was dependent on staff to document the correct percentages of meals consumed. The RD stated based on the items observed on the resident's breakfast tray, those items were not finger foods. The RD stated she could have done better, because nutrition was very important for the resident's overall health. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9 A.M. The DON stated he expected the IDT team to be collaborative and to get to the issue of the problem. The DON stated the IDT was supposed to develop and implement meaningful interventions to rectify the issue at hand. The DON stated Resident 3's visual issue should have been identified and investigated as contributing to the root cause of his weight loss. According to the facility's policy, titled Evaluation of Weight Nutritional Status, dated November 2022, 1. The facility will work to maintain acceptable nutritional status for residents by: a. Assessing the resident's nutritional status and the factors that put the resident at risk .b. Analyzing the assessment information to identify .causes and/or problems related to the resident's condition and needs .

Based on observation, interview and record review, the facility failed to identify triggers related to PTSD ( post-traumatic stress disorder- difficulty recovering after experiencing or witnessing a traumatic event ) for two of two residents (Resident 27 and 35) reviewed for trauma-informed care. This failure had the potential to result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience) that could lead to severe psychosocial harm and affect the resident's quality of life. Findings: 1.) A record review of the facility's Admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, anxiety disorder, and schizoaffective disorder (a mental illness that affects thought, mood and behavior). An interview on 1/27/25 at 10:50 A.M., with Resident 27 was conducted . Resident 27 stated the staff here did not know how to handle his PTSD. Resident 27 stated, his mother committed suicide and swallowed a large amount of her pills. Resident 27 further stated, his brother did something to him 5-[AGE] years ago but refused to elaborate further. Resident 27 stated, he heard demons and his mother 's voice and just talking about her, made him anxious and irritated. A review of Resident 27's minimum data set (MDS- a federally mandated assessment tool) dated 1/29/25 indicated Resident 27's, brief interview for mental status (BIMS) score was 15 which meant Resident 27's cognition was intact. An interview on 1/28/25 at 8:43 A.M., with licensed nurse (LN ) 12 was conducted. LN 12 stated Resident 27 had behavioral outburst when he did not get his cigarettes or his way and became verbally aggressive . LN 12 stated with regards to his PTSD, she was not aware and did not know of any triggers. LN 12 stated it was important for staff to know Resident 27's triggers to avoid them and at the same time know how to take care of Resident 27. A joint interview and record review on 1/28/25 at 4:04 P.M., with the Assistant Director of Nursing (ADON) was conducted. The ADON stated there was no identified triggers related to PTSD in Resident 27's care plan . The ADON stated it was important to know Resident 27's triggers to meet his needs. An interview on 1/20/25 at 8:01 A.M., with the Social Service Director (SSD ) was conducted. The SSD stated her role included arranging referrals to psychologist and psychiatrist for residents that needed their service. The SSD stated Resident 27 did not like people behind him and he did not like people screaming. The SSD stated it was important to identify Resident 27's triggers to prevent psycho- social , emotional issues and to prevent the past event from reoccurring and ensure Resident 27's needs are met. A joint observation and interview on 1/30/25 at 8:17 A.M., with Resident 27 was conducted. Resident 27 was observed holding his coffee cup with his breakfast tray untouched. Resident 27 stated he does not feel good and was not hungry at the moment. Resident 27 refused further comments. An interview on 1/30/25 at 9:35 A.M., with the Director of Nursing (DON) was conducted . The DON stated, we need to determine and implement ways to avoid or at least minimize the triggers and have them in the Resident 27's care plan. 49330 2.) A review of Resident 35's Admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder. A review of Resident 35's Minimum Data Set (MDS, an assessment and care-screening tool), dated 10/1/24 indicated Resident 2's cognition was intact. During an interview on 1/27/25 at 8:56 A.M., Resident 35 stated she had PTSD. Resident 35 stated, .my [PTSD] came from abuse when I was a child. It morphed into physical abuse at home, and more as an adult with an alcoholic husband . Resident 35 stated when she was triggered, .I get a physical response in my chest. It gets tighter and tighter . On 1/27/25 at 12:55 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 11. CNA 11 stated she was familiar with Resident 35 and had taken care of her multiple times. CNA 11 stated she was not aware that Resident 35 had PTSD. CNA 11 stated it was important to know about a resident's PTSD diagnosis, .so we can be familiar with what happened .if she has a trigger we can prevent it . On 1/27/25 at 3:40 P.M., an interview was conducted with Licensed Nurse (LN) 12. LN 12 stated she was Resident 35's assigned nurse. LN 12 stated, .[PTSD] is when something traumatic happened previously and you still suffer from that .it can provoke an emotion due to what happened previously .we should know [the resident's] triggers so they don't relive the trauma. LN 12 stated she was not aware that Resident 35 had PTSD. During an interview with the Social Services Director (SSD) on 1/29/25 at 12:50 P.M., the SSD stated knowing a resident's PTSD diagnosis and triggers are important, .to make sure their emotions are managed .to make sure we're tending to their emotional needs . During an interview with Director of Nursing (DON) on 1/29/25 at 12:55 P.M., the DON stated it was his expectation for staff to know a resident's PTSD diagnosis and the accompanying triggers. The DON stated, .its important to determine triggers to minimize the episode. It also gives some control back to the patient .we are trying to prevent harm and mental anguish for the patient . The DON stated it was important to provide trauma-informed care to prevent the resident from harming themselves, or staff. A review of Resident 35's care plans dated 5/25/24 indicated, Review identified triggers with the relevant staff . A review of the facility's policy titled, Trauma Informed Care ; Screening, Training, and Care Integration Program dated June 28, 2019 indicated .Policy .The facility will ensure residents who are trauma survivors receive culturally competent, trauma informed care; account for resident experience and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident .Trauma assessment and screening .The IDT will meet to discuss the results of the trauma informed screen document and implement a plan of care to address potential trauma triggers and prevent re-traumatization.

Based on interview and record review, the facility failed to monitor behaviors and side effects of a psychotropic medication (a drug to control thoughts and behaviors) for one of five residents (Resident 11) reviewed for unnecessary psychotropic medications. This failure placed the resident at risk for receiving unnecessary medication and having unrecognized adverse reactions. Findings: According to the Admission Record, Resident 11 was admitted on [DATE] with diagnoses which included Tourette's Disorder (a disorder that causes people to make sudden and repeated twitches, movements, or sounds) and dementia. According to the Minimum Data Set (MDS, an assessment tool) Resident 11 had a BIMS (a tool to assess cognition) of 8, which indicated cognitive impairment. On 1/27/25 at 8:46 A.M., an observation was conducted in Resident 11's room. Resident 11 was in bed and repeatedly stated, [NAME]! [NAME]! [NAME]! Resident 11 was observed with an open wound between the upper lip and nose. Resident 11 did not respond to questions by the surveyor. On 1/27/25 at 11:18 A.M., an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 11 had the open wound due to a behavior of repeatedly hitting himself with a plastic cup. LN 11 stated the behavior was a symptom of Tourette's Disorder. LN 11 stated, .he does it for twenty seconds, and then stops. LN 11 stated Resident 11 was on medication for the Tourette's disorder. A review of Resident 11's Order Summary Report dated 12/4/24 indicated, risperidone (a psychotropic medication) oral tablet 2.5 mg. Give 2.5 mg by mouth two times a day for Tourettes AEB (as evidenced by) tics and skin picking . A review of Resident 11's Medication Administration Record (MAR) did not indicate Resident 11's behaviors of tics and skin picking were being tracked by nursing. There was no evidence in the MAR that Resident 11 was being monitored for side effects of risperidone. On 1/30/25 at 12:54 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was important to monitor Resident 11's behaviors because, You want to see if what we're using is effective, or to go to something different, a new medication .we should have monitored the behaviors to see if the medication was working . The DON also stated it was important to monitor Resident 11 for side effects related to psychotropic medications. The DON stated, We need to look for side effects because it could be detrimental for the patients themselves. It might be necessary for a change in medication. On 1/30/25, a review of a policy titled Behavior/Psychoactive Drug Management dated 11/18 indicated, .F. Any order for psychoactive medications must include .v. Specific behavior manifested .I. Monitoring for Side Effects .the resident should be observed and/or monitored for side effects and adverse consequences.

Based on observation, interview, and record review, the facility failed to secure one of three treatment carts (East Station) and one of three medication carts (East Station), when reviewed for Pharmacy Services. This failure had the potential for residents, staff, and visitors to have access to unauthorized medications and wound supplies. Findings: An observation was conducted on 1/30/25 at 7:15 A.M., in East Station area near the nurse's station. A treatment cart was up against the wall between the nurse's station and the exit door to the secured unit (a specialized care unit which is locked and limits residents with memory loss or mental health issues from exiting the unit without supervision), and was unlocked. In the top drawer of the treatment cart were prescriptions creams and ointments. The second drawer contained scissors and wound dressing material. No staff were present in the area. An observation was conducted on 1/30/25 at 7:16 A.M., in the East Station area across from the treatment cart. A medication cart was pushed up against the exterior nurse's station and was unlocked. The first and second drawer contained, over-the-counter medications and prescription medications. No staff were present in the area. An observation and interview was conducted with licensed nurse 1 (LN 1) on 1/30/25 at 7:18 A.M., as she exited the secure unit. LN 1 stated she forgot to lock the medication cart when she left the East Station. LN 1 stated with the medication cart being left unlocked, residents, staff, and visitors could have access to medications, which could have caused harm. LN 1 stated she did not know who was responsible for locking the treatment cart, but it also contained prescriptions and equipment that could be harmful to unauthorized people. LN 1 stated the treatment cart should also have been locked when unattended. An interview was conducted with the Director of Staff Development (DSD) on 1/30/25 at 7:30 A.M. The DSD stated treatment carts and medication carts must be locked and secured when not in use to prevent theft. The DSD stated the treatment carts and medication carts contained medications which had the potential to cause harm if accessed by residents, staff, or visitors. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9:00 A.M. The DON stated he expected all treatment carts and medications carts to be locked when not in use. The DON stated when the carts were left unlocked, residents, staff, and visitors had access to unauthorized medications which could cause harm. According to to facility's policy, titled Medication Storage in the Facility, dated April 2008, .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications .

Based on observation, interview, and record review, the facility failed to accurately document: 1. Food intake percentages (how much a resident consumes for each meal) for one of one resident (Resident 3), reviewed for nutrition; and 2. Care given to one of three residents (Resident 84) reviewed for Activities of Daily Living (ADL'S). As a result, resident records were inaccurate and did not give a clear picture of the resident's current status to other care providers. Cross Reference (F-692) Findings: 1. Resident 3 was readmitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a progressive brain disorder that causes nerve cells in the brain to deteriorate, leading to body movement problems), per the facility's Admission Record. An observation was conducted of Resident 3 on 1/27/24 at 9:58 A.M., in his room. Resident 3 had a covered, untouched breakfast tray sitting on his bedside table. An observation and interview was conducted with Resident 3 on 1/27/25 at 12:52 P.M. in his room. Resident 3 was heard telling staff if did not want his lunch tray and to take it away. An unidentified staff returned Resident 3's lunch tray to the food cart. Resident 3 was observed dressed, lying in bed. Resident 3 stated he did not want his lunch because he could not see it and he did not eat anything he could not see. Resident yelled, I'm blind and can't see. I keep telling everyone, but no one listens. An observation and interview was conducted on 1/28/25 at 10:13 A.M. with Certified Nursing Assistant 1 (CNA 1). Resident 3's uneaten breakfast tray 2 was removed by CNA 1. CNA 1 stated Resident 3 does not usually eat breakfast. Resident 3's clinical record was reviewed on 1/28/25. According to the physician's order, dated 5/10/24, Resident 3 required a fortified diet, regular texture with regular to thin consistency. According to the facility's Change of Condition report, dated 1/16/25, Resident 3 has an identified weight loss. According to the facility's Task, certified nursing assistants documented food percentage consumed by Resident 3 on 1/27/25, as 75-100% of breakfast and lunch. An interview and record review was conducted with the Registered Dietician (RD) on 1/29/25 at 10:13 A.M. The RD stated she was dependent on staff to accurately document food intake, especially on residents experiencing weight loss. The RD stated if the documentation of food percentages was in inaccurate, she was not provided a clear picture of the resident, and it could cause additional weight loss. The RD reviewed Resident 3's clinical record for food percentages and stated Resident 3 was currently experiencing weight loss and she was monitoring his daily intake. The RD stated his intake for 1/27/25 was documented as 75-100% consumed and based on the surveyor's observation for breakfast and lunch, the documentation was not accurate. An interview was conducted with the Director of Nursing (DON) on 1/30/25 at 9 A.M. The DON stated documentation of food percentages was very important to staff to prevent weight loss. The DON stated he expected accurate documentation because it directly affects nutrition services. According to the facility's policy, titled Food Intake-Recording Percentage & Nutrition Assessment, dated January 2012, .II. After a resident had completed the meal, the CNA will record the amount eaten on the resident's food intake record after the completion of each meal . IV.A. If more than 50% of the entire meal is refused by the resident .the charge nurse will review the resident's fluid intake, weight stability pattern, presence/absence of acute underlying medical problem . 49330 2. According to the Admission Record, Resident 84 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) affecting the right dominant side, and functional quadriplegia (a condition that causes a person to be completely unable to move). A review of Resident 84's chart indicated Resident 84 received a shower on 1/27/25 at 8:05 P.M. Resident 84's chart indicated the shower was given by CNA 14. During an interview on 1/28/25 at 4 P.M., CNA 13 stated she gave Resident 84 a bed bath on 1/27/25, not a shower. CNA 13 further stated she was unable to access the Electronic Health Record (EHR), and used CNA 14's username and password to document the care given for Resident 84. CNA 13 stated it was important to document under her own username and password to communicate the correct care given. On 1/30/25 at 12:46 P.M. an interview was conducted with the Director of Staff Development (DSD). The DSD stated, .passwords should not be shared because its someone else's name and license. I wouldn't want someone else to make a mistake under my name .its not accurate . The DSD further stated, .its important to be accurate to know what got done, so if there's an issue we know where we go. We can't [initiate] proper interventions if the charting is inaccurate . On 1/30/25 at 12:56 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was his expectation for staff to accurately document what care was provided to the residents. During a record review on 1/30/25, a policy titled Medical Record Content dated 1/1/12, did not provide guidance on accuracy of documentation.

Based on observation, interview, and record review, the facility failed to implement its policy and procedure for fall prevention program for two of three sampled residents (Residents 2 and 3) who had incidents of repeated falls. This failure placed Residents 2 and 3 at risk for further falls and injuries. Findings: 1) According to the Admission Record, Resident 2 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included history of falling, lack of coordination, and abnormalities of gait and mobility. A review of the facility's Incidents By Incident Type log indicated Resident 2 had unwitnessed falls on 11/1/24 and 12/3/24. On 12/27/24 at 9:55 A.M., Resident 2 was observed in bed. There was a small cut on the left side of Resident 2's forehead. Resident 2's call light was observed plugged into the wall and was missing the cord and button. On 12/27/24 at 10:04 A.M., a concurrent interview and observation was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was the assigned CNA for Resident 2. CNA 1 stated Resident 2 recently had a fall but did not know when or why. CNA 1 stated Resident 1 sustained a laceration (cut) to the forehead during the fall. CNA 1 stated, .[Resident 2] is a fall risk. She can still walk but she's not stable . CNA 1 stated Resident 2 attempts to stand up and walk unassisted. CNA 1 acknowledged Resident 2 did not have a call light cord or button. CNA 1 stated, .its important for [Resident 2] to have a call light, especially if they need help, if there's an emergency. She could fall again . A review of Resident 2's Electronic Health Record (EHR) indicated an IDT (Interdisciplinary Team-a group of people with different areas of expertise) Meeting was not conducted to address the falls on 11/1/24 and 12/3/24. On 12/27/24 at 1:50 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated IDT meetings should have been conducted after each fall to determine the root cause. The IDON stated, .we didn't do an IDT. We didn't do a new intervention . The IDON stated it was important to determine the root cause to create a plan of care that would prevent further falls. A review of the facility's policy titled Fall Management Program revised 11/7/16 indicated, .The IDT will initiate a fall investigation .the IDT will summarize conclusions after their review of the fall and circumstances surrounding the fall on an IDT note. The plan of care will also be reviewed, and the care plan will be revised as necessary in an effort to prevent further falls . 2) According to the Admission Record, Resident 3 was admitted on [DATE] with diagnoses which included history of falling. According to the MDS (Minimum Data Set-an assessment tool) dated 10/22/24, Resident 3 had a BIMS (Brief Interview for Mental Status-a tool to assess cognition) of 1 indicating severe cognitive impairment. A review of the facility's Incidents By Incident Type log indicated Resident 3 had unwitnessed falls on 11/10/24 and 12/13/24. On 12/27/24 at 10:25 A.M., an observation was conducted in the hallway outside Resident 3's room. The door to Resident 3's bedroom was closed. Resident 3's name was on the wall along with the names of two roommates, without any indication of the residents being a fall risk. Upon entering the room, Resident 3 was observed laying in bed. Resident 3's call light was observed clipped to the wall, out of Resident 3's reach. On 12/27/24 at 10:33 A.M., an interview was conducted with CNA (Certified Nursing Assistant) 2. CNA 2 stated she was Resident 3's assigned CNA. CNA 2 stated Resident 3 was not a fall risk. CNA 2 stated Resident 3's bedroom door is always closed because , [Resident 3's roommate] likes the door closed . CNA 2 stated, .[Resident 3] moves around a lot in bed, all day. I've seen her scoot up, to her left and right . CNA 2 stated it was important for Resident 1 to have access to her call light .just in case something happens. In case they fall . On 12/27/24 at 11 A.M. an interview was conducted with LN (Licensed Nurse) 1. LN 1 stated he was the supervising nurse for the unit. LN 1 stated he did not that Resident 3 had a fall on 12/13/24 and he was not aware that she was a fall risk. LN 1 stated, She [Resident 3] should've had her call light next to her. Especially with her door closed, she could try to get up and we wouldn't see her . During an interview with the IDON on 12/27/24 at 1:50 P.M., the IDON stated the facility did not have any identifying logos or designations to alert staff to residents who were a fall risk. The IDON stated her expectation was for staff to ensure residents were able to easily access their call lights. The IDON stated, .yes they should have the call light to call for help, especially if they're a fall risk . A review of Resident 3's care plans indicated there were no new interventions implemented after the fall on 11/10/24 and 12/13/24. A review of the facility's policy titled Fall Management Program revised 11/7/16 indicated, .A resident who sustains multiple falls .will be considered a high risk to fall .These residents may: i. be identified by a special logo or designation to alert staff to their high-risk activity; ii. May require more frequent observation of activities and whereabouts .These interventions will be documented on the resident's plan of care .

Based on interview and record review, the facility failed to ensure resident rights were honored for 1 of 3 sample residents (1) when the Medical Record Department (MRD) could not provide evidence that Resident 1's representative received copies of the medical record requested in a timely manner. As a result, there was a delay in reviewing Resident 1's medical record. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, per the Admission Record. On 10/2/24 at 2:20 P.M., an unannounced onsite visit at the facility was conducted for an complaint investigation related to a medical record request. On 10/2/24 at 3 P.M., an interview was conducted with the Medical Record Director (MRD). The MRD stated she did not have a log of the names of the residents or representatives who requested access to medical records. The MRD further stated their process was for the resident or representative to complete the request form. The MRD then asked the corporation via e-mail for approval to release the medical records, and once the request was approved, she prepared the documents. The MRD stated she was unsure when the resident or the representative should receive a hard copy of the medical record. The MRD stated Resident 1's representative wrote them a letter dated 6/25/24 requesting to get a copy of Resident 1's medical record. She completed the request form and e-mailed the corporate on 7/23/24. The MRD stated the corporation responded to her e-mail on 7/30/24. The MRD printed Resident 1's medical record, and the representative picked up the copies around 8/2/24. A follow-up interview and policy review were conducted with the MRD. The MRD stated the representative did not receive the medical record within two working days and should have. On 10/2/24 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the facility's policy and procedure for requesting medical records should have been followed. Per the facility's policy and procedure, dated 10/1/15, titled Resident Access to PHI [Protected Health Information], .provide the resident and/or their personal representative with a copy of the medical record within two (2) working days after receiving the written request .Documentation A. The facility will document the following information on HP-08-Form C- Log of Requests for Access to PHI .The date the Facility's response .

Based on interview and record review, the facility failed to follow appropriate discharge protocols for one of one resident (Resident 1). This failure had the potential for Resident 1 not being able to return to the facility which he considered his home and not being able to appeal the discharge. Finding: During a review of the Admission Record, Resident 1 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (irreversible kidney failure). During a review of the Bed Hold Agreement dated September 10, 2024. The Bed Hold agreement indicated that the facility will hold Resident 1 ' s bed for up to seven (7) days if the resident is transferred to a general acute care hospital The document indicated that Resident 1 was being transferred to [name] Hospital. During a review of the facility census, it indicated Resident 1 had a bedhold for September 10, 11, 12, 13, 14, 15 and 16. Per the same facility census, on September 17, 18, 19 it indicated Resident 1 was no longer on the census and was listed as being discharged . During a phone interview on September 26, 2024, at 14:25 P.M., with the complainant who was the case manager at [name] hospital. The complainant stated Resident 1 was ready to be discharge on September 12 and had a discharge order. The complainant further stated she called the facility DON and the DON refused to take Resident 1 back and said Resident 1 had been discharged . During a phone interview on September 24, 2024, at 15:02 P.M., with Resident 1. Resident 1 stated, They say I am not welcome there, but that ' s like my home, my stuff is still there. How am I going to get that? During an interview on September 24, 2024, at 10:07 A.M., with DON. The DON stated Resident 1 was on a seven-day bed hold then discharged because the facility cannot meet his needs. The DON also stated that Resident was non-compliant with medications and diet, often refusing medications and ordering meals from outside of the facility. There were no evidence of documentation that Resident 1 was provided a 30 day notice and how to appeal. There were no evidence of documentation that the facility did a proper discharge for Resident 1. During a review of facility policy and procedure titled, Transfer and Discharge; Operational Manual- Social Services Revision date October 2017, the policy indicates, A . the Facility should provide at least 30 days ' notice before the resident is transferred or discharged .

Based on interviews and record review the facility failed to provide a medication as ordered by the physician to one (Resident 1) of three sampled residents. This failure had the potential to elevate Resident 1 ' s ammonia levels. Resident 1 ' s record was reviewed. Per Resident 1's Admission Record, Resident 1 is a [AGE] year-old female admitted to the facility on [DATE]. Resident 1 ' s diagnosis included cirrhosis of the liver (scarring that prevents the liver from working properly) and hepatic encephalopathy (loss of brain function when the liver does not work properly). During a record review of Resident 1 ' s admission orders dated 8/30/24, Resident 1 was admitted with a physician's order for lactulose (a medication used to prevent and treat hepatic encephalopathy) 30 grams by mouth three times a day. During a record review of Resident 1 ' s Medication Administration Record (MAR) for August 2024, the Licensed Nurse (LN) had not initialed or signed (recorded administration) lactulose medication was administered for the morning and midday doses for 8/31/24. During a record review of Resident 1 ' s MAR for September 2024, the recording areas of Resident 1's MAR for the morning dose on September 5, 2024, was left blank and the LN had not initialed or recorded administration of lactulose. During a record review of facility document Preparation and General Guidelines IIA2: Medication Administration-General Guidelines dated October 2017. C. Documentation 1) The individual who administers the medication dose records the administration on the resident ' s MAR directly after the medication is given . 4) The resident ' s MAR is initialed by the person administering the medication in the space provided under the date, and on the line for that specific medication dose administration. During an interview on 9/17/24 at 11:07 A.M. LN1 stated we (licensed nurses) give medications based on the resident ' s conditions and the doctor ' s orders. LN1 stated I mark it in the MAR. LN 1stated, I can tell when a medication was given because a name (of a LN) is next to the time. LN 1 further stated, If a dose is missed, we notify the doctor and see what they want to do. If the medication is missed there will be no licensed nurse name in the MAR. During an interview on 9/17/24 at 11:35 A.M. LN2 stated When medications are missed, the doctor is notified, and a note is added in the computer chart under the Prog Note tab. During an interview and record review on 9/17/24 at 12:23 P.M. with the DON, the MARs dated August 2024 and September 2024 for Resident 1 were reviewed. The DON stated according to the Resident 1's MAR the medication was not given. The DON also stated, depending on the medication, a missed dose could be very bad for the resident ' s health.

Based on interview and record review, the facility failed to provide a safe environment for one of three residents (Resident 1) reviewed for accidents. Resident 1, who was known to have a history of suicidal attempt (the act of intentionally causing one ' s death), was left unattended during a mealtime, and swallowed part of a metal fork. As a result, Resident 1 was transferred to the hospital to remove the metal fork from her body. Findings: Resident 1 ' s clinical Admission record was reviewed on 4/3/24. Per Resident 1 ' s Admission record, Resident 1 was admitted to the facility ' s secured unit (a specially designed space for residents to have resources they require to live safely) on 2/12/24. Per the same Admission record, Resident 1 ' s diagnoses included personal history of suicidal behavior. A review of Resident 1's hospital clinical record prior to being admitted to the facility was conducted. According to Resident 1 ' s ED (Emergency Department) Note, dated 10/27/23, Resident 1 swallowed the temple (the arms on each side of the frame, extending from the front of the frame to behind the ears) part of a pair of reading glasses. The note indicated that Resident 1 had a history of suicidal ideation and had multiple visits to the hospital due to swallowing foreign objects. According to Resident 1 ' s Hospital Discharge Summary, dated 2/12/24, Resident 1's primary diagnosis was a history of attempted suicide. A review of Resident 1 ' s facility ' s plan of care, initiated on 2/17/24 was conducted. The care plan indicated that Resident 1 had a behavior problem of harming self. According to Resident 1 ' s care plan, one of the interventions, initiated on 3/6/24, was to provide close monitoring of Resident 1 during mealtime. On 3/26/24, per the IDT (Interdisciplinary Team) meeting notes, the Director of Nursing (DON) documented Resident 1 would be closely monitored during mealtime. A record review of Resident 1 ' s progress notes, dated 3/26/24 at 5:07 P.M., written by licensed nurse (LN) 3, was conducted. LN 3 documented that Resident 1 had shown breaking the plastic and metal forks in half during mealtime. LN 3 further documented that Resident 1 would be closely monitored and one-to-one assistance would be provided to Resident 1 during meals. On 3/28/24 at 4:38 P.M., under System Note, LN 2 documented that Resident 1 continued to be supervised when eating. A record review of Resident 1 ' s progress notes, dated 3/29/24 at 9:29 A.M., written by the Assistant Director of Nursing (ADON) was conducted. The ADON documented that [on 3/29/24] Resident 1 verbalized ending her life and swallowed a fork. The progress note indicated that the staff (CNA 1) found a broken fork with a missing handle, and Resident 1 was transported to the hospital via 911 (emergency responders). On 4/3/24 at 1:15 P.M., an interview was conducted with the DON. The DON stated on 3/29/24 Resident 1 swallowed a metal fork and went to the hospital. Resident 1 was currently in the hospital for the removal of the object. On 4/3/24 at 4:20 P.M., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated that the LNs told her to stay in Resident 1 ' s room the entire time during meals. On 4/3/24 at 4:30 P.M., an interview was conducted with LN 1. LN 1 stated she was the assigned LN for Resident 1 on the day of the incident (when Resident 1 swallowed the fork) on 3/29/24. LN 1 stated she told CNA 1 in the morning to provide one-to-one supervision and monitor Resident 1 closely, and to not leave Resident 1 with utensils. On 4/4/24 at 4 P.M., an interview was conducted with CNA 3. CNA 3 stated that the LN instructed her to always sit with Resident 1 while eating for safety. On 4/4/24 at 4:14 P.M., an interview was conducted with LN 2. LN 2 stated she documented on 3/28/24 that Resident 1 need to be supervised when eating continued. On 5/7/24 at 1:45 P.M., an interview was conducted with LN 3. LN 3 stated on 3/26/24, he observed Resident 1 bending the plastic and the metal utensils. LN 3 stated, for Resident 1's safety nursing and medical staff accelerated the plan of care, and the intervention was to provide Resident 1 with one-to-one feeding assistance, not to feed Resident 1, but to ensure Resident 1 did not swallow anything that was not meant to be eaten. On 5/7/24 at 3:55 P.M., an interview was conducted with CNA 1. CNA 1 stated she was the assigned CNA to Resident 1 on 3/29/24, and LN 1 told her not to leave Resident 1 alone during mealtime. CNA 1 stated Resident 1 was having breakfast in her bed asked for a blanket. CNA 1 further stated she knew not to leave Resident 1, but she was naive and believed Resident 1 would be okay alone and left to get a blanket. CNA 1 stated she left Resident 1 ' s room for a minute and heard Resident 1 cough when she (CNA 1) was outside of Resident 1 ' s room. When CNA 1 returned to Resident 1 ' s room with a blanket and noticed Resident 1's fork was missing. CNA 1 stated, Resident 1 said she swallowed the fork, and she (CNA 1) called LN 1 and the ADON and DON came in the room, and Resident 1 was transferred to the hospital via 911. A record review on 5/15/24 of Resident 1 ' s hospital x-ray (a photographic or digital image of the internal composition of something, especially a part of the body, produced by X-rays being passed through it and being absorbed to different degrees by different materials) report dated 3/29/24, indicated an elongated metallic density (the degree of film darkening) measuring 13.5 centimeters (cm) by 1.5 cm projecting over the left upper abdomen. A record review on 5/15/24 of Resident 1 ' s GI (Gastro-Intestinal-) Procedure Report, dated 3/29/24, indicated Resident 1 had an EGD procedure (Esophagogastroduodenoscopy - a procedure that involves removing foreign objects from the esophagus, stomach or intestine using flexible tube-like instrument into the body to look inside. The report indicated the physician removed the utensil handle from Resident 1's stomach. The facility could not provide a policy about safe environment or supervision during meal time.