Every finding on record at Griffith Park Healthcare Center

Based on interview and record review, the facility failed to develop a care plan for one of four sample residents (Resident 1), to ensure resident was monitored for the effectiveness and side effects of Percocet (a strong pain medication combination of Oxycodone [a strong opioid] and Acetaminophen [Tylenol]) 5-325miligrams (mg, unit of weight) that was given as needed for moderate to severe (4-10/10 on the numerical pain scale [a way to rate pain intensity, ranging from 0 - no pain to 10 - worst pain felt]) pain in accordance with the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, This deficient practice placed Resident 1 at risk for ineffective pain management, overdose of medication or delayed identification of preventable side effects of Percocet such as drowsiness, constipation, dizziness, and nausea or vomiting. Findings: During a review of Resident 1's admission Record (AR), the AR indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) with exacerbation, urinary tract infection (UTI, an infection in the bladder/urinary tract), and acute kidney failure (kidneys suddenly stop working). During a review of Resident 1's history and physical (HP), dated 4/11/2026, the HP indicated that Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment), dated 4/17/2026, the MDS indicated that Resident 1 cognition (resident's thought process) was severely impaired. The MDS indicated that Resident 1 received scheduled pain management and was receiving an opioid. During a review of Resident 1's Order Summary Report, the order, dated 4/10/2026 and 4/23/2026, indicated that Resident 1 received Acetaminophen (Tylenol) 325 mg 2 tablets by mouth every 6 hours as needed for mild pain (1-3/10 on the numerical pain scale). During a review of Resident 1's Order Summary Report, dated 4/10/2026 and 4/23/2026, indicated the physician ordered Resident 1 to received Percocet Oral Tablet 5-325 mg 1 tablet by mouth every 6 hours as needed for moderate to severe pain. During a review of Resident 1's Medication Administration Record (MAR), for April and May 2026, Resident 1 received Percocet multiple times. Resident 1 received Percocet 13 times from 4/12/2026 to 4/18/2026 and 21 times from 5/1/2026 to 5/17/2026. During a concurrent interview and record review on 7/22/2026 at 1:40 PM with Licensed Vocational Nurse (LVN) 2, Resident 1's MAR for May 2026 was reviewed. LVN 2 stated that Resident 1 complained of pain and her pain medication management included Tylenol 325mg and Percocet 5-325mg. During a concurrent interview and record review on 7/22/2026 at 4:30 PM with the Quality Assurance (QA) nurse, Resident 1's care plans were reviewed. The QA nurse stated that Resident 1 did not have any care plans related to Percocet. The QA nurse stated that Percocet was an opioid, and a care plan needed to be developed for its indication for use, for monitoring the effectiveness of the pain medication, and monitoring for the side effects such as drowsiness, constipation, dizziness, and nausea or vomiting. During the same concurrent interview and record review on 7/22/2026 at 4:45 PM with the QA nurse, Resident 1's Order Summary Report were reviewed. The QA nurse stated that there was no order to monitor the side effects of Percocet such as monitoring for drowsiness, constipation, dizziness, or nausea or vomiting. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional need is developed and implemented for each resident. The P&P indicated that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. During a review of the same P&P titled Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated that the comprehensive, person-centered care plan will include, but not be limited to describing the service that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and will aid in preventing or reducing decline in the resident's functional status and/or functional levels.

Based on observation, interview, and record review, the facility failed to receive necessary services with activities of daily living (ADL) for one of four sample residents (Resident 2), a resident with a recent below the knee amputation (BKA, surgical removal of the portion of the leg below the knee), when the staff did not answer his call light (a safety and communication device resident use to signal staff for assistance) when he needed help to transfer in and out of his wheelchair (a chair with wheels used as a mode of transportation) to go to the bathroom for bowel movement in accordance with the facility's policy and procedure titled, Activities of Daily Living, Supporting, This deficient practice resulted in Resident 2 attempting to self-transfer in and out of his wheelchair to use the bathroom without assistance which could result in Resident 2 decline in performing ADLs and losing balance, falling, or sustaining an injury that may result in hospitalization. Findings: During a review of Resident 2's admission Record (AR), the AR indicated that Resident 2 was admitted to the facility on [DATE]. The AR did not provide documented evidence of Resident 2's medical diagnoses. During a review of Resident 2's history and physical (HP), dated 7/22/2026, the HP indicated that Resident 2's diagnoses included left foot with an open wound, acquired absence of the left leg below the knee and acute kidney failure (kidneys suddenly stop working). The HP indicated that Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, dated 7/22/2026, indicated, Resident 2 received a Physical Therapy (PT, type of therapy that uses exercise to promote, maintain, and restore physical movement and function) evaluation as needed. During a review of Resident 2's PT evaluation record, dated 7/22/2026, the record indicated that Resident 2 had a BKA on 7/9/2026, and on 7/14/2026 lost his balance while attempting to step up one stair and fell to the ground. The record indicated that Resident 2 had fallen at the facility on the morning of 7/22/2026 attempting to self-transfer in and out of the toilet without assistance. The PT evaluation indicated Resident 2's required maximum assistance with transfers from bed/chair to chair or to the toilet. During a concurrent observation and interview on 7/22/2026 at 2:45 PM in Resident 2's room with Resident 2, Resident 2 was observed sitting in bed with a left lower leg BKA wrapped in an ace bandage and a wheelchair by the bedside. Resident 2 stated he was admitted to the facility yesterday (7/21/2026) for rehabilitation after his recent left lower leg BKA surgery and has been experiencing diarrhea since yesterday (7/21/2026) night and this morning (7/22/2026). Resident 2 stated that he needed assistance transferring in and out of his wheelchair to go to bathroom because of his recent BKA. Resident 2 stated that last night (7/21/2026) and this morning (7/22/2026), he had pressed the call light for assistance to the bathroom and waited until he could not hold it anymore, so transferred himself in and out of his wheelchair to go to the bathroom without assistance. During the same interview on 7/22/2026 at 2:50 PM in Resident 2's room, Resident 2 stated that this morning (7/22/2026) when he attempted to stand up and self-transfer into his wheelchair since no one came to answer his call light, he lost balance in his right leg and almost fell down but [he] was able to grab the wall before he had the opportunity to fall. During an interview on 7/22/2026 at 3 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she saw Resident 2 attempting to stand up from his wheelchair at the doorway and he lost his balance. LVN 1 stated Resident 2 was able to lean up against the wall when he lost his balance to prevent himself from falling. During an interview on 7/22/2026 at 4:55 PM with the Director of Nursing (DON), the DON stated she did not know the reason why Resident 2's call light was not answered right away. The DON stated that it was important to respond to the call light as soon as possible to attend to a resident need such as assistance to the bathroom, especially a resident with a BKA as these residents require maximal assistance with transfers. During a review of the facility's policies and procedures (P&P) titled Activities of Daily Living, Supporting, dated March 2018, the P&P indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the same P&P titled Activities of Daily Living, Supporting, dated March 2018, the P&P indicated that the appropriate care and service will be provided for residents who are unable to carry out ADLs independently will include the appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks), and communication (speech, language, and any functional communication system).

Based on observation, interview and record review the facility failed to assist and supervise one of three sampled residents (Resident 2) who was at risk for fall, recent left below the knee amputation (BKA- surgical removal of the limb below the knee) and history of fall in the last three months, in accordance with the facility's policy and procedure titled Safety and Supervision of Residents when the facility staffs did not answer his call lights when the resident needed assistance with transfers from bed to wheelchair to go to the toilet due to having diarrhea. This deficient practice resulted in Resident 2's losing his balance when transferring to and from the wheelchair and had a near fall incident that could result in pain and injuries prolonging resident's hospitalization on 7/22/2026. Findings: During a review of Resident 2's admission Record (AR), the AR indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), chronic kidney disease (kidneys suddenly stop working), and acquired absence of the left leg below knee. During a review of Resident 2's Fall Risk Assessment, dated 7/21/26, indicated resident was at risk for all due to history of fall in the last 3 months, balance problem while standing, walking and unstable when turning. During a review of Resident 2's history and physical (HP), dated 7/22/2026, the HP indicated that Resident 2's diagnoses included left foot with an open wound, acquired absence of the left leg below the knee and acute kidney failure (kidneys suddenly stop working). The HP indicated that Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, dated 7/22/2026, indicated, Resident 2 received a Physical Therapy (PT, type of therapy that uses exercise to promote, maintain, and restore physical movement and function) evaluation as needed. During a review of Resident 2's PT evaluation record, dated 7/22/2026, the record indicated that Resident 2 had a BKA on 7/9/2026, and on 7/14/2026 lost his balance while attempting to step up one stair and fell to the ground. The record indicated that Resident 2 had fallen at the facility on the morning of 7/22/2026 attempting to self-transfer in and out of the toilet without assistance. The PT evaluation indicated Resident 2's required maximum assistance with transfers from bed/chair to chair or to the toilet. During a concurrent observation and interview on 7/22/2026 at 2:45 PM in Resident 2's room with Resident 2, Resident 2 was observed sitting in bed with a left lower leg BKA wrapped in an ace bandage and a wheelchair by the bedside. Resident 2 stated he was admitted to the facility yesterday (7/21/2026) for rehabilitation after his recent left lower leg BKA surgery and has been experiencing diarrhea since yesterday (7/21/2026) night and this morning (7/22/2026). Resident 2 stated that he needed assistance transferring in and out of his wheelchair to go to bathroom because of his recent BKA. Resident 2 stated that last night (7/21/2026) and this morning (7/22/2026), he had pressed the call light for assistance to the bathroom and waited until he could not hold it anymore, so transferred himself in and out of his wheelchair to go to the bathroom without assistance. During the same interview on 7/22/2026 at 2:50 PM in Resident 2's room, Resident 2 stated that this morning (7/22/2026) when he attempted to stand up and self-transfer into his wheelchair since no one came to answer his call light, he lost balance in his right leg and almost fell down but [he] was able to grab the wall before he had the opportunity to fall. During an interview on 7/22/2026 at 3 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she saw Resident 2 attempting to stand up from his wheelchair by the doorway and he lost his balance. LVN 1 stated Resident 2 was able to lean up against the wall when he lost his balance to prevent from falling. During an interview on 7/22/2026 at 4:55 PM with the Director of Nursing (DON), the DON stated she did not know the reason why Resident 2's call light was not answered right away. The DON stated that it was important to respond to the call light as soon as possible to attend to a resident need such as assistance to the bathroom, especially a resident with a BKA as these residents require maximal assistance with transfers to prevent falling and accidents. During a review of the facility's policy and procedure, dated 3/2018, titled Fall Risk Assessment the staff and the attending physician will collaborate to identify and address modifiable fall risk and interventions to minimize the consequence of risk factors that are not modifiable. During a review of the same P&P titled Activities of Daily Living, Supporting, dated March 2018, the P&P indicated that the appropriate care and service will be provided for residents who are unable to carry out ADLs independently will include the appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting). During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017, indicated the facility shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated resident supervision is a core component to safety.

Based on interview and record review , the facility failed to provide quarterly statements of the residents personal trust fund account ( P&I - money that belongs to the resident but is held, safeguarded, and managed by the facility on the resident's behalf) for 3 of 3 sampled residents ( Resident 2, 3, and 4), in accordance with the facility's Policy and Procedure (P&P) titled, Quarterly Accounting of Resident Funds. This deficient practice had the potential to prevent residents and / or their representatives from monitoring account balances and ensuring proper management of resident personal funds. Findings: During a review of Resident 2's admission Record ( AR), the AR indicated Resident 2 was originally admitted to the facility on [DATE], with diagnosis that included toxic encephalopathy( condition in which the brain does not function normally because it has been affected by a toxic substance or imbalance), Respiratory failure( a condition in which the lungs cannot adequately oxygenate the blood and / or remove carbon dioxide) , and pulmonary disease( diseases affecting the lungs and respiratory system). During a review of Resident 2's Minimum Data Set ( MDS- a resident assessment tool) dated 4/1/2026, the MDS indicated the resident had moderate cognitive ( ability to reason and thought process) impairment. The MDS also indicated the resident required moderate assistance with activities of daily living ( ADLs) such as oral hygiene, toileting , shower/ baths, and dressing.During a review of Resident 3's admission Record ( AR), the AR indicated Resident 2 was originally admitted to the facility on [DATE], with a diagnosis that included respiratory failure ( a condition which the lungs cannot provide enough oxygen to the body or cannot remove enough carbon dioxide from the blood) , contracture of left ankle ( the left ankle has become stiff and cannot move normally because the tissues around the joint have tightened) , and malignant neoplasm ( cancerous tumor ) of right kidney. During a review of Resident 3's History and Physical (H&P) dated 2/23/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 11/8/2025, the MDS indicated the resident was cognitively intact ( able to think, understand, and remember, with normal thinking abilities) and requires only supervision with most activities of daily living. During a review of Resident 4's admission record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE], with a diagnosis of fibromyalgia( the body's pain signals become overactive, causing a person to hurt all over, even when there is no injury) , Rheumatoid Arthritis( The body mistakenly attacks the joints, making them swollen, stiff, and painful) and epilepsy ( the electrical signals in the brain sometimes misfire, causing shaking or jerking movements). During a review of Resident 4's History and physical (H&P) dated 4/14/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set ( MDS - a resident assessment tool) dated 12/3/2025, the MDS indicated the resident was cognitively intact ( able to thin, understand, and remember , with normal thinking abilities) and requires only set up or clean up assistance for eating, oral hygiene , toileting and dressing. During a review of a note transcript maintained by third-party representative ( a person or organization appointed by the Social Security Administration ( SSA) to receive and manage benefits on behalf of an individual who is unable to manage their own finances), the transcript indicated documented contacts with facility staff regarding requests for personal trust fund (P&I) ledgers and accounting information for residents of the facility. The transcript indicated entries dated 12/29/2025, 01/28/2026, 03/25/2026, and 04/16/2026 with requests for P&I ledgers. An entry dated 04/16/2026 noted that the facility's business office voicemail had not responded to prior requests and that the requested ledgers dating back to November 2025 had not been received. The document indicates repeated effort by the resident's representative to obtain personal fund accounting records from the facility. During a concurrent interview and Record review on 6/10/2026 at 10:40 AM with regional office representative, Resident 2's fund management service records were reviewed. Regional office representative stated quarterly trust account statements should be generated and provided to the resident's responsible party or representative. However, the regional office representative was unable to verify whether quarterly statements had been provided to Resident 1 and stated she did not have access to that information and had no way to verify it. The Regional office representative further stated the facility had been without a Business Office Manager for approximately five months. During an interview on 6/10/2026 at 11:07 AM with the Facilities Regional Consultant, the consultant stated quarterly statements are typically printed and mailed but could not confirm if quarterly trust account statements were provided to the resident or 3rd party representative appointed by Social Security Department ( SSD).During an interview on 6/10/2026 at 11:40 AM with Resident 2's responsible party (RP), RP stated he was not involved with management of the resident's finances and identified 3rd party representative as the payee. Resident 2's RP further stated the facility has been provided with the payee's information and informed the facility that that payee was responsible for handling the resident's share of cost and personal funds. During an interview on 6/10/2026 with Resident 2, Resident 2 stated she was unaware of her personal funds and did not receive statements showing how much money was available in her account. During an interview on 6/10/2026 at 12:40PM with Director of Nursing ( DON), DON stated the facility had been without a permanent Business Office Manager since February 2026, approximately 5 months . The DON sated the Assistant Business office Manager had been responsible for providing statements, however the DON was unable to explain how the facility ensured quarterly statements were being provided to residents or their representatives. DON stated the normal process required resident to sign a log acknowledging receipt of statements, or statements should be mailed, copies should be maintained, and records should be filed. The DON further stated accountability is necessary to ensure resident funds are properly handled. During an interview on 6/10/2026 at 3:28 PM with Resident 3, Resident 3 stated she was responsible and made her own healthcare decision. Resident 3 stated she had never been provided statements regarding billing or personal funds. Resident 3 stated she would like to know whether she had any money available in her account. During an interview on 6/10/2026 at 3:45 PM with Resident 4 , Resident 4 stated being self-responsible and aware that she had personal funds available through her resident allowance. However, Resident 4 stated she was not provided statements for her personal funds account and was not receiving any quarterly statements. Resident 4 stated she would like to receive statements and reported that when she wanted to know her account balance, she would ask facility staff how much money was available. During a review of the facility's policy and procedure ( P&P) titled, Quarterly Accounting of Resident Funds dated April 2018, indicated that each resident with personal funds managed by the facility shall receive an individual quarterly accounting of funds. The policy further stated that the business office will prepare quarterly statements that include the resident's beginning balance, deposits, withdrawals, interest earned, ending balance, petty cash on hand, and total funds on deposit. The policy identified the Business Office Manager ( BOM) and / or designee as responsible for implementation and enforcement of the policy.

Based on observation, interview, and record review, the facility failed to provide a safe and hazard free environment for one of four sampled residents (Resident 1), who was bedbound and required total care, by failing to identify and address Resident 1's specific risks associated with the use of the Low Air Loss (LAL- an air powered mattress that helps prevent skin breakdown by keeping the skin dry and reducing pressure) Mattress. The facility failed to: 1. Assess and monitor Resident 1's LAL mattress for proper functioning, appropriate settings, and the resident's tolerance to the LAL mattress in accordance with the resident's care plan. 2. Ensure staff communicated and reported significant changes in Resident 1's condition, including repeated observations on different occasions by Certified Nurse Assistant (CNA) 1 that Resident 1 would be found lying on different side positions in bed despite requiring total assistance, preventing timely reassessment and implementation of appropriate safety interventions while on the LAL mattress. 3. Complete the required Quarterly Side Rail Assessment and/or the Alternatives for Bedside Rail Utilization Assessment for [DATE] to determine Resident 1's need for side rails or alternative safety measures, in accordance with the facility's Fall Prevention Program policy, which requires identifying and implementing interventions such as environmental hazard prevention and monitoring. 4. Individualize the care plan to address risks associated with elevated head-of-bed positioning while on a LAL mattress. The facility failed to incorporate interventions to ensure Resident 1's safety while the head of bed was elevated 30 to 45 degrees while on gastrostomy tube (GT) feeding. These deficient practices resulted in Resident 1 sliding out of bed on [DATE], sustaining two open lacerations to the right frontal forehead and mid left hairline. On [DATE], Resident 1 developed severe head pain, headache, and loss of vision, prompting emergency transfer to the General Acute Care Hospital (GACH), where imaging revealed a scalp hematoma, 7 mm leftward midline shift, bilateral nasal bone fractures, and no acute intracranial hemorrhage. Findings: During a review of Resident 1's admission Record (AR) , the AR indicated Resident 1 was originally admitted to the facility on [DATE] with diagnosis that included hemiplegia (complete paralysis on one side of the body) and hemiparesis (weakness on one side of body) following cerebral infarction (stroke caused by a blockage of blood flow to part of the brain) affecting right dominant side of body, ankylosing spondylitis (inflammatory disease that affects the spine and joints of lower back and pelvis) of lumbosacral region, and atrial fibrillation ( an abnormal heartbeat that can cause blood clots and strokes). During a record review of Resident 1's care plan Risk for Skin Breakdown Care Plan dated [DATE], the care plan indicated that Resident 1 may have a LAL mattress and for staff to monitor the setting, placement and functioning for skin management. During a review of Resident 1's care plan Feeding Tube dated [DATE], the care plan indicated that Resident 1's head of the bed must be elevated 30 to 45 degrees when the feeding is on. The care plan did not address resident safety while Resident 1's head of bed was elevated 30 to 45 degrees when using the LAL mattress and without siderails for bed mobility and safety. During a review of Resident 1's most current Fall Risk Evaluation dated [DATE], prior to the fall ([DATE]), the Fall Risk Evaluation indicated Resident 1's gait (a person's way of walking) has balance problems while standing/walking, jerking or unstable when making turns, decreased muscular coordination. The Fall Risk Evaluation indicated that a Score 10 or higher indicated the resident is at high risk for fall. During a review of Resident 1's care plan Fall Risk Care Plan dated [DATE], the Fall Risk Care Plan indicated, Resident 1 was at risk for falls related to gait/balance problem psychoactive drug (a chemical substance that alters brain function, directly affecting how you perceive, think, feel, or behave) use and unaware of safety needs. During a review of Resident 1's physician orders, an order dated [DATE] was reviewed for the use of low air loss mattress (LAL) and for facility staff to monitor the setting at number 3 (weight of 140 lbs. - 174 lbs., a setting used to identify the resident's weight for the proper air-filled chamber redistribution pressure across the body surface), the placement and the functioning of the LAL for skin management. During a review of Resident 1's physician orders, an order dated [DATE] was reviewed for the use of a low air loss (LAL) mattress and for facility staff to monitor the setting at number 3 (for Micro Air 65 LAL model - this setting corresponds to a weight range of 140 to 174 pounds, used to identify the resident's weight for appropriate air filled chamber pressure redistribution), as well as to monitor the placement and functioning of the LAL mattress for skin management. During a review of Resident 1's Order Summary Report for [DATE], the Order Summary Report indicated a physician order for Resident 1 to keep head of the bed elevated 30 to 45 degrees when the feeding is on. The Order Summary Report also had an order to elevate the head of the bed as tolerated while lying for breathing comfort as evidence by shortness of breath when lying flat. During a review of Resident 1's Bed Rail Entrapment Risk Assessment dated [DATE], the Assessment indicated a quarterly assessment completed resident's needs and safety in using bedrails. The Assessment indicated Resident 1 did not have any types of bedside rails. During a review of Resident 1's Minimum Data set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had severe impaired cognition (having difficulty with memory, understanding, decision- making, and communication, which affected his ability to perform daily activities safely and independently), slurred speech, and totally dependent on staff for all activities of daily living such as personal hygiene, toilet transfer, chair-to-bed transfers, sit to lying, lying to sitting. Resident 1 also required maximal assistance with rolling to left or right side. The MDS indicated Resident 1 had impairments on both upper (shoulders. Elbows, wrists, hands) and lower extremities (hips, knees, ankles, feet) range of motion (refers to how far a joint or series of joints can move in a specific direction). During a review of Resident 1's Alternatives for Bedside Rail Utilization Assessment dated [DATE], the assessment was left blank and not completed by a licensed staff. During a review of Resident 1's bedside rail records, there was no documented evidence of a quarterly assessment for [DATE] following the Bed Rail Entrapment Risk Assessment completed on [DATE]. During a review of Resident 1's Weight Summary dated [DATE], the summary indicated Resident 1's weight was 146 pounds (lbs.). During a review of Resident 1's Progress Notes dated [DATE] at 10:15 AM, Certified Nurse Assistant (CNA) 1 stated when she went to check on Resident 1, Resident 1 was already observed sliding from the bed. CNA 1 stated she attempted to catch Resident 1 from falling off of the bed, but Resident 1 lost balance and fell to the ground. CNA 1 stated she called for assistance and then placed Resident 1 back to bed with CNA1. The Progress notes indicated Resident 1 sustained a laceration to the front of the forehead, left side of the head and the posterior left wrist. The Progress Note indicated notification to the Physician and family member was done. During a review of a facility provided document titled Interview Record, dated [DATE] and signed by CNA 1, the record indicated CNA 1's witness statement. The statement indicated I [CNA 1] . was going in the room . I [CNA 1] noticed that [Resident 1] had his head off bed. I [CNA 1] immediately called for help and was running to patient [Resident 1]. DSD was nearby. DSD came to assist before she [CNA 1] can get the patient [Resident 1] fell. During a review of a facility provided document titled Interview Record, dated [DATE], signed by Resident 2 (Resident 1's roommate), the record indicated an interview taken by the DSD. The record indicated I [Resident 2] was reading [and] seen [Resident 1] on [the] edge and seen [CNA 1] trying to hold [Resident 1] from falling out of bed. I [Resident 2] seen you [DSD] run in trying to help. During a review of a facility provided document titled Investigation Report Summary (undated), signed by the Director of Nurses (DON), the document indicated an investigation was initiated regarding Resident 1's witnessed fall on [DATE] according to CNA 1. The Investigation Summary indicated CNA 1 witnessed Resident 1 was at the edge of the bed with the resident's headfirst and sliding off the bed upon entering the room. The Investigation Summary indicated CNA called for assistance and the DSD came, however, CNA 1 and the DSD but was unable to reach Resident 1 before reaching the ground. The Investigation Summary indicated that after the resident's head to toe assessment, the mattress was also assessed with proper functioning setting on #3. The Investigation Summary indicated fall was unavoidable. During further record reviews from [DATE] through [DATE], the date of Resident 1's fall, there was no documented evidence that facility staff monitored the low air loss (LAL) mattress settings at level #3 or monitored the placement and functioning of the LAL mattress for skin management as ordered by the physician. During a review of Resident 1's Rehabilitation (Rehab) Post Fall/Incident assessment dated [DATE] timed at 1:01 PM and authored by Physical Therapist (PT) 1, the Rehab Post Fall Assessment indicated the rehab performed a post-fall screening on [DATE] for a fall that happened on [DATE] due to Resident 1 sliding off from the bed. The Assessment indicated Resident 1 sustained skin tear/s to the left wrist and the mid left side of the forehead. The Assessment further indicated PT 1's post fall recommendations for the use of bed bolsters for proper positioning, use of call light and asking for help, and for nurses to provide supervision at all times to prevent future falls. During a review of Resident 1's Progress Notes dated [DATE] at 4:29 AM, the Progress Note indicated Resident 1 complained of loss of vision to both eyes and complained of a headache with a 10 out 10 pain on a pain scale (a clinical tool used to measure the intensity and impact of a patient's pain- where 0 means no pain and 10 represents the worst possible pain imaginable. Progress notes indicate Physician was notified. During a review of Resident 1's Medication Administration Record (MAR) for month of [DATE], the MAR indicated Resident 1 received medication for head pain (Hydrocodone (Narcotic used to treat moderate to severe pain)- Acetaminophen (non-opioid pain reliever that helps enhance pain control) for 10 /10 pain, 10 being the highest on [DATE] at 7:10 AM. During a review of Resident 1's Progress notes dated [DATE] at 7:16 AM, the Progress Note indicated Resident 1 was transferred to GACH 1 Emergency Department (ED) via Ambulance for complaints of headache and head pain. During a review of Resident 1's GACH Emergency Department (ED) Provider Note dated [DATE] indicated a Computed Tomography (CT, a diagnostic medical imaging test that combines a series of x-rays taken from various angles with computer processing) Head without Contrast (substances usually iodine or barium based used to enhance the visibility of tissues, blood vessels, and organs during CT scan) was performed. The results of the CT indicated findings of the brain had moderate parenchymal volume loss (atrophy, describes a moderate shrinking of brain) and 7 millimeters (mm, unit of measure) of leftward midline shift. The results of the CT indicated the following impressions: (1) no acute intracranial hemorrhage; (2) 7 mm of leftward midline shift of undetermined etiology, no other evidence of mass effect, and recommendation for brain Magnetic Resonance Imaging (MRI, non-invasive medical imaging test that uses powerful magnets and radio waves to create highly detailed, cross-sectional pictures of the internal organs, tissues, and bones) for further evaluation; (3) bilateral nasal bone fractures, layering hyperdense fluid in the right sphenoid sinus, possibly blood; (4) frontal scalp swelling/hematoma (abnormal, localized collection of blood outside of blood vessels, typically caused by trauma, surgery, or medical conditions); and (5) Chronic right frontal infarcts (area of tissue that has died due to lack of adequate blood supply). During a record review of Resident 1's Rehabilitation Post-Fall/Incident Assessment dated [DATE], the Rehabilitation Post/Fall Incident Assessment indicated, Resident 1 does not have sufficient strength and correct posture while sitting. During an interview on [DATE] at 2:15 PM with the Director of Staff Development (DSD), the DSD stated Resident 1 was bedbound, required total care, could not stand, and demonstrated only minimal movement of his arms and legs. The DSD stated Resident 1 sustained a laceration to the midforehead with visible bleeding from sliding out of bed on [DATE] but was unsure if he hit his forehead on a pole or the floor. The DSD further stated a few days later ([DATE]) Resident 1 complained that resident was in pain and had blurry vision. The DSD further stated that no diagnostic imaging, including x- rays, was ordered after Resident 1 fell from the bed on [DATE]. During an interview on [DATE] at 2:30 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated on [DATE] at approximately 10:15 AM, CNA 1 entered Resident 1's room and observed Resident 1' head sliding out of bed. CNA 1 stated Resident 1 slid off the bed headfirst and face down. CNA 1 stated Resident 1 sustained a cut to the forehead, and it was bleeding. CNA 1 stated that the DSD instructed staff to obtain an ice pack and to apply a bandage to the resident's head wound. During an interview on [DATE] at 11:41 AM with the facility's Medical Director (MD), the MD stated that he was notified that Resident 1 had sustained a fall with a head injury resulting in a forehead laceration on [DATE]. The MD stated that he instructed staff to perform routine monitoring and neurological assessments. He stated that no diagnostic testing or imaging was ordered following the fall because the injury did not appear to be serious at that time. The MD explained that he does not order an X-ray or CT scan solely because a resident has fallen. The MD stated that Resident 1 appeared to be fine following the fall and did not sustain a significant hematoma. The MD further stated that diagnostic imaging was not ordered because there was no indication of an obvious fracture, and an X-ray would only have been considered if a fracture had been suspected. During an interview on [DATE] at 9:24 AM, CNA 1 stated that she was assigned to Resident 1 on [DATE]. CNA 1 stated that Resident 1's mood was calm and cooperative throughout the morning. CNA 1 stated that Resident 1 was repositioned onto his right side at approximately 8:30 to 8:45 AM. CNA 1 stated that at approximately 10 AM on [DATE], she entered the room and first went to the resident's roommate, whose bed was on the left-hand side of the room. CNA 1 stated she then looked toward Resident 1's bed and observed Resident 1 dangling face down and about to fall from the bed. CNA 1 reported that she yelled for help and ran to Resident 1 but was unable to reach him in time to prevent the fall. During the continued interview on [DATE] at 9:24 AM, CNA 1 further stated that Resident 1 did not have bedside rails, bed bolsters (soft protective barriers used to prevent individuals from accidentally rolling out of bed), or a floor mat prior to the fall on [DATE]. CNA 1 reported that she repeatedly found Resident 1 lying on his side shifted into a different orientation than the side lying position she had originally placed him in. CNA 1 stated this was unusual because she thought Resident 1 could not move in bed or change positions in bed on his own and required two person total assistance for bed mobility. CNA 1 stated she could not ask Resident 1 because of severe cognitive impairment. CNA 1 stated that she did not report Resident 1's unusual changes in positions in bed to the charge nurse or supervisors for appropriate evaluation for safety during bed mobility. During an interview on [DATE] at 1:06 PM, the DSD stated that she had been walking in the hallway when she saw CNA 1 running toward Resident 1's bed. The DSD reported that she also ran toward Resident 1 in an attempt to prevent him from falling but was unable to reach him in time. The DSD stated that Resident 1 fell onto the metal pole of the feeding tube stand (a medical stand used to hold liquid nutrition or medication bags) that was positioned near his bed. During an interview on [DATE] at 2:27 PM, RN 2 stated that a Side Rail Assessment is conducted every three months, or quarterly, and that there are no specific criteria required to determine the need for side rails; the assessment is based on the assessor's clinical judgment. RN 2 stated that the Side Rail Assessment for Resident 1 was not completed for [DATE]. RN 2 stated that assessing the need for side rails every three months is important because a resident's condition may change. During the continued interview on [DATE] at 2:27 PM, RN 2 further stated that Resident 1 had a physician order for monitoring the Low Air Loss (LAL) mattress; however, there was no documented evidence that licensed nurses had been monitoring the mattress's functionality and settings. RN 2 explained that if the air mattress is set too low for the resident's weight, the resident may sink into the mattress, reducing its effectiveness in preventing skin breakdown. RN 2 also stated that if the LAL mattress is too firm or set incorrectly, Resident 1 could slip and fall from the bed. RN 2 further stated that had Resident 1 been assessed for the need for side rails or bed bolsters prior to the fall, the fall could potentially have been prevented. RN2 stated Resident 1 did not change position on his own or was aware that Resident 1 was found in different positions than how CNA 1 had positioned Resident 1. During an interview on [DATE] at 3:44 PM with the Director of Maintenance (DOM), the DOM stated that Resident 1 was issued the low air loss (LAL) mattress [NAME] Apex Model 9P 079000. The DOM further stated that, based on observations of other residents in the facility, Resident 3 also had the same [NAME] Apex Model 9P 079000. The DOM explained that this LAL model does not have a display that shows a numerical weight setting, such as setting number 3. Instead, staff must set the resident's weight by selecting the appropriate weight range on the machine. The type of LAL model with the numerical setting would be a Micro Air 65 LAL model and that is not Resident 1's LAL mattress. During a concurrent observation at the same time, the DOM provided an example by showing a [NAME] Apex Model 9P 079000 currently in use by another resident. This LAL mattress did not have a setting labeled as number 3. The DOM also noted that the [NAME] Apex Model 9P 079000 included other operational modes, such as static, alternate, pulsation, and seat inflate. During an interview on [DATE] at 5:43 PM, the Director of Nursing (DON) stated that the Low Air Loss (LAL) mattress settings are adjusted according to the resident's weight or the resident's comfort level. The DON stated that on [DATE], Resident 1's LAL mattress was set at level number 3 because she observed that the number 3 was handwritten and taped onto the LAL mattress pump, rather than being an actual numerical setting displayed on the pump. The DON stated that she did not document the other settings that were in use on Resident 1's LAL mattress at that time and could not recall the model of the pump. The DON stated that the facility determines the safety of a resident using a LAL mattress by ensuring the correct weight setting is entered and by monitoring the LAL mattress pump settings every shift. The DON stated that Resident 1 did not move independently and was totally dependent on staff for bed mobility. During a review of the facility's policy and procedure (P&P) Fall Prevention Program dated 12/2016, the P&P indicated that the facility would identify interventions related to the resident's specific risks and causes to try to prevent resident from falling and try to minimize complications from falling. The P&P indicated to include in the care plan interventions such as environmental hazard prevention and monitoring, assistance to any sensory, and perception deficits. During a review of the facility's policy and procedure (P&P) Pressure Reducing Mattress dated 4/2022, the P&P indicated, that for setting the pressure reducing mattress the height and weight will be utilized and to include in the physician order or plan of care. During a review of Resident 1's undated [NAME] Air User Manual, the manual indicated that each time the mattress is initially inflated, it will automatically inflate to maximum firm and then enter alternate mode (alternating pressure that inflates and deflates specific air cells in cycles to actively shift weight) or return to the user's pre set function. The [NAME] Air User Manual also indicated that when a resident needs to be raised up, the seat inflate setting provides additional support to help prevent possible bottoming out (refers to a scenario in which a pressure relief mattress (or cushion) fails to adequately support a person-allowing them to sink so far that their weight is transferred directly onto the underlying bed or base structure).

Based on interview and record review, the facility failed to provide care and services consistent with the resident's condition, physician orders, and professional standards of practice for one of three sampled residents (Resident 1). The facility failed to: 1. Assess known risk factors and develop a care plan associated with Resident 1's use of anticoagulant and antiplatelet medications addressing Resident 1's anticoagulant related bleeding risks (Apixaban and Clopidogrel), despite active orders requiring monitoring for bleeding. 2. Conduct an adequate post fall assessment after Resident 1 slid from the bed and struck his head on [DATE], including failure to assess for possible delayed intracranial bleeding or other complications expected in an anticoagulated resident. 3. Notify the physician that Resident 1 was receiving anticoagulant and antiplatelet medications at the time of the fall, and obtain guidance on whether medications should be held, and whether diagnostic imaging was required following a head injury. Resident 1 continued to receive Apixaban and Clopidogrel from [DATE] through [DATE]. 4. Follow the facility's Fall - Clinical Protocol requiring identification of conditions that increase the risk of complications such as active anticoagulation and requiring monitoring for delayed subdural or intracranial bleeding after a head injury. This deficient practice resulted in delayed medical evaluation and intervention, during which Resident 1 developed severe head pain, headache, and loss of vision on [DATE], prompting an emergency transfer to the General Acute Care Hospital (GACH) imaging subsequently revealed a scalp hematoma, and a 7 mm leftward midline shift but no acute intracranial hemorrhage. Findings: During a review of Resident 1's admission Record (AR) , the AR indicated Resident 1 was originally admitted to the facility on [DATE] with diagnosis that included hemiplegia(complete paralysis on one side of the body) and hemiparesis(weakness on one side of body) following cerebral infarction ( stroke caused by a blockage of blood flow to part of the brain) affecting right dominant side of body, ankylosing spondylitis( inflammatory disease that affects the spine and joints of lower back and pelvis) of lumbosacral region, and Atrial fibrillation ( an abnormal heartbeat that can cause blood clots and strokes). During a review of Resident 1's Minimum Data set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had severe impaired cognition (having difficulty with memory, understanding, decision- making, and communication, which affected his ability to perform daily activities safely and independently) and is totally dependent on staff for all activities of daily living such as personal hygiene. Resident 1 also requires maximal assistance with rolling to left or right side. During a review of Resident 1's General Acute Care Hospital (GACH 1) records, the records indicated resident was transferred to GACH 1 Emergency Department (ED) dated [DATE]. GACH 1 ED record indicated Resident 1's anticoagulation status was uncertain due to the facility's report that Resident 1 was not taking any blood thinners. The GACH records indicated Resident 1 had the following differential diagnoses: intracranial hemorrhage (a life-threatening medical emergency involving bleeding inside the skull), compression fracture (a break in vertebra [a spine bone] and it then collapses), traumatic injury (any sudden physical damage to the body caused by an external force) due to fall, and ankle fracture. The GACH records indicated Resident 1's admission to GACH was considered due to concern for intracranial hemorrhage, possible compression fracture in the setting of anticoagulation use, and Resident 1's baseline cognitive impairment. The GACH records indicated Imaging and laboratory evaluation were initiated to assess for acute injuries and clarify anticoagulation status with the facility. During a review of Resident 1's GACH Emergency Department (ED) Provider Note dated [DATE] indicated a Computed Tomography (CT, a diagnostic medical imaging test that combines a series of x-rays taken from various angles with computer processing) Head without Contrast (substances usually iodine or barium based used to enhance the visibility of tissues, blood vessels, and organs during CT scan) was performed. The results of the CT indicated findings of the brain had moderate parenchymal volume loss (atrophy, describes a moderate shrinking of brain) and 7 millimeters (mm, unit of measure) of leftward midline shift. The results of the CT indicated the following impressions: (1) no acute intracranial hemorrhage; (2) 7 mm of leftward midline shift of undetermined etiology, no other evidence of mass effect, and recommendation for brain Magnetic Resonance Imaging (MRI, non-invasive medical imaging test that uses powerful magnets and radio waves to create highly detailed, cross-sectional pictures of the internal organs, tissues, and bones) for further evaluation; (3) bilateral nasal bone fractures, layering hyperdense fluid in the right sphenoid sinus, possibly blood; (4) frontal scalp swelling/hematoma (abnormal, localized collection of blood outside of blood vessels, typically caused by trauma, surgery, or medical conditions); and (5) Chronic right frontal infarcts (area of tissue that has died due to lack of adequate blood supply). During a review of Resident 1's Order Summary Report, the report indicated the following physician orders: Dated [DATE], a prescribed order for Clopidogrel Bisulfate (Plavix, a prescription antiplatelet medication used to prevent serious blood clots in people who have had a recent heart attack, stroke, or severe circulation issues) Oral Tablet 75 milligram (mg, unit of measure) give 1 tablet via gastrostomy tube (g-tube, medical device inserted through the abdomen directly into the stomach) one time a day for prevention of blood clots. Dated [DATE], a prescribed order for Apixaban (Eliquis, a prescription oral anticoagulant [blood thinner] that prevents and treats harmful blood clots) Oral Tablet 5 mg give 1 tablet via g-tube two times a day for deep vein thrombosis (DVT, a serious medical condition where a blood clot [thrombus] forms in a deep vein, usually in the leg or pelvis) prophylaxis. Dated [DATE], a prescribed order to monitor for signs/symptoms of bleeding/bruising, report to Physician (MD) if noted. Dated [DATE], a prescribed order to observe closely for significant side effects of anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift. The order indicated to document the number of episodes if observed and 0 if none of the above observed, if any of the above was observed, select chart code 'other/see nurses notes' and progress notes findings. Dated [DATE], a prescribed order for Apixaban Oral Tablet 5 mg give 1 tablet via g-tube two times a day related to unspecified atrial fibrillation (common heart rhythm disorder where the heart's upper chambers beat chaotically and out of sync with the lower chambers) hold for signs/symptoms of bleeding. During a review of Resident 1's Progress Notes dated [DATE] at 10:15 AM, Certified Nurse Assistant (CNA) 1 stated when she went to check on Resident 1, Resident 1 was already observed sliding off of the bed. CNA 1 stated she attempted to catch Resident 1 from falling off of the bed, but Resident 1 lost balance and fell to the ground. CNA 1 stated she called for assistance and then placed Resident 1 back to bed with CNA1. The Progress notes indicated Resident 1 sustained a laceration to the front of the forehead, left side of the head and the posterior left wrist. The Progress Note indicated notification to the Physician and family member was done. During a review of a facility provided handwritten document titled Interview Record, dated [DATE] and signed by CNA 1, the record indicated CNA 1's witness statement. The statement indicated I [CNA 1] . was going in the room . I [CNA 1] noticed that [Resident 1] had his head off bed. I [CNA 1] immediately called for help and was running to patient [Resident 1]. DSD was nearby. DSD came to assist before she [CNA 1] can get there patient [Resident 1] fell. During a review of Resident 1's care plan developed on [DATE], the care plan indicated Resident 1 had an open area to the forehead and to the left side of the forehead. The care plan goal included wound would show signs of healing and no signs of infection would occur. The care plan did not include monitoring for nursing oversight for a resident who are taking anticoagulants which increases the risk for bleeding. During a review of Resident 1's care plan developed on [DATE] (3 days after the fall), the care plan indicated that on [DATE], Resident 1 had an actual fall witnessed fall. The care plan goal indicated Resident 1 to resume usual activities without further incident. The care plan interventions included monitoring/documenting/reporting pain, bruising, neurological checks, and pharmacy consult to evaluate medications. The care plan interventions further included providing visual checks, lighting, placing the resident on fall prevention program and rehab consult. During a review of Resident 1's Rehabilitation (Rehab) Post Fall/Incident assessment dated [DATE] timed at 1:01 PM and authored by Physical Therapist (PT) 1, the Rehab Post Fall Assessment indicated the rehab performed a post-fall screening on [DATE] for a fall that happened on [DATE] due to Resident 1 sliding off from the bed. The Assessment indicated Resident 1 sustained skin tear/s to the left wrist and the mid left side of the forehead. The Assessment further indicated PT 1's post fall recommendations for the use of bed bolsters for proper positioning, use of call light and asking for help, and for nurses to provide supervision at all times to prevent future falls. During a review of Resident 1's Medication Administration Record (MAR) for month of [DATE], the MAR indicated Resident 1 continued to receive the anticoagulant and antiplatelet medications after the fall that happened on [DATE] at around 10 AM, on the following dates: On [DATE], Resident 1 received Apixaban 5 mg at 5 PM. On [DATE], Resident 1 received Apixaban 5 mg at 5 PM. On [DATE], Resident 1 received both Apixaban 5 mg and Clopidogrel Bisulfate 75 mg scheduled at 8 AM. During a review of Resident 1's Progress Notes dated [DATE] at 4:29AM, the Progress Note indicated Resident 1 complained of loss of vision to both eyes and complained of a headache with a 10 out 10 pain on a pain scale (a clinical tool used to measure the intensity and impact of a patient's pain- where 0 means no pain and 10 represents the worst possible pain imaginable. Progress notes indicate Physician was notified. During a review of Resident 1's Medication Administration Record (MAR) for month of [DATE], the MAR indicated Resident 1 received medication for head pain (Hydrocodone (Narcotic used to treat moderate to severe pain)- Acetaminophen (non-opioid pain reliever that helps enhance pain control) for 10 /10 pain, 10 being the highest on [DATE] at 7:10 AM. During a review of Resident 1's Progress notes dated [DATE] at 7:16 AM, the Progress Note indicated Resident 1 was transferred to GACH 1 via Ambulance for complaints of headache and head pain. During an interview on [DATE] at 1:15 PM with GACH 1 Social Worker (SW), GACH 1 SW stated Resident 1 was transferred to the GACH 1 emergency room via ambulance on [DATE] at approximately 7:08 AM for complaints of head injury and loss of vision. SW stated residents sustained a nasal fracture, front scalp hematoma and midline shift as a result of the reported fall that occurred at the facility on [DATE]. During an interview on [DATE] at 2:15 PM with the Director of Staff Development (DSD), the DSD stated Resident 1 was bedbound, required total care, could not stand, and demonstrated only minimal movement of his arms and legs. The DSD stated Resident 1 sustained a laceration to the midforehead with visible bleeding from sliding out of bed on [DATE] but was unsure if he hit his forehead on a pole or the floor. The DSD further stated a few days later ([DATE]) Resident 1 complained that resident was in pain and had blurry vision. The DSD further stated that no diagnostic imaging, including x- rays, was ordered after Resident 1 fell from the bed on [DATE]. During an interview on [DATE] at 2:30 PM with Certified Nursing Assistant (CNA), CNA 1 stated on [DATE] at approximately 10:15 AM, CNA 1 entered Resident 1's room and observed Resident 1' head sliding out of bed. CNA 1 stated Resident 1 slid off the bed headfirst and face down. CNA 1 stated Resident 1 sustained a cut to the forehead, and it was bleeding. CNA 1 stated that the DSD instructed staff to obtain an ice pack and to apply a bandage to the resident's head wound. During an interview on [DATE] at 11:41 AM with the facility's Medical Director (MD), the MD stated that he was notified that Resident 1 had sustained a fall with a head injury resulting in a forehead laceration on [DATE]. The MD stated that he instructed staff to perform routine monitoring and neurological assessments. He stated that no diagnostic testing or imaging was ordered following the fall because the injury did not appear to be serious at that time. The MD explained that he does not order an X-ray or CT scan solely because a resident has fallen. He stated that Resident 1 appeared to be fine following the fall and did not sustain a significant hematoma. The MD further stated that diagnostic imaging was not ordered because there was no indication of an obvious fracture, and an X-ray would only have been considered if a fracture had been suspected. During an interview on [DATE] at 1:34 PM with the responsible party (RP), the RP stated that the facility contacted her on [DATE] and informed her that Resident 1 was experiencing vision problems and had been transferred to the emergency department for evaluation. The RP stated that during this notification, facility staff did not inform her that Resident 1 had sustained a fall on [DATE]. The RP further stated that after being notified of the transfer, she contacted the GACH 1 emergency department nurse, who informed her that Resident 1 had sustained brain swelling as a result of a fall from the bed at the facility. During a concurrent interview and record review on [DATE] at 2:00 PM with Registered Nurse (RN) 1, Resident 1's Medication Administration Record (MAR) for [DATE] was reviewed. The MAR showed an active order to monitor for signs and symptoms of bleeding every shift (day, evening, and night) from [DATE] through [DATE]. The MAR documentation indicated 0 for no symptoms of bleeding during this period. RN 1 stated that any symptoms of bleeding should have been documented, as such documentation is essential to alert staff to a potential change in condition. During a concurrent interview and record review on [DATE] at 2:15 PM with Registered Nurse (RN) 1, Resident 1's active care plans were reviewed. RN1 stated there was no documented evidence that care plans were developed related to Resident 1's anticoagulant (blood thinners) and antiplatelet therapy (apixaban or plavix). RN 1 stated that a care plan should have been developed to address Resident 1's anticoagulant medications. RN1 further stated anticoagulant therapy has increased risk for bleeding, and a care plan is important to provide guidance to staff when monitoring or recognizing warning signs and symptoms of bleeding. During a concurrent interview and record review on [DATE] at 2:20 PM with RN 1, Resident 1's Progress notes documented dated [DATE] at 11:46 AM were reviewed. The progress notes indicated that the Medical Doctor (MD) and Family Member (FM1) were notified of the fall according to documentation. Further review of the record indicated no documentation indicating MD was informed of Resident 1 receiving anticoagulant therapy including Apixaban and antiplatelet at the time of fall. There was also no documented evidence that the MD was asked if the anticoagulant and antiplatelet medications should be put on hold after Resident 1's fall as part of Resident 1's post fall monitoring. RN1 stated it was important for the MD to be notified that a resident is receiving anticoagulant and antiplatelet medications because of the resident's increased risk for bleeding. RN 1 further stated this knowledge could affect the physician's decision - making, including whether to send the resident to the hospital immediately for further evaluation. During a review of the facility's policy and procedure ( P&P) titled Fall- Clinical Protocol, revised [DATE], indicated that staff are responsible for assessing residents following a fall, including evaluation of recent injuries, neurological status, cognition, pain, medication associated with dizziness or lethargy, and risk factors for falls. The policy further directs staff and the physician to identify conditions that increase the risk of significant complications from falls, such as increased risk of bleeding in residents receiving anticoagulant therapy. The policy states that falls should be evaluated and residents monitored for delayed complications, including subdural hematomas or intracranial bleeding, which may occur hours, days, or several weeks following a fall.

Based on observation, interview, and record review, the facility failed to protect three of three (Resident 2, 3 and 4) to be free from sexual abuse (non-consensual [without the person's permission] sexual contact of any type with a resident who does not wish to engage in sexual activity or may not have the capacity to consent) when the facility failed to: 1.Monitor Resident 1 for aggressive behaviors and verbal threats as indicated in his care plan created on 4/28/26 after Resident 1 verbally threatened to harm his roommate when Resident 1 was transferred to a new room with Resident 3. 2. Maintain close supervision and vigilance at all possible times for Resident 1, who had a reported history of inappropriate sexual behavior toward females, as indicated in his care plan initiated on 3/28/26. 3. Monitor Resident 1's pacing and wandering as indicated in the resident's care plan developed on 5/4/26 after Resident 1 exhibited verbal aggression while pacing and wandering at night. As a result, the facility's staff did not prevent Resident 1 from frequently wandering into Resident 2's room, who was bed bound, and watching her while she was in bed. This made Resident 2 feel uncomfortable. Staff also did not prevent Resident 1 from wandering into Resident 4's room and touching his own genitals while looking at Resident 4. This made Resident 4 feel unsafe and afraid that the facility's staff were not monitoring their residents. The staff also did not prevent Resident 1 from exposing his genitals to his bedbound roommate, Resident 3, and putting Resident 3's toes in his mouth. This made Resident 3 feel disgusted and helpless due to being unable to move his body. These deficient practices caused Residents 2, 3, and 4 emotional distress and compromised their right to a safe and dignified living environment. Findings: 1. During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/31/26, the MDS indicated Resident 1 had moderate cognitive impairment (some difficulty with memory and orientation) and required moderate assistance (helper does less than half the effort) for most cares such as dressing and toileting. During a review of Resident 1's Care Plan (CP) initiated on 3/28/26, the CP indicated, per hospital record, Resident 1 had a history of inappropriate behavior toward female staff and attempted to touch residents. The CP further indicated a goal for Resident 1 to have no episodes of inappropriate behavior toward female staff and/or attempting to touch residents. The CP also indicated interventions for staff to maintain close supervision and vigilance at all possible times, for Resident 1 to remain on 24-hour hourly monitoring, for Resident 1 to remain on 24-hour hourly location monitoring, and for staff to implement an hourly behavior monitoring log. During a review of Resident 1's Change in Condition Evaluation (CIC- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 4/28/26 at 2:59 AM, the CIC indicated, Resident is going in roommates personal belongings and taking their belongings, threaten roommates and staff, resident is using foul language, showing signs of being a danger to other residents and staff, resident stated, 'I will beat your ass I am a gangster I don't care about going to jail' and got in staff face. The CIC further indicated Resident 1 exhibited behavioral changes that included verbal aggression, being a danger to self and others, and other behavioral symptoms. The CIC further indicated Resident 1 exhibited dangerous behavior that included threatening to hit roommates and staff and stealing roommate's belongings. The CIC further indicated the description of Resident 1's behavioral changes included aggressive behavior. The CIC was created and signed by Licensed Vocational Nurse (LVN) 2. During a review of Resident 1's CP dated 4/28/26, the care plan indicated Resident 1 had the potential to be physically aggressive related to threatening residents and staff, anger, and poor impulse control. The CP indicated a goal that Resident 1 would not harm himself or others through the review date. The CP further indicated for staff to monitor, document, and report as needed any signs or symptoms of Resident 1 posing danger to self and others. During a review of Resident 1's Progress Notes (PN) from 4/28/26 to 5/1/26, the PN did not include documentation from licensed nurses monitoring Resident 1 related to the CIC of making verbal threats and going into roommate's belongings for five (5) shifts: 1. 4/28/26 from 3 PM - 11 PM2. 4/28/26 from 11 PM - 7 AM3. 4/29/26 from 11 PM - 7 AM4. 4/30/26 from 7 AM - 3 PM5. 4/30/26 from 3 PM - 11 PM During a review of Resident 1's CIC dated 5/4/26 at 12:04 PM, the CIC indicated Resident 1 exhibited a change in condition related to insomnia/mood disorder, pacing in the hallway, [and] angry outburst. The CIC further indicated, Patient observed during shift exhibiting behavioral changes, including insomnia, pacing, and angry outburst. Patient noted to be standing and facing the hallways for extended periods, appearing restless and agitated. No incidents of physical aggression. During the shift, patient [had] difficulty sleeping, and an episode of angry verbal outburst. The CIC was created and signed by LVN 1. During a review of Resident 1's CP dated 5/4/26, the CP indicated Resident 1 was noted pacing in the hallways. The CP indicated a goal for Resident 1 to remain in his room or designated safe area and avoid standing or wandering in the hallway for prolonged periods during the shift. The CP indicated interventions to provide frequent check-ins and gentle reminders to return to his room or a safe area. During a review of Resident 1's PN dated 5/4/26 to 5/7/26, the PN did not include documentation from licensed nurses monitoring Resident 1 related to the CIC of pacing and having angry outbursts for two (2) shifts: 1. 5/6/26 from 3 PM - 11 PM2. 5/7/26 from 7 AM - 3 PM During a review of Resident 1's psychiatric note dated 5/11/26, the note indicated Resident 1 had a history of trying to touch female staff at his previous home. The note also indicated Resident 1 had a behavior of restlessly pacing but was easily redirectable. During a review of Resident 1's CIC dated 5/19/26 at 12:30 PM, the CIC indicated a change in condition related to two police department (PD) officers reporting that Resident 1 was allegedly performing oral sex with other residents. The CIC further indicated Resident 1's primary clinician recommended to transfer Resident 1 to a general acute care hospital (GACH) for further evaluation. During a review of Resident 1's CIC dated 5/19/26 at 4:30 PM, the CIC indicated a change in condition related to Resident 1 pacing the hallways, entering other residents' room without permission, entering a male resident's room and touching Resident 1's own private parts, making sexual remarks to female staff to come into his room, and attempting to touch another resident's foot. Resident 1 was placed on one-to-one (1:1) monitoring with a recommendation from Resident 1's primary clinician to transfer the resident to a GACH for psychiatric evaluation. 2. During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and major depressive disorder. During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2 had intact cognition (good memory, accurate orientation, and minimal to no cognitive deficits) and required maximal assistance (helper does more than half the effort) for most cares such as toileting and dressing. Resident 2 was dependent on staff (helper does all the effort) for bathing. 3. During a review of Resident 3's admission Record, the record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including anxiety, bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 3's History and Physical (H&P) dated 4/9/26, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was dependent (helper does all the help) for most cares such as toileting and bathing. 4. During a review of Resident 4's admission Record, the record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including a left leg fracture (broken bone) and difficulty walking. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had intact cognition and was dependent on staff for cares such as toileting and showering. During an interview on 5/20/26 at 10:37 AM with the Director of Nurses (DON), the DON stated that on 5/19/26, two officers from the local PD came to the facility and reported that they received an anonymous report alleging that Resident 1 performed oral sex with other residents in the facility. The DON stated Resident 1 was known to pace in the facility at night and was known to attempt to touch female staff. The DON stated that after interviews with other residents near Resident 1's room, the following was reported: A. Resident 4 reported that Resident 1 went to Resident 4's room and touched himself inappropriately in the morning of 5/19/26B. Resident 5 reported that Resident 1 was always gazing at females in the hallways.C. Resident 2 reported that Resident 1 would go to Resident 2's room and stare at her from the door.D. Certified Nursing Assistant (CNA) 1 reported that Resident 1 invited CNA 1 into bed with him on 5/19/26. The DON further explained she was not aware of Resident 1's inappropriate behavior toward other residents and staff. The DON stated, We thought everything was fine. During an interview on 5/20/26 at 12:58 PM with CNA 1, CNA 1 stated that on 5/19/26 around 2 PM, Resident 1 told her, Hey, come to my bed. I'll give you hugs and kisses. CNA 1 stated Resident 1 liked to walk around the entire facility throughout the day and would stand by other residents' doors. During an interview on 5/20/26 at 1:34 PM with Resident 2, Resident 2 stated that Resident 1 had frequently come into her room uninvited for weeks. Resident 2 stated Resident 1 would stand at the foot of Resident 2's bed and mutter under his breath while staring at Resident 2. Resident 2 stated it made her feel very uncomfortable. During an interview on 5/20/26 at 1:40 PM with Resident 3, Resident 3 stated that Resident 1 would kiss Resident 3's feet while playing with his own genitals. The last time Resident 1 kissed Resident 3's feet was on 5/18/26 but Resident 1 had been inappropriate more than once. For multiple days, Resident 1 would stand at the foot of Resident 3's bed and would stare at Resident 3 while playing with his own genitals and talking to him. Resident 3 stated that when he asked Resident 1 to go away, Resident 1 would threaten him and say, What are you going to do to me? Resident 1 would lunge at Resident 3 as if he were trying to hit Resident 3 and say, You're not going to do anything. Resident 3 stated that he felt very uncomfortable and disgusted that Resident 1 kissed his feet. Resident 3 further explained that he felt helpless and unsafe in the facility because he was unable to move his body and the staff would not be able to help him in time. Resident 3 further stated, It's a little too late because it already happened. During an interview on 5/20/26 at 1:51 PM with Resident 4, Resident 4 stated he had concerns about lack of supervision of the residents that liked to wander in the facility. Resident 4 explained that, on 5/18/26, Resident 1 came into Resident 4's room and stared at Resident 4 while rubbing his genitals. Resident 4 stated he recognized Resident 1 as the same resident that always walked by his door in the hallways. Resident 4 stated that when he asked Resident 1 to leave his room, Resident 1 stated, You're not going to do anything. Resident 4 stated he was afraid to tell the staff about what happened with Resident 1 because he would get neglected or retaliated against by the staff whenever he brought up a concern. Resident 4 stated he felt very uncomfortable and did not feel safe being in the facility. During an interview on 5/20/26 at 2:49 PM and concurrent record review with Registered Nurse (RN) 1, Resident 1's care plans and Medication Administration Record (MAR) dated May 2026 were reviewed. RN 1 stated that Resident 1's care plan initiated on 4/28/26 for threatening residents and staff indicated to monitor, document, and report as needed any signs or symptoms of posing a danger to self and others as an intervention for Resident 1's behaviors. RN 1 stated Resident 1's behavior monitoring did not begin until 5/4/26 and there was no documentation on behavior monitoring between 4/28/26 to 5/4/26 in Resident 1's MAR. RN 1 stated it was important to follow Resident 1's care plan to prevent further abuse from happening. RN 1further explained that staff was responsible for following the care plan to apply appropriate interventions and ensure resident safety. During an interview on 5/20/26 at 3:10 PM and concurrent record review with the DON, Resident 1's CIC dated 4/28/26 for threatening roommates and staff and stealing from roommates was reviewed. The DON stated she was not aware of the CIC because LVN 4 did not report the incident to her. The DON stated that if she knew about it, she would have pushed for an immediate psychiatric consult and pushed for the resident to be medically and psychologically evaluated in a general acute care hospital (GACH). The DON stated that because LVN 2 failed to notify her of the CIC, the facility was unable to apply appropriate interventions such as sending Resident 1 out for medical and psychological evaluation to prevent further abuse from happening. During an interview on 5/20/26 at 3:49 PM and concurrent record review with LVN 1, Resident 1's CICs, care plans, and progress notes were reviewed. LVN 1 stated she knew that Resident 1 changed rooms due to roommate incompatibility on 4/28/26, but she was not aware of a CIC for verbally threatening staff and roommates and stealing from roommates. LVN 1 stated that if she witnessed Resident 1 verbally threatening his roommates, she would have notified the DON, CDPH, local PD, and local omb as a mandated reporter. LVN 1 further stated that Resident 1 was considered a danger to himself and others and therefore required further medical evaluation and PD involvement. During the same interview on 5/20/26 at 3:49 PM and concurrent record review with LVN 1, Resident 1's progress notes and Hourly Behavior Monitoring Binder were reviewed. LVN 1 stated the Behavioral Monitoring Binder was the facility's internal hourly monitoring log for residents with behavioral issues. LVN 1 stated that if any portion of the hourly behavioral monitoring sheet was blank, then monitoring was not done. The following dates and shifts were left blank (87 shifts):3/29/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM3/30/26: 11 PM - 7 AM, 3 PM - 11 PM3/31/26: 11 PM - 7 AM, 3 PM - 11 PM4/1/26: 11 PM - 7 AM, 3 PM - 11 PM4/2/26: 11 PM - 7 AM, 3 PM - 11 PM4/3/26: 11 PM - 7 AM, 3 PM - 11 PM4/4/26: 11 PM - 7 AM4/5/26: 11 PM - 7 AM4/6/26: 11 PM - 7 AM, 3 PM - 11 PM4/7/26: 11 PM - 7 AM, 3 PM - 11 PM4/8/26: 11 PM - 7 AM, 3 PM - 11 PM4/9/26: 11 PM - 7 AM, 3 PM - 11 PM4/10/26: 11 PM - 7 AM4/11/26: 11 PM - 7 AM4/12/26: 11 PM - 7 AM4/13/26: 11 PM - 7 AM4/14/26: 11 PM - 7 AM4/15/26: 11 PM - 7 AM4/16/26: 11 PM - 7 AM4/17/26: 11 PM - 7 AM4/18/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM4/19/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM4/20/26: 11 PM - 7AM4/21/26: 11 PM - 7AM4/22/26: 11 PM - 7AM4/23/26: 11 PM - 7AM4/24/26: 11 PM - 7AM, 3 PM - 11 PM4/25//26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM4/26/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM4/27/26: 11 PM - 7AM4/28/26: 11 PM - 7AM4/29/26: 11 PM - 7AM, 3 PM - 11 PM4/30/26: 11 PM - 7 AM, 3 PM - 11 PM5/1/26: 3 PM - 11 PM5/3/26: 3 PM - 11 PM5/6/26: 3 PM - 11 PM5/7/26: 11 PM - 7 AM, 3 PM - 11 PM5/8/26: 11 PM - 7 AM, 3 PM - 11 PM5/9/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM5/10/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM5/11/26: 11PM - 7 AM, 3 PM - 11 PM5/12/26: 11PM - 7 AM, 3 PM - 11 PM5/13/26: 11PM - 7 AM, 3 PM - 11 PM5/14/26: 11PM - 7 AM, 3 PM - 11 PM5/15/26: 11PM - 7 AM, 3 PM - 11 PM5/16/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM17. 5/17/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM18. 5/18/26: 11PM - 7 AM, 3 PM - 11 PM19. 5/19/26: 11PM - 7 AM LVN 1 stated Resident 1's internal hourly monitoring binder and Progress Notes did not have complete monitoring documentation. LVN 1 stated it was important for staff to follow monitoring protocol for safety. During another interview with the DON on 5/20/26 at 4:53 PM, the DON stated that Resident 1's abuse could have been avoided if LVN 4 had reported Resident 1 being a danger to self and others on 4/28/26. The DON stated Resident 1 would have been hospitalized for medical and psychiatric evaluation and stabilization. The DON also explained that when there was a CIC, the staff was expected to monitor and document on the resident for 72 hours to ensure the resident no longer exhibited the behaviors in the CIC. During the same interview with the DON on 5/20/26 at 4:53 PM, the DON stated that prior to Resident 1's admission into the facility, she received report from the previous facility that Resident 1 had a history of exhibiting inappropriate behaviors toward female staff. The DON stated a care plan was initiated regarding Resident 1's behaviors and it was important to implement appropriate interventions to protect female staff and residents. During a phone interview on 5/21/26 at 8:35 AM with LVN 2, LVN 2 stated she could not remember the specifics of her documentation for the CIC created on 4/28/26. LVN 2 stated she only notified Resident 1's physician of his CIC. LVN 2 did not state that she notified CDPH, PD, omb, or the DON of Resident 1's verbal threats to harm his roommate. LVN 2 stated she could not remember which roommate Resident 1 verbally threatened because the incident happened a long time ago with a roommate that was no longer in the facility. During an interview with the Quality Assurance (QA) on 5/21/26 at 2:21 PM, the QA stated that on 5/19/26, Resident 1 said to her, With a behind like that, I'll follow you anywhere. The QA stated she did not know what prompted Resident 1 to say that to her. During another interview with the DON on 5/21/26 at 2:21 PM, the DON stated that Resident 1's internal behavioral monitoring binder was intended to be indefinite monitoring during Resident 1's stay in the facility because it was necessary for staff to monitor Resident 1 every hour to ensure he did not exhibit inappropriate behaviors toward female staff and residents. The DON stated the documentation should have been continuous and completed but it was not. The DON also stated the care plan should have been followed for Resident 1's reported inappropriate sexual behavior toward female staff but was not. The DON also stated that all staff hired into the facility were mandated reporters and should report every type of abuse, including verbal abuse, to CDPH, local PD, and ombudsman. During a review of the facility's P&P titled Abuse Prevention Program revised in December 2016, the P&P indicated the facility's residents had the right to be free from abuse. As part of the resident abuse prevention, the administration would protect the facility's residents from abuse by anyone including other residents or any other individual. The policy further indicated for the administration to identify and assess all possible incidents of abuse and investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on interview and record review, the facility failed to report resident-to-resident verbal abuse to the California Department of Public Health (CDPH- the state agency responsible for providing regulatory oversight of healthcare facilities), local police department (PD), and the local ombudsman (omb- an independent, impartial official who investigates and helps resolve complaints or concerns about an organization's services, practices, or compliance) as written in their policy titled, Abuse Investigation and Reporting when Resident 1 made verbal threats to physically beat his roommate on 4/28/26. This deficient practice compromised the protection of residents, denied timely intervention by oversight and law enforcement authorities, and increased the potential for further harm.Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/31/26, the MDS indicated Resident 1 had moderate cognitive impairment (some difficulty with memory and orientation) and required moderate assistance (helper does less than half the effort) for most cares such as dressing and toileting. During a review of Resident 1's Change in Condition Evaluation (CIC- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 4/28/26 at 2:59 AM, the CIC indicated, Resident is going in roommates personal belongings and taking their belongings, threaten roommates and staff, resident is using foul language, showing signs of being a danger to other residents and staff, resident stated, 'I will beat your ass I am a gangster I don't care about going to jail' and got in staff face. The CIC further indicated Resident 1 exhibited behavioral changes that included verbal aggression, being a danger to self and others, and other behavioral symptoms. The CIC further indicated Resident 1 exhibited dangerous behavior that included threatening to hit roommates and staff and stealing roommates belongings. The CIC further indicated the description of Resident 1's behavioral changes included aggressive behavior. The CIC was created and signed by Licensed Vocational Nurse (LVN) 2. During an interview on 5/20/26 at 3:10 PM and concurrent record review with the DON, Resident 1's CIC dated 4/28/26 for threatening roommates and staff and stealing from roommates was reviewed. The DON stated she was not aware of the CIC because LVN 4 did not report the incident to her. The DON stated that if she knew about it, she would have pushed for an immediate psychiatric consult and pushed for the resident to be medically and psychologically evaluated in a general acute care hospital (GACH). The DON stated LVN 4 was a mandated reporter and should have reported Resident 1's verbal abuse to CDPH, local PD, and the local omb as written in their policy. The DON stated that because LVN 2 failed to notify her of the CIC, the facility was unable to apply appropriate interventions such as sending Resident 1 out for medical and psychological evaluation to prevent further abuse from happening. During an interview on 5/20/26 at 3:49 PM and concurrent record review with LVN 1, Resident 1's CICs, care plans, and progress notes were reviewed. LVN 1 stated she knew that Resident 1 changed rooms due to roommate incompatibility on 4/28/26, but she was not aware of a CIC for verbally threatening staff and roommates and stealing from roommates. LVN 1 stated that if she witnessed Resident 1 verbally threatening his roommates, she would have notified the DON, CDPH, local PD, and local omb as a mandated reporter. LVN 1 further stated that Resident 1 was considered a danger to himself and others and therefore required further medical evaluation and PD involvement. LVN 1 stated that Resident 1's progress notes did not contain documentation of notifying CDPH, local PH, and local ombudsman. During another interview with the DON on 5/20/26 at 4:53 PM, the DON stated that any abuse, including verbal abuse, should be reported to the appropriate agencies (CDPH, PD, and omb) so that proper investigations can be initiated and should be reported up the chain of command (to the DON) to implement appropriate interventions for the resident experiencing or causing abuse. During a phone interview on 5/21/26 at 8:35 AM with LVN 2, LVN 2 stated she could not remember the specifics of her documentation for the CIC created on 4/28/26. LVN 2 stated she only notified Resident 1's physician of his CIC. LVN 2 did not state that she notified CDPH, PD, omb, or the DON of Resident 1's verbal threats to harm his roommate. LVN 2 stated she could not remember which roommate Resident 1 verbally threatened because the incident happened a long time ago and she believed the roommate was no longer in the facility. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting and dated July 2017, the P&P indicated, All alleged violations involving abuse. will be reported by the facility Administrator, or his designee, to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; the local/state ombudsman; the resident's representative of record;. law enforcement officials; the resident's attending physician; the facility medical director. The P&P also indicated, an alleged violation of abuse. will be reported immediately, but not later than two hours if the alleged violation involves abuse.

Based on observation, interview, and record review, the facility failed to properly supervise Resident 1, allowing the resident to enter the rooms of three of three sample residents (Residents 2, 3, and 4) and engage in inappropriate behavior, which occurred as a result of inadequate monitoring by failing to: 1.Monitor Resident 1 for aggressive behaviors and verbal threats as indicated in his care plan created on 4/28/26 after Resident 1 verbally threatened to harm his roommate when Resident 1 was transferred to a new room with Resident 3. 2. Implement a care plan of Resident 1's inappropriate sexual behaviors of touching his genital area in front of Resident 4 as Resident 1 had previously performed prior to his admission to the facility. 3.Monitor Resident 1's pacing and wandering as indicated in the resident's care plan developed on 5/4/26 after Resident 1 exhibited verbal aggression while pacing and wandering at night. As a result, the facility's staff did not prevent Resident 1 from frequently wandering into Resident 2's room, who was bed bound, and watching her while she was in bed. This made Resident 2 feel uncomfortable. Staff also did not prevent Resident 1 from wandering into Resident 4's room and touching his own genitals while looking at Resident 4. This made Resident 4 feel unsafe and afraid that the facility's staff were not monitoring their residents. The staff also did not prevent Resident 1 from exposing his genitals to his bedbound roommate, Resident 3, and putting Resident 3's toes in his mouth. This made Resident 3 feel disgusted and helpless due to being unable to move his body. These deficient practices caused Residents 2, 3, and 4 emotional distress and compromised their right to a safe and dignified living environment.Findings: a. During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/31/26, the MDS indicated Resident 1 had moderate cognitive impairment (some difficulty with memory and orientation) and required moderate assistance (helper does less than half the effort) for most cares such as dressing and toileting. During a review of Resident 1's Care Plan (CP) initiated on 3/28/26, the CP indicated, per hospital record, Resident 1 had a history of inappropriate behavior toward female staff and attempted to touch residents. The CP further indicated a goal for Resident 1 to have no episodes of inappropriate behavior toward female staff and/or attempting to touch residents. The CP also indicated interventions for staff to maintain close supervision and vigilance at all possible times, for Resident 1 to remain on 24-hour hourly monitoring, for Resident 1 to remain on 24-hour hourly location monitoring, and for staff to implement an hourly behavior monitoring log. During a review of Resident 1's Change in Condition Evaluation (CIC- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 4/28/26 at 2:59 AM, the CIC indicated, Resident is going in roommates personal belongings and taking their belongings, threaten roommates and staff, resident is using foul language, showing signs of being a danger to other residents and staff, resident stated, 'I will beat your ass I am a gangster I don't care about going to jail' and got in staff face. The CIC further indicated Resident 1 exhibited behavioral changes that included verbal aggression, being a danger to self and others, and other behavioral symptoms. The CIC further indicated Resident 1 exhibited dangerous behavior that included threatening to hit roommates and staff and stealing roommate's belongings. The CIC further indicated the description of Resident 1's behavioral changes included aggressive behavior. The CIC was created and signed by Licensed Vocational Nurse (LVN) 2. During a review of Resident 1's CP dated 4/28/26, the care plan indicated Resident 1 had the potential to be physically aggressive related to threatening residents and staff, anger, and poor impulse control. The CP indicated a goal that Resident 1 would not harm himself or others through the review date. The CP further indicated for staff to monitor, document, and report as needed any signs or symptoms of Resident 1 posing danger to self and others. During a review of Resident 1's Progress Notes (PN) from 4/28/26 to 5/1/26, the PN did not include documentation from licensed nurses monitoring Resident 1 related to the CIC of making verbal threats and going into roommate's belongings for five (5) shifts: 1. 4/28/26 from 3 PM - 11 PM2. 4/28/26 from 11 PM - 7 AM3. 4/29/26 from 11 PM - 7 AM4. 4/30/26 from 7 AM - 3 PM5. 4/30/26 from 3 PM - 11 PM During a review of Resident 1's CIC dated 5/4/26 at 12:04 PM, the CIC indicated Resident 1 exhibited a change in condition related to insomnia/mood disorder, pacing in the hallway, [and] angry outburst. The CIC further indicated, Patient observed during shift exhibiting behavioral changes, including insomnia, pacing, and angry outburst. Patient noted to be standing and facing the hallways for extended periods, appearing restless and agitated. No incidents of physical aggression. During the shift, patient [had] difficulty sleeping, and an episode of angry verbal outburst. The CIC was created and signed by LVN 1. During a review of Resident 1's CP dated 5/4/26, the CP indicated Resident 1 was noted pacing in the hallways. The CP indicated a goal for Resident 1 to remain in his room or designated safe area and avoid standing or wandering in the hallway for prolonged periods during the shift. The CP indicated interventions to provide frequent check-ins and gentle reminders to return to his room or a safe area. During a review of Resident 1's PN dated 5/4/26 to 5/7/26, the PN did not include documentation from licensed nurses monitoring Resident 1 related to the CIC of pacing and having angry outburst for two (2) shifts:1. 5/6/26 from 3 PM - 11 PM2. 5/7/26 from 7 AM - 3 PM During a review of Resident 1's psychiatric note dated 5/11/26, the note indicated Resident 1 had a history of trying to touch female staff at his previous home. The note also indicated Resident 1 had a behavior of restlessly pacing but was easily redirectable. During a review of Resident 1's CIC dated 5/19/26 at 12:30 PM, the CIC indicated a change in condition indicating an allegation that Resident 1 was performing oral sex with other residents as reported by two police department officers. The CIC further indicated Resident 1's primary clinician recommended to transfer Resident 1 to a general acute care hospital (GACH) for further evaluation. During a review of Resident 1's CIC dated 5/19/26 at 4:30 PM, the CIC indicated a change in condition related to Resident 1 pacing the hallways, entering other residents' room without permission, entering a male resident's room and touching Resident 1's own private parts, making sexual remarks to female staff to come into his room, and attempting to touch another resident's foot. Resident 1 was placed on one-to-one (1:1) monitoring with a recommendation from Resident 1's primary clinician to transfer the resident to a GACH for psychiatric evaluation. b. During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and major depressive disorder. During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2 had intact cognition (good memory, accurate orientation, and minimal to no cognitive deficits) and required maximal assistance (helper does more than half the effort) for most cares such as toileting and dressing. Resident 2 was dependent on staff (helper does all the effort) for bathing. c. During a review of Resident 3's admission Record, the record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including anxiety, bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 3's History and Physical (H&P) dated 4/9/26, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was dependent (helper does all the help) for most cares such as toileting and bathing. d. During a review of Resident 4's admission Record, the record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including a left leg fracture (broken bone) and difficulty walking. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had intact cognition and was dependent on staff for cares such as toileting and showering. During an interview on 5/20/26 at 10:37 AM with the Director of Nurses (DON), the DON stated that on 5/19/26, two officers from the local PD came to the facility and reported that they received an anonymous report alleging that Resident 1 performed oral sex with other residents in the facility. The DON stated Resident 1 was known to pace in the facility at night and was known to attempt to touch female staff. The DON stated that after interviews with other residents near Resident 1's room, the following was reported:A. Resident 4 reported that Resident 1 went to Resident 4's room and touched himself inappropriately in the morning of 5/19/26B. Resident 5 reported that Resident 1 was always gazing at females in the hallways.C. Resident 2 reported that Resident 1 would go to Resident 2's room and stare at her from the door.D. Certified Nursing Assistant (CNA) 1 reported that Resident 1 invited CNA 1 into bed with him on 5/19/26.The DON further explained she was not aware of Resident 1's inappropriate behavior toward other residents and staff. The DON stated, We thought everything was fine. During an interview on 5/20/26 at 12:58 PM with CNA 1, CNA 1 stated that on 5/19/26 around 2 PM, Resident 1 told her, Hey, come to my bed. I'll give you hugs and kisses. CNA 1 stated Resident 1 liked to walk around the entire facility throughout the day and would stand by other residents' doors. During an interview on 5/20/26 at 1:34 PM with Resident 2, Resident 2 stated that Resident 1 had frequently come into her room uninvited for weeks. Resident 2 stated Resident 1 would stand at the foot of Resident 2's bed and mutter under his breath while staring at Resident 2. Resident 2 stated it made her feel very uncomfortable. During an interview on 5/20/26 at 1:40 PM with Resident 3, Resident 3 stated that Resident 1 would kiss Resident 3's feet while playing with his own genitals. The last time Resident 1 kissed Resident 3's feet was on 5/18/26 but Resident 1 had been inappropriate more than once. For multiple days, Resident 1 would stand at the foot of Resident 3's bed and would stare at Resident 3 while playing with his own genitals and talking to him. Resident 3 stated that when he asked Resident 1 to go away, Resident 1 would threaten him and say, What are you going to do to me? Resident 1 would lunge at Resident 3 as if he were trying to hit Resident 3 and say, You're not going to do anything. Resident 3 stated that he felt very uncomfortable and disgusted that Resident 1 kissed his feet. Resident 3 further explained that he felt helpless and unsafe in the facility because he was unable to move his body and the staff would not be able to help him in time. Resident 3 further stated, It's a little too late because it already happened. During an interview on 5/20/26 at 1:51 PM with Resident 4, Resident 4 stated he had concerns about lack of supervision of the residents that liked to wander in the facility. Resident 4 explained that, on 5/18/26, Resident 1 came into Resident 4's room and stared at Resident 4 while rubbing his genitals. Resident 4 stated he recognized Resident 1 as the same resident that always walked by his door in the hallways. Resident 4 stated that when he asked Resident 1 to leave his room, Resident 1 stated, You're not going to do anything. Resident 4 stated he was afraid to tell the staff about what happened with Resident 1 because he would get neglected or retaliated against by the staff whenever he brought up a concern. Resident 4 stated he felt very uncomfortable and did not feel safe being in the facility. During an interview on 5/20/26 at 2:49 PM and concurrent record review with Registered Nurse (RN) 1, Resident 1's care plans and Medication Administration Record (MAR) dated May 2026 were reviewed. RN 1 stated that Resident 1's care plan initiated on 4/28/26 for threatening residents and staff indicated to monitor, document, and report as needed any signs or symptoms of posing a danger to self and others as an intervention for Resident 1's behaviors. RN 1 stated Resident 1's behavior monitoring did not begin until 5/4/26 and there was no documentation on behavior monitoring between 4/28/26 to 5/4/26 in Resident 1's MAR. RN 1 stated it was important to follow Resident 1's care plan to prevent further abuse from happening. RN 1further explained that staff were responsible for following the care plan to apply appropriate interventions and ensure resident safety. During an interview on 5/20/26 at 3:10 PM and concurrent record review with the DON, Resident 1's CIC dated 4/28/26 for threatening roommates and staff and stealing from roommates was reviewed. The DON stated she was not aware of the CIC because LVN 4 did not report the incident to her. The DON stated that if she knew about it, she would have pushed for an immediate psychiatric consult and pushed for the resident to be medically and psychologically evaluated in a general acute care hospital (GACH). The DON stated that because LVN 2 failed to notify her of the CIC, the facility was unable to apply appropriate interventions such as sending Resident 1 out for medical and psychological evaluation to prevent further abuse from happening. During an interview on 5/20/26 at 3:49 PM and concurrent record review with LVN 1, Resident 1's CICs, care plans, and progress notes were reviewed. LVN 1 stated she knew that Resident 1 changed rooms due to roommate incompatibility on 4/28/26, but she was not aware of a CIC for verbally threatening staff and roommates and stealing from roommates. LVN 1 stated that if she witnessed Resident 1 verbally threatening his roommates, she would have notified the DON, CDPH, local PD, and local ombudsman as a mandated reporter. LVN 1 further stated that Resident 1 was considered a danger to himself and others and therefore required further medical evaluation and PD involvement. During the same interview on 5/20/26 at 3:49 PM and concurrent record review with LVN 1, Resident 1's progress notes and Hourly Behavior Monitoring Binder were reviewed. LVN 1 stated the Behavioral Monitoring Binder was the facility's internal hourly monitoring log for residents with behavioral issues. LVN 1 stated that if any portion of the hourly behavioral monitoring sheet was blank, then monitoring was not done. The following dates and shifts were left blank (87 shifts):3/29/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM3/30/26: 11 PM - 7 AM, 3 PM - 11 PM3/31/26: 11 PM - 7 AM, 3 PM - 11 PM4/1/26: 11 PM - 7 AM, 3 PM - 11 PM4/2/26: 11 PM - 7 AM, 3 PM - 11 PM4/3/26: 11 PM - 7 AM, 3 PM - 11 PM4/4/26: 11 PM - 7 AM4/5/26: 11 PM - 7 AM4/6/26: 11 PM - 7 AM, 3 PM - 11 PM4/7/26: 11 PM - 7 AM, 3 PM - 11 PM4/8/26: 11 PM - 7 AM, 3 PM - 11 PM4/9/26: 11 PM - 7 AM, 3 PM - 11 PM4/10/26: 11 PM - 7 AM4/11/26: 11 PM - 7 AM4/12/26: 11 PM - 7 AM4/13/26: 11 PM - 7 AM4/14/26: 11 PM - 7 AM4/15/26: 11 PM - 7 AM4/16/26: 11 PM - 7 AM4/17/26: 11 PM - 7 AM4/18/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM4/19/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM4/20/26: 11 PM - 7AM4/21/26: 11 PM - 7AM4/22/26: 11 PM - 7AM4/23/26: 11 PM - 7AM4/24/26: 11 PM - 7AM, 3 PM - 11 PM4/25//26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM4/26/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM4/27/26: 11 PM - 7AM4/28/26: 11 PM - 7AM4/29/26: 11 PM - 7AM, 3 PM - 11 PM4/30/26: 11 PM - 7 AM, 3 PM - 11 PM5/1/26: 3 PM - 11 PM5/3/26: 3 PM - 11 PM5/6/26: 3 PM - 11 PM5/7/26: 11 PM - 7 AM, 3 PM - 11 PM5/8/26: 11 PM - 7 AM, 3 PM - 11 PM5/9/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM5/10/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM5/11/26: 11PM - 7 AM, 3 PM - 11 PM5/12/26: 11PM - 7 AM, 3 PM - 11 PM5/13/26: 11PM - 7 AM, 3 PM - 11 PM5/14/26: 11PM - 7 AM, 3 PM - 11 PM5/15/26: 11PM - 7 AM, 3 PM - 11 PM5/16/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM17. 5/17/26: 11PM - 7 AM, 7 AM - 3 PM, 3 PM - 11 PM18. 5/18/26: 11PM - 7 AM, 3 PM - 11 PM19. 5/19/26: 11PM - 7 AMLVN 1 stated Resident 1's internal hourly monitoring binder and Progress Notes did not have complete monitoring documentation. LVN 1 stated it was important for staff to follow monitoring protocol for safety. During the same interview with the DON on 5/20/26 at 4:53 PM, the DON stated that prior to Resident 1's admission into the facility, she received report from the previous facility that Resident 1 had a history of exhibiting inappropriate behaviors toward female staff. The DON stated a care plan was initiated regarding Resident 1's behaviors and it was important to implement appropriate interventions to protect female staff and residents. The DON also stated that when there was a CIC, the staff was expected to monitor and document on the resident for 72 hours to ensure the resident no longer exhibited the behaviors in the CIC. During an interview with the Quality Assurance (QA) on 5/21/26 at 2:21 PM, the QA stated that on 5/19/26, Resident 1 said to her, With a behind like that, I'll follow you anywhere. The QA stated she did not know what prompted Resident 1 to say that to her. During another interview with the DON on 5/21/26 at 2:21 PM, the DON stated that Resident 1's internal behavioral monitoring binder was intended to be indefinite monitoring during Resident 1's stay in the facility because it was necessary for staff to monitor Resident 1 every hour to ensure he did not exhibit inappropriate behaviors toward female staff and residents. The DON stated the documentation should have been continuous and completed but it was not. The DON also stated the care plan to monitor Resident 1 due to his reported inappropriate sexual behavior toward female staff should have been followed but was not. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, revised on July 2017, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated that the facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive device.

Based on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for one out of five sampled residents (Resident 3) by failing to ensure to implement a care plan for Resident 3, who had a gastrostomy tube (G-tube, a device surgically inserted through the abdominal wall directly into the stomach to provide long-term nutrition, hydration, and medication to individuals unable to eat enough by mouth). These deficient practices had the potential to result in confusion of resident's care and negatively affect the residents psychosocial wellbeing.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the resident was readmitted to the facility on [DATE] with unspecified protein-calorie malnutrition, unspecified dementia (decline in mental ability), and gastrostomy status. During a review of Resident 3's Minimum Data Set (MDS, an assessment and screen tool) dated 3/3/2026, the MDS indicated Resident 3's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 3 had a feeding tube. During a review of Resident 3's Order Summary Report dated 10/02/2025, the Report indicated a physician order for Enteral Feed Order two times a day Jevity 1.2 at 50 millilliters (ml, unit of measure) per hour for 20 hours via pump, and to provide 1000 ml per 1200 calories in 24 hours off at 8 AM and on at 12 PM or until dose limit. During a review of Resident 3's care plans, there was no care plans initiated that indicated the use of or care for Resident 3's g-tube. During an interview on 4/30/2026 at 2:09 PM with the Director of Nursing (DON), the DON stated it was important to have a care plan for each resident to ensure goals are met. The DON stated if changes to the care plan are necessary to met the residents specific goal, the care plan would be revised. The DON stated the care plan helped to monitor the care of the resident and assisted staff on how to care for the residents specific needs. During the same interview on 4/30/2026 at 2:15 PM, in the presence of the DON, the Quality Assurance Nurse (QAN) stated the importance of a care plan was to have specific goals and interventions for resident so the staff know how to take care of resident. A review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 3/2022 indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The P&P indicated the comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on observation, interview and record review the facility failed to ensure proper and effective Basic Life Support (BLS-the level of care provided to victims of life-threatening illnesses or injuries until full medical care is available, including recognition of cardiac arrest and activation of the emergency response system), that included cardiopulmonary resuscitation (CPR, an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases). The facility did not perform BLS for one of two sampled residents (Resident 1) identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR. When Resident 1 was found weak, with shallow breathing, no longer talking and became unresponsive and failed to ensure: 1. Registered Nurse Supervisor (RN) 1 and Licensed Vocational Nurse (LVN) 1 initiated CPR immediately when Resident 1 was found weak and unresponsive with an oxygen saturation (a measurement of the oxygen blood level) of 89% (blood oxygen level normal range 94-100%) without delay on [DATE], at 6:45PM. 2. RN 1 placed Resident 1 flat on the back on a firm, flat surface and use the head-tilt, chin-lift maneuver to open the airway while delivering oxygen (to ensure optimal oxygen flow and blood circulation during CPR) via simple mask (lightweight, clear plastic medical device that fits over a patient's nose and mouth, secured with an elastic strap, to deliver oxygen), but instead placed Resident 1 at a 70-90 degree angle while Resident 1 remained unresponsive. 3. RN 1, LVN 1 and LVN 2 performed continuous and uninterrupted CPR until emergency medical services (EMS- ambulance services or emergency services that provide treatment and stabilization for the patient) assumed care. 4. Immediate CPR was provided without delay due to the unavailability of an oxygen regulator that could deliver 15 L/min flow required to keep the Bag-valve-mask (BVM - a manual resuscitation technique that provides positive pressure ventilation to patients with inadequate or absent spontaneous breathing) fully inflated to deliver 100% oxygen. As a result of the deficient practice, paramedics arrived at the facility on [DATE] at 6:52 PM. According to the Emergency Medical Services (EMS) report, facility staff reported to EMS that the resident's (Resident 1) last known well (LKW) time (a time someone was last seen acting normally or without new symptoms) was approximately 30 minutes prior. The report also noted that no CPR was being performed by facility staff, and that Resident 1 was found with no measurable blood pressure, pulse rate, respirations, or oxygen saturation upon EMS arrival. A determination was made that the facility's noncompliance with one or more requirements of participation placed Resident 1 in immediate jeopardy, beginning [DATE]. On [DATE] at 4:42 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an immediate jeopardy situation (IJ, a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the failure to ensure CPR was immediately performed on Resident 1. The survey team notified Director of Nursing (DON), the administrator (ADM) of the IJ situation. After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope of isolated (when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved) and lower severity of Level 3 (Actual Harm that is Not Immediate Jeopardy). On [DATE] at 4:45 PM, the IJ was removed in the presence of the ADM and the DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE] at 4:45 PM, included the following: 1. The RN 1 last day worked at the facility was [DATE] and has resigned as of [DATE]. 2. On [DATE] staff involved LVN 1, LVN 2 were removed by the DON from direct patient care until competency was validated. 3. On [DATE] immediate re-education was reinforced by the DON for direct care staff on (immediate initiation of CPR, proper positioning on a firm, flat surface, continuous, uninterrupted CPR, crash cart (mobile cart with equipment used during CPR to ensure all necessary tools are organized and immediately available to save a patient's life) utilization including oxygen regulators that could deliver 15L/minute flow and backboards, using oxygen tanks and how to know if full or empty). 4. On [DATE] Crash cart was immediately checked by the DON and oxygen regulators were replaced to ensure 15 l/minute capability, BVM bag and oxygen delivery systems verified to be functional, oxygen tanks are full. 5. On [DATE] the Director of Nurses and the Director of Staff Developer (DSD) reviewed current certifications of all direct care staff and only staff with validated CPR certification are assigned to residents' care. 6. On [DATE] Medical Records Director (MRD) identified 60 residents were designated as full code. Facility staff are aware of where to find the code status in the residents' file paper medical records and the health record system. 7. On [DATE] DON initiated immediate in-service to Licensed Nurses (RNs and LVNs) and Certified Nurse Assistants (CNAs) 7AM-3 PM shift (first shift, day staff) and on [DATE] to 3PM to11 PM shift (second shift, evening staff) regarding the facility's policy and procedure (P&P) tilted Emergency Procedures Cardiopulmonary Resuscitation revised date 2/2018, with emphasis on the following: Calling code blue (a code called via hospital paging system when there is critical medical emergency within a hospital when a person is experiencing cardiac or respiratory arrest and requires immediate resuscitation) when a resident is found unresponsive. Able to locate the code status information (a medical order indicating the type of emergency treatment a person would not receive if their heart or breathing stopped) in the resident's medical record to ensure that CPR is immediately for a full code status resident found unresponsive. Placing a resident on a firm, flat surface while performing CPR by utilizing a backboard a rigid board inserted under a resident's back to create a firm surface, preventing soft surfaces [like mattresses] from absorbing compression force, thereby improving the depth and effectiveness of chest compressions) and use the head-tilt, chin-lift maneuver to open the airway while delivering oxygen (to ensure optimal oxygen flow and blood circulation during CPR) via simple mask, utilization of an oxygen regulator that could deliver 15 L/min flow required to keep the BVM bag fully inflated to deliver 100% oxygen. Performing continuous and uninterrupted CPR on the resident's bed until emergency medical services EMS assumed care. 8. On [DATE], a Code Blue drill was initiated and will continue weekly once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective Basic Life Support, including CPR. 9. On [DATE], the development of crash cart checklist was implemented by DON. The crash cart and oxygen equipment checklist was Implemented on [DATE] and shall be checked every shift by the lead licensed staff. 10. On [DATE] any room changes include residents' medical records to change reflecting new room assignment along with electronic health records and physical medical record will be completed during room changes. 11. On [DATE], a Certified CPR instructor came to the facility on 7-3 and 3-11 shift and provided mandatory re-education and training for all Licensed Nurses and CNAs which was also attended by the DON and DSD with return demonstration conducted. 12. Starting on [DATE], the DSD/Designee will validate that any newly hired Licensed Nurses and CNAs have a current valid CPR certification prior to scheduling the employee for direct resident care. No direct care staff will be allowed to work with residents directly without a valid CPR certification. 13. On [DATE] DON had a 1:1 (one on one) in-service with LVN 1, and LVN 2 regarding Medical Emergency Response (immediate initiation of CPR, proper positioning on a firm, flat surface, continuous, uninterrupted CPR, crash cart utilization including oxygen regulators that could deliver 15L/minute flow and backboards, using oxygen tanks and how to know if full or empty). 14. On [DATE], the DSD updated all current direct care staff for CPR certification and will update monthly. The DSD shall audit and communicate with direct care staff if CPR certification expires. 15. The DON/Designee will provide a summary of findings for the monthly Quality Assurance Committee (QAC-a data driven proactive approach to improvement used to ensure services are meeting quality standards). During a review of Resident 1's admission Record dated [DATE] indicated that Resident 1 was admitted to the facility from another Skilled Nursing Facility (SNF) 2 on [DATE] for long term care. Resident 1's diagnoses included Diabetes Mellitus (DM-a disorder characterized by high blood sugar), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), atrial fibrillation (A-Fib - a heart condition causing an irregular and rapid heart rate). A review of Resident 1's Physician's Orders for Life Sustaining Treatment (POLST - a record signed by the resident/representative and the physician that indicates the resident's medical treatment wishes so that emergency personnel know what treatments the resident wants during a medical emergency), dated [DATE] indicated resuscitation/CPR should be attempted and that Resident 1 had full treatment status. This information was known to facility staff and available for review by staff in the event of a code. During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment dated [DATE], indicated that Resident 1 had a severe cognitive (thought process or ability to think and reason) impairment. During a review of Resident 1's Physician Orders dated [DATE] indicated an order to administer oxygen 2-5 liters via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath or oxygen saturation below 92% as needed. During a review of Resident 1's Care Plan indicated Resident 1 was potential for cardiac distress related to A-Fib, heart failure, and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls) dated [DATE]. Resident 1's care plan indicated to monitor and observe for signs of elevated blood pressure (the force of your blood pushing against the walls of your arteries, dizziness (feeling lightheaded, unsteady), chest pain, dyspnea (difficulty breathing), shortness of breath, tachycardia (fast heart rate), edema (fluid retention) congestion, nausea, and vomiting. The care plan indicated to promptly contact the medical doctor if any symptoms occurred. During a review of Resident 1's Progress Notes dated [DATE] timed at 6:45 PM, indicated RN 1 was called to Resident 1's room by the Certified Nurse Assistant (CNA 2). RN 1 indicated that LVN 2 made him aware that Resident 1 was having difficulty breathing. RN1 indicated when he entered Resident 1's room and found the resident (Resident 1) sitting up in a 90-degree angle with the head tilted back, RN 1 proceeded to start taking vital signs (VS-measurement of the body temperature, blood pressure, respiratory rate, oxygen and pain level). RN1 indicated Resident 1 was not verbally responsive and made noises. RN1 then indicated he went to verify Resident 1's code status with LVN 1 and proceeded to grab the crash cart. Vital signs were obtained with a blood pressure measuring at 126/72 (normal ranges between 120/80 to 100/60), heart rate 71 (heart rate per minute, normal range is 60 to 100), respiratory rate 18 (number of breaths per minute normal range is between 12 to 20) and oxygen level of 98% (normal oxygen level in the blood-normal range 94-100%). RN1 indicated that he listened to Resident 1 lung sounds and were clear, eye pupils were normal at 3 millimeters (mm) (normal pupil size 2 to 4 mm) RN1 indicated Resident 1 had shallow breathing. RN1 indicated that on [DATE] at 6:54 PM oxygen level was rechecked but dropped to 96%, and at 7 PM Resident 1's oxygen level quickly dropped to 89%. RN1 indicated a 911 emergency call was initiated and he increased the resident's oxygen to 2-5 liters via mask. RN1 indicated that vital signs were obtained and the resident was still breathing. RN1 indicated that the paramedics arrived and started CPR. CPR included chest compressions, the use of mechanical breathing [a device used to help someone breathe]) for approximately 20 minutes and at 7:25 PM Resident 1 was pronounced dead by the paramedics. RN 1 indicated the paramedics arrived and started CPR. CPR included chest compressions and breathing help. After about 20 minutes, at 7:25 PM, the paramedics pronounced Resident 1 dead. During a review of Resident 1's Emergency Medical Services (EMS) report dated [DATE] at 6:52 PM, the paramedics dispatched time 6:46 PM and arrived at the facility at 6:52 PM. EMS was at Resident 1's bedside at 6:55 PM found Resident 1 lying supine (lying on one's back with face upward) n bed with the complaint of cardiac arrest and no CPR being done by the facility staff. Paramedics found Resident 1 in asystole (heart completely stops beating) at 6:55 paramedics-initiated CPR at 6:57 PM Resident 1 was found to have no blood pressure, no pulse, no respiratory rate, and no pulse oximeter. At 7:07 PM the paramedics report indicated Resident 1 had fixed and dilated (enlarge) pupils and pale skin. At 7:29 after 34 minutes of continuous CPR efforts by paramedics Resident 1 was pronounced dead. During an observation and concurrent interview on [DATE] at 3:50 PM with RN 1, RN 1 was unable to determine that the oxygen tank on the crash cart was empty. RN 1 could not demonstrate the proper procedure to connect the suction tube to the suction machine. During the interview, RN 1 stated he did not know how to determine whether the oxygen tank was empty or how to properly connect the suction machine. Upon inspection of the first drawer of the crash cart, an oxygen valve regulator with a maximum output of only 8 liters per minute was found and verified by RN 1. RN1 stated he did not know how to check if the oxygen tank was empty or how to connect the suction machine. During an interview on [DATE] at 4:28 PM with LVN 2, LVN 2 stated that on [DATE] Resident 1 was stable throughout the day and ate 100% of dinner. LVN 2 stated, on [DATE] at 6:54 PM, CNA 1 and CNA 2 asked her to come see Resident 1 who was unresponsive. LVN 2 stated she attempted to take Resident 1's VS but the VS was not documented in the resident's clinical record. LVN 2 stated at 7PM a 911 was called and the paramedics arrived at approximately 7:05 PM who placed Resident 1 on a bag valve mask (BVM), started chest compression and respiratory resuscitation. During an interview on [DATE] at 4:55 PM with CNA 1, CNA 1 stated, on [DATE] before dinner time, Resident 1 was talking and wanted to make a phone call to her Family Member (FM 1). CNA 1 stated after dinner CNA 1 and CNA 2 assisted Resident 1 to reposition in bed to keep the resident comfortable. CNA 1 stated as soon as CNA 2 stepped out of the room, CNA1 noticed Resident 1's eyes rolled back and became unresponsive, so she immediately called CNA 2 to go get help. CNA 1 stated RN1 came into the room and looked at Resident 1 and immediately left to go to the nursing station. CNA 1 reported that LVN 1 entered the room with the crash cart; however, no CPR was initiated by facility staff. CNA 1 stated that when paramedics arrived, Resident 1 was pulseless, and the paramedics began chest compressions and provided respiratory resuscitation. During an interview on [DATE] at 1:40 PM with RN1, RN 1 stated on [DATE] at 6:45 PM, he was called by CNA 2 to go check on Resident 1 who did not look good. RN 1 stated that Resident 1 was unresponsive, and he proceeded to obtain the resident's vital signs. According to RN 1, the initial pulse oximetry reading was 96%, but when he repeated the reading, it had decreased to 89%. He instructed staff to place Resident 1 on oxygen via a simple mask. RN 1 reported that he touched Resident 1's ear, and the resident responded by making a noise. RN 1 stated he did not initiate CPR because the resident demonstrated responsiveness to pain. He reported administering 2-5 liters of oxygen by simple mask when the oxygen saturation dropped to 89%; however, he did not reassess the oxygen saturation after applying the oxygen. RN 1 also stated that the vital signs were obtained but were not documented. During a continued interview on [DATE] at 1:40 PM, RN 1 stated that Resident 1 was becoming weak, exhibited shallow breathing, and was not talking. RN 1 reported that Resident 1 remained in a seated position at an angle of approximately 70-90 degrees while unresponsive. RN 1 further stated that he did not attempt to place the resident in a supine position to open the airway using a head-tilt chin-lift maneuver because the resident made a noise in response to pain when he touched the resident's ear. RN 1 also stated that staff did not initiate chest compressions while Resident 1 remained unresponsive with shallow breathing. During an interview on [DATE] at 5:15 PM, the Director of Nurses (DON) stated that several oxygen regulators in the facility only provide up to 8 liters per minute; however, the facility also has regulators capable of delivering up to 15 liters per minute. The DON stated she was unsure why the crash cart did not contain a regulator capable of delivering up to 15 liters per minute. During an interview on [DATE] at 8:30 AM, the Paramedic Captain (PC) who responded to the 911 call stated the department received a report of an unresponsive resident with CPR in progress. The PC stated that upon arrival to the facility, no CPR was being performed to the residents by facility staff. The resident (Resident 1) was found unresponsive, pulseless, and apneic. The PC immediately requested a backboard (a CPR backboard is a rigid, flat board designed to be placed underneath a patient to provide a firm surface for effective chest compressions) and was informed by RN1 that the facility did not have one. The PC stated that the crash cart contained only one bag valve mask (BVM), and the oxygen tank valve being used delivered a maximum of 8 liters of oxygen per minute. The PC reported that he had to search through every drawer of the crash cart to locate a valve capable of increasing the oxygen flow to 15 liters per minute. The PC further stated that a BVM must be connected to oxygen at 15 liters per minute to keep the reservoir bag fully inflated and deliver 100 percent oxygen. The paramedics used the available BVM; however, it could not be used appropriately during the code due to the inability to increase the oxygen flow beyond 8 liters per minute. According to the PC, the crash cart did not contain the necessary equipment to adequately respond to a code. During a continued interview with the PC on [DATE] at 8:30 AM the code blue on [DATE], the oxygen regulator connected to Resident 1's oxygen tank was limited to a maximum of 8 liters per minute which could not deliver 100% oxygen. The paramedics were unable to use the BVM appropriately during the Code Blue because the oxygen flow could not be increased beyond 8 liters/minute. PC found another regulator inside the crash cart that only increased to 8 liters/minute. PC stated he had to switch to their own oxygen valve regulator to be able to increase it to 15 liters to be able to deliver 100% oxygen. The PC stated, This resulted in delayed delivery of 100% oxygen that is needed during resuscitation. During an interview on [DATE] at 9:14 AM, LVN 1 stated that CNA 2 called him to Resident 1's room because staff needed assistance with the resident, who had become unresponsive. LVN 1 reported that Resident 1 was on oxygen via nasal cannula and was breathing, but he observed two to three long breaths and recognized that the breathing pattern was not normal. LVN 1 stated that he knew 911 needed to be called. LVN 1 reported that when he attempted to turn on the oxygen tank on the crash cart, it made a loud noise as if oxygen was leaking. He stated that he went to the oxygen room to obtain a valve capable of delivering 15 liters per minute for use with a non rebreather mask (a non-rebreather mask is an oxygen mask that delivers high concentrations of oxygen). According to LVN 1, as he returned from the oxygen room, he saw paramedics entering the facility and immediately applying oxygen, followed by chest compressions, and initiating intravenous fluids. During an interview on [DATE] at 2:19 PM, Resident 1's Medical Doctor (MD) stated that he received a call from the facility reporting that Resident 1 was experiencing breathing difficulties. The MD stated that he did not recall all the details of the telephone conversation; however, if the resident was a full code and had gone into cardiac arrest, he would have expected facility staff to initiate CP. During an interview on [DATE] at 12:28 PM with LVN 2 stated that on [DATE] at approximately 6:45 PM, Resident 1 was having shortness of breath because Resident 1 was breathing slow and stated that Resident 1 was not aware that you could provide ventilation when a resident is unresponsive and breathing slow. LVN 2 also stated that the progress notes documentation times are inaccurate in her documentation stating, I don't know why it mark those times. During a facility's policy and procedure (P&P) titled Oxygen Administration revised 10/2010, indicated that while resident is receiving oxygen therapy the following symptoms should be assess for: restlessness, confusion, shallow breathing, vital signs, and oxygen saturation. During a facility's policy and procedure (P&P) titled Emergency Procedure - Cardiopulmonary Resuscitation revised on 2/2018, indicated that sudden cardiac arrest is a loss of heart function due to abnormal heart rhythms (arrhythmias) victims of cardiac arrest may initially have gasping respirations and chances of survival increase if CPR is initiated immediately upon collapse. The P&P indicated that if an individual is found unresponsive and not breathing normally a licensed staff member certified in CPR shall initiate CPR unless there is a Do Not Resuscitate (DNR) order. If the resident status is unclear, CPR will be initiated until it is determined that there is a DNR order. During a review of Basic Life Support Provider Manual by American Heart Association, dated 2020, indicated: High-quality CPR (proper hand position and depth of chest compression) with minimal interruptions and early defibrillation (administering a controlled electric shock to allow restoration of the normal rhythm.) are the actions most closely related to good resuscitation outcomes.

Based on observation, interview and record review the facility failed to ensure three of three licensed nursing staff (LVN 1, LVN 2, RN 1) had the competent skills sets to provide care in accordance with the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing) and resident assessment for one of two sampled resident (Resident 1) who was unresponsive with difficulty breathing and required cardiopulmonary resuscitation (CPR - an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases). These deficient practices resulted in delayed provisions of emergency care for Resident 1 and other potential residents with full code status treatment (full support which includes CPR if the patient has no heartbeat and is not breathing) in a life-threatening situation. Findings: During a review of Resident 1's Physician Orders for Life Sustaining Treatment (POLST - a record signed by the resident/representative and the physician indicated the resident's medical treatment wishes so that emergency personnel know what treatments the resident wants during medical emergency) dated [DATE] indicated attempt resuscitation/CPR and full treatment status that was known to the facility staffs and available to the staffs for review in an event of a code. During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] for long term care with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by high blood sugar), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), atrial fibrillation (AFib - a heart condition causing an irregular and rapid heart rate). During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) with assessment dated [DATE], indicated the resident had a severe cognitive (thought process or ability to think and reason) impairment and was dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene. During a review of Resident 1's Physician Orders dated [DATE] indicated an order to administer oxygen 2-5 liters via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath or oxygen saturation below 92% as needed. During a review of Resident 1's Care Plan indicated Resident 1 has potential for cardiac distress related to A-Fib, heart failure, and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). dated [DATE] indicated to monitor and observe for signs of elevated blood pressure (the force of your blood pushing against the walls of your arteries, dizziness (feeling lightheaded, unsteady), chest pain, dyspnea (difficulty breathing), shortness of breath, tachycardia (fast heart rate), edema (fluid retention) congestion, nausea, and vomiting. The care plan indicated to promptly contact the medical doctor if any symptoms occurred. During an observation and concurrent interview on [DATE] at 3: 50 PM with RN 1, RN 1 was unable to determine that the oxygen tank on the crash cart was empty. RN 1 could not demonstrate the proper procedure to connect the suction tube to the suction machine (a device that uses vacuum pressure to remove fluids from airway or body) RN1 stated he did not know how to check if the oxygen tank was empty or how to connect the suction machine. During an interview on [DATE] at 4:10 PM with RN 1, RN 1 couldn't verbalize that a backboard was needed during CPR. During an interview on [DATE] at 4:28 with the Licensed Vocational Nurse (LVN 2) stated that Resident 1 was stable in the morning shift of [DATE] and ate 100% of her dinner. LVN 2 stated that around 6:54 PM on [DATE] the Certified Nurse Assistants (CNA 1 & CNA 2) called for help for Resident 1 who was weak, breathing slow. LVN 2 stated he attempted to take Resident 1's VS but he was not able to document the results. LVN 2 stated that as soon as the paramedics arrived, they started CPR. During a review of the undated Licensed Nurse Core Clinical Competencies for RN 1indicated RN 1 did not have a skills and competency evaluation for the use of a suction machine, vital signs and emergency response. During an interview on [DATE] at 5:30 PM with the Director of Nurses (DON), the DON stated that RN1 experiences a language barrier. The DON explained that RN1 demonstrates better understanding of information when it is communicated in written form, such as notes on a piece of paper. The DON stated that she deliberately pairs the RN Supervisor with experienced Licensed Vocational Nurses (LVNs), taking into consideration RN1's comprehension of the English language and communication needs. During an interview on [DATE] at 8:30 AM the Paramedic Captain (PC) who responded to the 911 call on [DATE], stated that upon arrival to the facility the facility staff were not performing CPR, the backboard was not placed on Resident 1's back and the oxygen valve regulator connected to the oxygen tank only delivered up to 8 liters/minute. During an interview on [DATE] at 12:28 PM with LVN 2 stated that Resident 1 was having shortness of breath because she was breathing slow and stated that she was not aware that ventilation could be provided when a resident was unresponsive and breathing slow. LVN 2 also indicated that her documentation times are inaccurate in the documentation stated, I don't know why it mark those times. During a facility's policy and procedure (P&P) titled Oxygen Administration revised 10/2010, indicated that while resident is receiving oxygen therapy the following symptoms should be assess for: restlessness, confusion, shallow breathing, vital signs, and oxygen saturation. During a review of the facility's policy and procedure (P&P) titled Emergency Procedure - Cardiopulmonary Resuscitation revised on 2/2018, indicated that sudden cardiac arrest is a loss of heart function due to abnormal heart rhythms (arrhythmias) victims of cardiac arrest may initially have gasping respirations and chances of survival increase if CPR is initiated immediately upon collapse. The P&P indicated that if an individual is found unresponsive and not breathing normally a licensed staff member certified in CPR shall initiate CPR unless there is a Do Not Resuscitate (DNR) order. If the resident status is unclear, CPR will be initiated until it is determined that there is a DNR order. During a review of the facility's policy and procedure (P&P) titled Charting and Documentation dated 7/2017, indicated that documentation of procedures and treatments will include care-specific details, including the date and time the treatment and procedure was provided, the name and title of the individual that provided the care, the assessment data and any unusual findings during the procedure/treatment, notification of family, physician or other staff, if indicated. During a review of the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing) revised [DATE] indicated that the facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a behavioral problem were assessed, monitored, supervised and provided necessary care since admission to the facility on 1/26/2026. This deficient practice resulted in Resident 1 hitting another resident (Resident 2) on 1/29/2026.Findings: During a review of General Acute Care Hospital (GACH) Psychiatry evaluation (assessment conducted by mental health professionals to diagnose mental health, behavioral, or learning disorders) dated 1/18/2026, the Evaluation indicated Resident 1 had a history of depression, anxiety, frustration, irritability, agitation, and lack of motivation. Resident 1 reported having dark thoughts and thoughts of (suicide the act of intentionally causing one's own death). Resident 1 was having difficulty resisting urges to self-harm. Resident 1 was unpredictable with a lack of coping skills and frustration. Resident 1 was reluctant to share details of why he was admitted , Resident reported he cannot quite understand. The Evaluation indicated Resident 1 appeared to be disheveled, guarded, and poor eye contact with psychomotor agitation. Mood and affect were labile, with thoughts of suicidal plan to overdose. The Evaluation indicated Resident 1's insight, judgement and impulse control were impaired. During a review of GACH History and Physical, dated 1/19/2026, Resident 1 was admitted for increased agitation and anxiety for two days. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of fear, dread, and uneasiness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Social Service History and Initial Assessment, dated 1/27/2026, timed 8:52 AM, the Assessment indicated blank check marks on the following boxes has no check marks for Resident 1's psychosocial (relating to the interrelation of social factors and individual thought and behavior) adjustment factors.Distressed moodHistory of depressionHistory of suicidal ideation/gesturesAnxiety/uneasinessInsomnia (trouble falling asleep or staying asleepUse of psychotropic medicationsHistory of drug/alcohol abuseDisruptive behaviorDifficulty controlling behaviorAgitation, aggressionResistant to care During a review of Resident 1's Interdisciplinary Team (IDT, a collaborative group of health professionals and direct care staff responsible for developing, implementing, and reviewing a resident's comprehensive care plan) conference record, dated 1/27/2026, timed 10:30 AM, the IDT indicated Resident 1 and Resident 1's responsible agent participated in the IDT meeting. The IDT indicated the team looked closer on several considerations and deemed to admit Resident 1 to psych services under nursing. For it will be more beneficial to Resident 1, to prevent further decline with the treatment for diagnosis of schizophrenia, anxiety, depression and bipolar. The IDT indicated Resident 1 will be on close daily monitoring for medication regimen, treatment, compliance of the plan of care. The IDT indicated Resident 1's responsible agent stated Resident 1 has history of psychiatric hospitalization. During a review of Resident 1's Order Summary Report dated from 1/26/2026 to 2/9/2026, the Report indicated the following orders:Monitor anxiety manifested by repetitive anxious complaints, ordered on 1/26/2026.Monitor schizophrenia manifested by paranoia, ordered on 1/26/2026.Monitor insomnia manifested by inability to sleep, ordered on 1/26/2026. During a review of Resident 1's Care Plan (CP) focusing on psychosocial wellbeing (actual or potential) related to anxiety, dependent behavior, disease process. Distractibility/inability to concentrate, inability to meet role expectations, ineffective coping, lack of acceptance to current condition. Lack of motivation, initiated on 1/28/2026, the Care Plan interventions included the following:Consult with social servicesMonitor/document Resident 1's usual response to problemsMonitor behavior every shift and recordPsychiatric (a medical practitioner specializing in the diagnosis and treatment of mental illness) consultWhen conflict arises, remove Resident 1 to a calm safe environment and allow to vent/share feelings. During a review of Resident 1's Change of Condition (COC) Evaluation, dated 1/29/2026, timed 8:46 AM, the COC indicated Resident 1 has alleged physical abused of slap another resident. The COC evaluation also indicated Resident 1 was observed by staff slapping another resident on the right upper back. Resident 1 stated he do not know why he did it. During an interview on 2/11/2026 at 11:31 AM, with Payroll, Payroll stated she witnessed Resident 1 walking in the hallway, then out of nowhere, Resident 1 stopped behind Resident 2, and with Resident 1's right hand's open palm, Resident 1 hit Resident 2. Payroll stated the action looks like a harder than a tap, like a hard smack, with a sound. After Resident 1 hit Resident 2, Resident 1 continued to walk down the hallway away from Resident 2. During an interview on 2/11/2026 at 12:02 PM, with central supply staff (CSS), CSS stated he witnessed on 1/29/2026, morning before resident's smoke break (8 AM - 9 AM), CSS stated he was with Payroll in the front lobby with Resident 2 who is sitting in a wheelchair, CSS observed Resident 1 walking up and down the hallway, then suddenly, Resident 1 hit Resident 2's back area. CSS stated the hit was like a slap from the sound of it. CSS stated Resident 1 walked away after hitting Resident 2. During an interview on 2/11/2026 at 2:18 PM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated that on 1/29/2026, Resident 1 rushed to eat breakfast and left the room for smoke break. CNA 1 stated the incident of Resident 1 hitting Resident 2 happened before the smoke break. CNA 1 stated Resident 1 was just walking up and down the hallway while waiting for the staff and other residents to go out to smoke. During a concurrent interview and record review on 2/12/2026 at 8:20 AM with Social Service Director (SSD), Resident 1's Social Service History and Initial Assessment, dated 1/27/2026, and admission IDT dated 1/27/2026 were reviewed. SSD stated the Social Service History and Initial Assessment and IDT meeting was conducted on 1/27/2026, the day after Resident 1 was admitted to the facility. SSD stated she had not reviewed Resident 1's hospital records prior to admission to the facility. SSD stated that she was not aware of Resident 1's behavior of increased agitation and having dark thoughts and thoughts of suicide. SSD verified the Social Service assessment and IDT did not and should have indicated Resident 1's past behaviors that was documented in the GACH records. SSD stated Resident 1's past behaviors were not and should have been discussed during IDT, and plan of care, such as to conduct one to one (1:1, staff continually stay with resident) monitoring since admission until psychiatrist evaluated and checked if medications are enough and if care is appropriate. During a concurrent record review and interview on 2/12/2026 at 8:56 AM with Licensed Nurse 1 (LN 1), Resident 1's medical records were reviewed. LN 1 stated she admitted Resident 1 in the facility on 1/26/2026. LN 1 stated she received the report from GACH that Resident 1 had increased aggressive behavior. LN 1 admitted she did not ask and should have asked GACH staff which specific aggressive behavior Resident 1 manifested and if psychiatrist evaluation was conducted in GACH. LN 1 stated she did not review the hospital records that came along with Resident 1 on 1/26/2026. LN 1 stated the following orders were made on 1/26/2026 based on what she observed with Resident 1:Monitor anxiety manifested by repetitive anxious complaints.Monitor schizophrenia manifested by paranoia.LN 1 stated Resident 1 was observed on 1/26/2026 to be a little anxious and kept asking what is this place again?, What time is smoking again?, repetitively. LN 1 stated these behaviors was care planned on 1/29/2026, after Resident 1 slapped another resident. LN 1 stated Resident 1's past behaviors should have been known to the facility, and plan of care should have been initiated. Resident 1's past behaviors should have been considered, and 1:1 monitoring should have been ordered until Resident 1 was seen by the Psychiatrist. LN 1 verified the Psychiatrist consult was ordered on 1/28/2026, and the Psychologist (a person who specializes in the study of mind and behavior) consult was ordered on 1/29/2026. LN 1 stated Resident 1 was not evaluated in the facility by the Psychiatrist before 1/29/2026 incident of slapping another resident. LN 1 stated a Psychiatrist consult order upon admission should have been ordered. LN 1 stated Resident 1's GACH records and behaviors should have been discussed during IDT on 1/27/2026. LN 1 stated all licensed staff can initiate and develop a care plan. During a concurrent interview and record review and interview on 2/12/2026 at 10:30 AM with LN 2, Resident 1's medical records were reviewed. LN 2 stated she was not aware of Resident 1's specific past psychiatric behaviors. LN 2 stated an IDT meeting was conducted on 1/27/2026 with Resident 1 and Resident 1's responsible agent, and specific behaviors were not discussed. LN 2 stated she had not and should have reviewed Resident 1's GACH medical records, and that Resident 1's GACH records should have been reviewed, and it should have been discussed during the IDT meeting on 1/27/2026. LN 2 stated Resident 1's baseline care plan was completed on 1/26/2026, indicating the use of psychotropic medications, but mental health needs and behavioral concerns remained blank and unanswered. LN 2 stated Resident 1's past behavior should have been assessed properly to determine appropriate care for Resident 1's safety and other residents. LN verified Resident 1 did not have a care plan to manage behaviors prior to 1/29/2026, where Resident 1 hit another resident. LN 2 further stated a Psychiatrist consult order should have been ordered upon admission on [DATE] since Resident 1 was taking psychotropic medication, and to determine the care to be rendered to Resident 1. During a review of facility's Policy and Procedures (P&P) titled Behavioral Assessment, Intervention and Monitoring, revised in March 2019, indicated the IDT will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including depression, anxiety, alteration in routines and change in caregivers. The P&P also indicated the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the residents and others from harm. During a review of facility's P&P titled Care Plans - Baseline, revised in December 2016, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive, resident centered care plan was developed for one of three sampled resident (Resident 1), who was legally blind to address and assist specific needs. This deficient practice resulted in Resident 1 not being provided with specific care and services required to maintain her independence. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted on [DATE], with a diagnosis of, but not limited to Blindness of left and right eye, respiratory failure( a serious condition where your lungs cannot get enough oxygen into your blood) , and diabetes(a condition where your body has trouble controlling sugar in your blood). During a review of Resident 1's History and Physical (H&P), dated 8/11/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), indicated the resident is cognitively intact (fully alert, oriented, and able to make decisions and participate in care planning) requiring moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, lower and upper body dressing and putting on / taking off foot ware. During an interview on 1/28/2026 at 10:30AM with Resident 1, Resident 1 stated that due to her blindness she was unable to visually identify her meals. Resident 1 stated that she used her hands to determine what she was eating by touching the texture of food and feeling the temperature. During an interview on 1/28/2026 at 11:45AM with Registered Nurse (RN) 1, RN1 stated that Resident 1 was blind in both eyes. RN1 stated that usually, assistance would be provided for meal set- up (including identifying food items and their location on the tray), as well as for transfers and toileting due to her visual impairment. During a concurrent interview and record review on 1/28/2026 at 2 PM with RN 2, Resident 1's Care Plans were reviewed. RN 2 stated there was no care plan initiated to address Resident 1's specific diagnosis for blindness. RN2 stated the care plan should have been initiated and should include measurable goals and address interventions for behaviors and needs to decrease stress and anxiety. During an interview on 1/29/2026 at 11:53AM with minimum data set nurse (MDSN) , MSDN stated there was no care plan initiated to address Resident 1's blindness. During a review of the facility's policy and procedure ( P&P) titled, Care Plans, Comprehensive Person - Centered, revised December 2016, indicates a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. A comprehensive, person-centered care plan is developed and implemented for each resident. A comprehensive, person -center care plan developed within seven (7) days after a significant change in status with care plan interventions chosen only after data gathering, proper sequencing of events, careful consideration between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing, and care plans are revised as information about the residents' conditions change.

Based on observation, interview and record review, the facility failed to implement infection control practices in accordance with the facility's Policy and Procedure (P&P) titled Oxygen Administration and Departmental (Respiratory Therapy) for a one of two sampled residents ( Resident 1) by failing to : Ensure Resident 1's oxygen tubing (a flexible plastic tube, often green, that delivers supplemental oxygen from a tank or concentrator to a patient via nasal prongs) was labeled with a date the oxygen tubing was last changed.Ensure Resident 1's breathing nebulizer (a device that converts liquid medication into a fine mist for inhalation) was changed within seven (7) days. The nebulizer was last dated 1/5/2026.Document oxygen set- up, which included the date and time the procedure was performed in Resident 1's medical record. These deficient practices had the potential to increase the risk and spread of infections. Findings: During a review of Residents 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 08/08/2026, with a diagnosis of chronic respiratory failure (lungs can't get enough oxygen), obstructive pulmonary disease (blocked airways, hard to breathe out) and delusional disorders (false beliefs). During a review of Resident 1's History and Physical (H&P), dated 8/11/2026, the H&P indicated Resident 1 has the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/15/2025, indicated resident is cognitively intact (can understand, remember and make decisions appropriately) and requires moderate assistance (helper does less than half the effort) with Activities of Daily living ( ADLS) such as personal and oral hygiene, and dressing. During a review of Resident 1' s Order Summary Report, the report indicated an order start date of 12/25/2025 for oxygen at 5 liters per minute(lpm) by nasal canula (small tub in the nose that gives extra oxygen) to be administered continuously (all the time) every shift. During an observation on 1/28/2026 at 10:30AM in Resident 1's room, Resident 1's oxygen tubing was observed without a date or time to indicate when the tubing was last changed and breathing nebulizer tubing was dated 1/5/2026. During a concurrent observation and interview on 1/28/2026 at 11 AM with Licensed Vocation Nurse (LVN) 1 in Resident 1's room, Resident 1's oxygen tubing and breathing nebulizer was observed. LVN 1 stated oxygen tubing must be dated to ensure staff know when to change the tubing next. During a concurrent observation and interview on 1/28/2026 at 11:45 AM with Registered Nurse ( RN1), Resident 1's oxygen tubing and nebulizer was observed. RN 1 stated the oxygen tubing was not labeled and should be labeled weekly to ensure the tubing was changed to prevent infection. RN1 stated the nebulizer tubing was dated 1/5/2026 and that the tubing should have been changed since not changing the nebulizer tubing would increase the risk of infection. RN 1 stated there was no way to know when the tubing's were last changed since there was no date or documentation to indicate when Resident 1's oxygen tubing was changed. RN 1 stated that the nebulizer tubing was last changed on 1/5/2026, since that date was indicated on the label, and that the nebulizer tubing should have been changed every 7 days, which would have been last changed on 1/19/2026. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration dated October 2010, indicated the purpose of the P&P is to provide guidelines for safe oxygen administration and documentation. The policy requires that, after completing oxygen se-up, the date and time the procedure was performed be documented in the resident's medical record. During a review of the facility's P&P titled Departmental ( Respiratory Therapy)dated November 2011 indicated the purpose of the P&P is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators , among residents and staff. The P&P indicates to change the oxygen cannula and tubing every seven ( 7) days, or as needed and to document the following information in the resident's medical record, the date and time the respiratory therapy was performed.

Based on observation, interview, and record review, the facility failed to provide care and services to three of three (Resident 1, 2 and 3) who needed assistance with ADL (activities of daily living) by not answering the call lights (a button or touch pad device that residents use to communicate assistance from the nursing staff) in a timely manner in accordance with the facility's policy and procedure by failing to assist: 1.Resident 1 and Resident 2 reported it took the facility one (1) to two (2) hours to respond to their call light when their adult briefs needed to be changed. 2.Resident 3 reported he waited about one (1) hour in the bathroom for a nurse to assist in cleaning him after having a messy bowel movement. As a result of this deficient practice, the residents were placed at risk for infection, skin breakdown and discomfort. Findings: 1.During a review of Resident 1 admission Record (AR), the facility admitted Resident 1 on 7/23/2025 with diagnoses that included encephalopathy (any disease, damage, or malfunction that may cause altered brain function), epilepsy (an abnormal burst of electrical activity in the brain that causes changes in behavior, movement, awareness, or sensation), and hypertension (high blood pressure). During a review of Resident 1's History and Physical (HP), dated 7/25/2025, the HP indicated Resident 1 did not have the capacity to understand and make decisions and the surrogate decision maker was Family Member (FM) 1. The HP indicated Resident 1 was bed bound and had a decrease tone and no movement on the right side of his body. During a review of Resident 1's Minimal Data Set (MDS- a resident assessment and care planning tool), dated 10/28/2025, the MDS indicated Resident 1's cognitive (a resident's thought process) skills were severely impaired. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with ADLs such as toileting hygiene (ability to maintain perineal hygiene before and after urinating or having a bowel movement), showering, and dressing himself. The MDS indicated Resident 1 required moderate assistance (helper does less than half the help) when repositioning himself in bed but required substantial assistance when transferring from a lying to sitting position and when transferring from chair/bed to chair transfer. The MDS indicated Resident 1 was always incontinent (loss of control of bladder and bowel movement) of urine and bowel. During a review of Resident 1's care plan (CP), revised 9/30/2025, Resident 1's CP indicated he had an ADL deficient related to ambulation, toileting, and personal hygiene. The CP's goal, revised on 1/26/206, indicated Resident 1's ADL needs will be met for 90 days. The CP's interventions, initiated on 9/30/2025, included monitoring and assisting Resident 1 with his ADL needs, keeping him clean and dry and changing [his adult briefs] as needed, having the call light within reach and the staff to answer call lights promptly. During an interview on 1/9/2026 at 9:15 AM with FM 1, FM 1 stated on 1/6/2025, Resident 1 had to wait over an hour for his adult briefs to be changed. FM 1 stated, when she visits Resident 1, all I hear are the bells going off all the time. During a concurrent observation and interview on 1/9/2026 at 11:50 PM with Resident 1 in Resident 1's room, Resident 1 was observed lying on his back in bed, with the head of bed at 90 degrees and call light within reach. Resident 1 stated that he will call the nurses for assistance with the call light when his adult briefs need to be changed. Resident 1 stated, it will take one (1) hour for the call light to be answered, and he had to wait in his wet and soiled adult briefs, which was uncomfortable. 2.During a review of Resident 2's AR, the facility admitted the resident on 10/23/2024 with diagnoses that included benign prostatic hyperplasia (BPH-enlarged prostate), polyneuropathy (multiple peripheral nerve damage), spondylosis of the lumbar region (degeneration of the bones and disk in the lower back) and bilateral osteoarthritis (progressive disorder of the joints, caused by a gradual loss of cartilage) of the knee. During a review of Resident 2's MDS, dated [DATE], the MDS indicated that Resident 2's cognitive skills were moderately impaired that required supervision with toileting hygiene, oral hygiene, and dressing, transferring from a sitting to lying position and transferring from the chair/bed to chair. The MDS indicated Resident 2 was frequently incontinent (no control of bowel and bladder) with urine and stool. During a review of Resident 2's CP, revised 5/18/2025, the CP indicated Resident 2 had an ADL deficient related to his bilateral knee osteoarthritis and polyneuropathy. The CP's goal, revised on 12/9/2025, indicated Resident 2's ADL needs will be met daily for 90 days. The CP's interventions included monitoring and assisting Resident 2 with his ADL needs, keeping him clean and dry, and changing him as needed, and having the call light within reach and the staff to answer call lights promptly. During a concurrent observation and interview on 1/9/2026 at 1 PM with Resident 2 in Resident 2's room, Resident 2 was observed sitting in his wheelchair next to the bed with the call light on top of the bed. Resident 2 stated that he calls the nurses for assistance with the call light. Resident 2, he used the urinal (a portable container used to collect urine) when he urinates, but he used an adult brief when he needed to have a bowel movement. Resident 2 stated that he would have to wait one (1) to two (2) hours to have his adult brief changed after pressing the call light. Resident 2 stated, sometimes it takes a while for [the nurses] to come, and that's why I feel bad. 3. During a review of Resident 3's AR, the facility admitted Resident 3 on 2/13/2023 and readmitted Resident 3 on 11/27/2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (generalized weakness on one side of the body) following cerebral infraction (stroke, loss of blood flow to a part of the break) affecting the left non-dominant side, osteoarthritis of the right and left shoulder, and glaucoma (damage to the optic nerve in the eye). During a review of Resident 3's HP, dated 11/10/2025, the HP indicated that Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognitive skills were intact. The MDS indicated Resident 3 required substantial assistance with performing toileting hygiene and substantial assistance with repositioning himself in bed and with chair/bed to chair transferring. The MDs indicated Resident 3 was frequently incontinent with urine and occasionally incontinent of bowel. The MDS indicated Resident 3 was on a toileting program for his bowel continence. During a review of Resident 3's CP, dated 4/20/2025, the CP indicated Resident 3's bowel and bladder function. The CP's interventions included assisting Resident 3 with toileting as needed and keeping the call light within reach and use for assistance. During a review of Resident 3's CP, dated 12/4/2024, the CP indicated Resident 3 had an ADL self-care performance deficit related to his activity intolerance, hemiplegia, impaired balance, and osteoarthritis. The CP's interventions indicated Resident 3 required limited to extensive assistant by 1 staff with personal hygiene, oral care, and toileting and Resident 3 required extensive assistance by 1 staff member during toileting schedule. During an interview on 1/9/2026 at 1:42 PM with Restorative Nurse Assistant (RNA) 1, RNA 1 stated, the resident's call light should be within reach of the resident. RNA 1 stated, residents used the call light to communicate their needs with the nursing staff and to ask for assistance such as adult brief changes or assistance to the bathroom. During an interview on 1/9/2026 at 2:15 PM with Licensed Vocational Nurse (LVN) 1 , LVN 1 stated, residents used the call light to communicate assistance from the nurses. LVN 1 stated that the call light should be within reach of the resident and answered timely for the resident's safety and needs. During a concurrent observation and interview on 1/9/2026 at 3:54 PM in Resident 3's room, Resident 3 was sitting in his wheelchair in front of his bed and the call light was on top of the bed. Resident 3 stated he would pressed the call light when he needed assistance from the nurses such as going to the bathroom to urinate or to have a bowel movement. Resident 3 stated, he used the call light in the bathroom to alert the nurses he needed assistance to be cleaned especially after a bowel movement because it can be very messy. Resident 3 stated that he would have to wait at least one (1) hour before someone came into his room. During an interview on 1/9/2026 at 4:15 PM with the Director of Staff Development (DSD), the DSD stated, call lights were used as a means of communication by the residents to ask for assistance from the nursing staff. The DSD stated, call lights were answered promptly by the nursing staffing, which would be no more than 15 minutes. The DSD stated that a resident should not be waiting one (1) hour for their call light be answered because it was important for the resident's needs to be attended timely, especially for an adult brief changed or assistance in the bathroom, to prevent skin breakdown and for the safety of the resident. During an interview on 1/9/2026 at 4:30 PM with the Administrator (ADM), the ADM stated that call lights should be answered promptly to address the resident's needs. The ADM stated that one (1) hour might be too long for the call light to be answered. During a review of the facility's policies and procedures (P&P) titled Activities of Daily Living (ADL), Supporting, dated March 2018, the P&P indicated that the appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including the appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care), mobility (transfer and ambulation), elimination (toileting), dining, and communication. During a review of the facility's P&P titled Call System, Residents, dated September 2022, the P&P indicated that the residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. The P&P indicated that calls for assistance are answered as soon as possible, but no later than 5 minutes.

Based on observation, interview, and record review, the facility failed to provide Orajel 2X Toothache & Gum Mouth/Throat Gel 20-0.26% (Orajel cream, topical cream applied to gums to relieve pain and discomfort) as for three days that was ordered by the physician to manage and relieve pain for one of three sample residents (Resident 1) who complained of upper left jaw toothache (pain around the tooth). As a result of this deficient practice Resident 1 reported experiencing consistent pain at 8 of 10 pain on the numerical number scale (a way of rating pain intensity, ranging from 0 - no pain to 10 - worst pain felt) and difficulty eating from 12/27/2025 to 12/29/2025 which could lead to weigh loss and/or prevents the resident to prevent in participation in activities of daily living that affects the quality of life. Findings: During a review of Resident 1 admission Record (AR), the facility admitted Resident 1 on 7/23/2025 with diagnoses that included encephalopathy (any disease, damage, or malfunction that may cause altered brain function), epilepsy (an abnormal burst of electrical activity in the brain that causes changes in behavior, movement, awareness, or sensation), and hypertension (high blood pressure). During a review of Resident 1's History and Physical (HP), dated 7/25/2025, the HP indicated Resident 1 did not have the capacity to understand and make decisions and the surrogate decision maker was Family Member (FM) 1. The HP indicated Resident 1 was bed bound (stays in bed most of the time) and had a decrease tone and no movement on the right side of his body. During a review of Resident 1's Minimal Data Set (MDS-a resident assessment and care planning tool), dated 10/28/2025, the MDS indicated Resident 1's cognitive (a resident's thought process) skills were severely impaired and required substantial assistance (helper does more than half the effort) with ADLs such as toileting hygiene (ability to maintain perineal hygiene before and after urinating or having a bowel movement), showering, and dressing himself. The MDS indicated Resident 1 required moderate assistance (helper does less than half the help) when repositioning himself in bed but required substantial assistance when transferring from a lying to sitting position and when transferring from chair/bed to chair transfer. The MDS indicated Resident 1 was not receiving a pain management regimen and denied pain. The MDS indicated the staff assessment for pain was blank. During a review of Resident 1's Order Summary Report, dated 8/26/2025, the physician order indicated to monitor Resident 1's pain level every shift using the pain scale (0 = no pain, 1 - 3 = mild pain, 4 - 7 = moderate pain, 8 - 10 = severe pain. During a review of Resident 1's Order Summary Report, an order dated 7/23/2025, the physician order indicated Resident 1 was to received Acetaminophen (Tylenol, pain and fever reducer medication) oral (by mouth) tablet 325 milligrams (mg, unit of weight) with the instructions to give two (2) tablets by mouth every 4 hours as needed for moderate pain (pain scale 4 -7) management. During a review of Resident 1's Care Plan (CP), revised on 11/25/2025, the CP indicated Resident 1 had dental health problems related to poor oral hygiene and missing teeth. The CP's interventions, dated 11/4/2025, indicated to monitor, document, and report any signs and symptoms of oral or dental pain such as pain (in the gums, toothache, palate), missing teeth, or ulcers in the mouth. During a review of Resident 1's Change of Condition (CoC) evaluation, dated 12/27/2025, the CoC indicated Resident 1 had mild swelling of the lymph nodes (lumps of tissue that filter fluid in the body and fights infection) and left cheek. The CoC indicated Resident 1 had a pain level of 5 out of 10 on the upper left jaw tooth ache on his face. During a review of Resident 1's Order Summary Recap Report, an order dated 12/27/2025, the order indicated the physician ordered Resident 1 to receive Orajel 2X Toothache & Gum Mouth/ Throat Gel 20 - 0.26% with instructions to give 1 application by mouth every 6 hours as needed for toothache for 7 days. During a review of Resident 1's Medication Administration Record (MAR) for the month of December 2025, the MAR indicated from 12/27/2025 to 12/31/2025, Resident 1 denied pain. During a review of Resident 1's MAR for the month of December 2025, there was no documented evidence Resident 1 received Acetaminophen Oral Tablet for pain from 12/27/2025 to 12/29/2025. During a review of Resident 1's MAR for the month of December 2025, there was no documented evidence Resident 1 received Orajel cream for his toothache from 12/27/2025 to 12/29/025. During a review of Resident 1's CP, dated 1/3/2026, the CP indicated Resident 1 had acute pain related to lymph node swelling as evidence by facial swelling and tenderness. The CP's interventions, dated 1/3/2026, included assessing Resident 1's pain level, swelling size, and tenderness every shift and administering pain medications as needed. During an interview on 1/9/2026 at 8:55 AM with Family Member (FM) 1, FM 1 stated Resident 1 complained of a toothache and was prescribed Orajel cream on 12/27/2025. FM 1 stated that the Orajel cream was not delivered until 12/30/2025. During a concurrent observation and interview on 1/9/2025 at 11:50 AM with Resident 1 and FM 2 in Resident 1's room, Resident 1 was observed lying on his back in bed, with the head of bed at 90 degrees, eating from the lunch tray placed in front of him on the overbed table (a rolling, adjustable table that slides over the bed to provide a portable surface). Resident 1 pointed to the upper left side of his jaw and stated he experienced frequent 8 out of 10 pain severity in this area a couple weeks ago. Resident 1 stated, when he received the cream for his toothache, the pain level decreased to 2 out of 10 pain severity and was able to eat more comfortably. During the same concurrent observation and interview on 1/9/2025 at 11:55 AM with Resident 1 and FM 2 in Resident 1's room, Resident 1 was observed pointing to his upper right jaw area. FM 2 stated, Resident 1 had a hard time eating for three days because it was difficult for him to chew with the left side of his mouth. FM 2 stated, Resident 1 had to move the food to the right side of his mouth and chew slowly. During the same concurrent observation and interview on 1/9/2025 at 12 PM, FAM 1 and FM 2 were in in Resident 1's room. FM 2 stated, during those 3 days, 12/27/2025 to 12/29/2025, FM 1 and FM 2 frequently told the nursing staff that Resident 1 was having pain and discomfort in his mouth. FM 1 stated the nursing staff kept saying the medication had not arrived from the pharmacy yet. FAM 1 stated she even offered to pick up the medication from the pharmacy but she was informed by the facility that the facility will follow up with the pharmacy staff.FM 1 stated, nothing was done until Tuesday [12/30/2025]. During an interview on 1/9/2025 at 2:30 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was aware Resident 1 had an infection in his mouth. LVN 1 stated, she was aware Resident 1 had an order for Orajel cream in December 2025, but it was not reported to me that Resident 1 had mouth pain. During a concurrent interview and record review on 1/19/2025 at 4:10 PM with the Director of Staff Development (DSD), Resident 1's Order Recap Report and December 2025 MAR were reviewed. The DSD stated, Resident 1's Orajel cream was ordered on 12/27/2025 but the first dose was given on 12/30/2025. The DSD stated, he did not know why it took three (3) days before the first dose was given. During the same interview and record review on 1/19/2025, at 4:35 PM with the DSD, Resident 1's December 2025 MAR was reviewed. The DSD stated, from 12/27/2025 to 12/29/2025, there was no documented evidence Resident 1 received Orajel cream or Tylenol for Resident 1's complain of toothache. The DSD stated, from 12/27/2025 to 12/29/2025, the MAR indicated Resident 1 denied having pain. The DSD stated, Resident 1's family members were very involved and vocal about ensuring all of Resident 1's needs were met. The DSD stated, if Resident 1's family members informed the nurses of Resident 1's toothache, there should have been a thorough pain assessment completed. The DSD stated there was no documented evidence of a thorough pain assessment, including pain level, location, frequency, and description from 12/27/2025 to 12/29/2025. During the same concurrent interview and record review on 1/19/2025 at 4:45 PM with the DSD, Resident 1's December 2025 was reviewed. The DSD stated, the MAR indicated from 12/27/2025 to 12/29/2025 Resident 1 denied pain. The DSD stated that pain assessment for 12/27/2025 to 12/29/2025 did not make sense if Resident 1's family members were informing the nurses of Resident 1's mouth pain and if there was an order for an Orajel cream. The DSD stated, if Resident 1 did not have mouth pain on 12/27/2025, there would be no order for Orajel cream. During a review of the facility's policies and procedures (P&P) titled Pain - Clinical Protocol, dated March 2018, the P&P indicated that the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The P&P indicated that the staff and physician will identify characteristics of pain such as location, intensity, frequency, pattern, and severity. The P&P indicated that the nursing staff will identify any situation or intervention where an increase in the resident's pain may be anticipated. During a review of the same facility's P&P titled Pain - Clinical Protocol, dated March 2018, the P&P indicated that the staff will reassess the individual's pain and related consequences at regular intervals and should include a frequency, duration, intensity of pain, and the ability to perform ADLs.

Based on observation, interviews, and record review, the facility failed to provide care in a manner that maintained or enhanced residents' dignity and respect in full recognition of their individuality for three (3) of six sampled residents (Residents 32, 69, and 81) by failing to: 1. Ensure Occupational Therapist (OT 1) was seated at eye level while assisting Resident 32 with the use of an adaptive utensil during meals. 2. Ensure Staff were at eye level while assisting with feeding; specifically, certified nurse assistant (CNA) 1 was observed standing over Resident 69 while feeding her. 3. Ensure Staff provided assistance with attention to safety, comfort, and dignity; specifically, CNA 2 was observed removing Resident 81 from the dining room without assisting with personal hygiene or cleaning noticeable phlegm (mucus produced by the cells lining the upper airways and lungs) after Resident 81 coughed. This failure did not support a respectful, person-centered approach to care and had the potential to negatively impact Residents 32, 69, and 81's psychosocial well-being and feelings of self-worth. Findings: 1. During a review of Resident 32's admission Record (AR), the facility admitted Resident 32 on 2/10/2025 and readmitted Resident 32 on 11/17/2025 with diagnoses that included dysphagia (difficulty swallowing) and lack of coordination. During a review of Resident 32's History and Physical (H&P), dated 11/29/2025, the HP indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS, a resident's assessment), dated 11/21/2025, the MDS indicated Resident 32's cognitive (a resident's thought process) skills for daily decision making were severely impaired. The MDS indicated Resident 32 required substantial assistance (helper does more than half the effort) when eating, which includes the ability to use suitable utensils to bring food or liquid to her month. During an observation on 12/10/2025 at 12:35 PM in the activities room, Resident 32 was sitting in her wheelchair with her lunch tray on the table in front of her. OT 1 was standing over Resident 32 on her right side and assisted Resident 32 with griping the spoon to scoop some pureed food onto the spoon. OT 1 continued to stand over Resident 32 as she assisted Resident 32 using the adaptive utensil to scoop up her pureed lunch. During an interview on 12/10/2025 at 12:52 PM with OT 1, OT 1 stated she was standing next to Resident 32 as she assisted Resident 32 use the adaptive utensil. OT 1 stated, she was trying to assess Resident 32's ability to use the adaptive utensil to feed herself. OT 1 stated, she forgot to sit down next to Resident 32 during this evaluation and while feeding because my main concern was to assess if she can use the adaptive utensil. OT 1 stated, it was important to sit down at eye level with the resident especially during feeding, so the resident does not feel rushed or intimidated during this time. During an interview on 12/12/2025 at 8:53 AM with the Director of Rehabilitation (DOR), the DOR stated, it was important to sit down and be at eye level with the resident during feeding because it is a dignity issue. The DOR stated, during the evaluation of Resident 32's ability to use the adaptive utensil, OT 1 needed to be sitting down with the resident, so the resident does not feel rushed or intimated by the staff member. The DOR stated, the moment a staff member works with the resident, especially during treating or feeding, the staff member needs to be sitting down and be at eye level with the resident to maintain the resident's dignity. 2. During a review of Resident 69's AR, the record indicated Resident 69 was originally admitted to the facility on [DATE] with diagnoses including Parkinson's Diseases (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69 had impaired cognition (profound decline in mental abilities—such as memory, attention, and reasoning—that results in full dependence on others for basic daily activities) and required partial assistance (helper does less than half the effort) with eating. During an observation on 12/12/2025 at 7:59 AM in Resident 69's room, CNA 1 was observed feeding Resident 69 breakfast. Resident 69 was lying in her bed with her meal tray placed in front of her. CNA 1 was observed standing next to Resident 69's bed and spoon feeding Resident 69 her meal. During an interview with CNA 1 on 12/12/2025 at 8:05 AM, CNA 1 stated she knew that she should have been sitting down while feeding Resident 69, however, there was no chair to sit on in the room. CNA 1 stated she chose to continue feeding Resident 69 while standing. During an interview with the Director of Nursing (DON) on 12/12/2025 at 2:05 PM, the DON stated that staff members who assist residents with feeding are expected to position themselves at eye level to promote dignity and respectful interaction during mealtimes. 3. During a review of Resident 81's AR, the AR indicated that Resident 81 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including degenerative disease of basal ganglia (brain structures that help control muscle movements), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81 had severely impaired cognition (profound decline in mental abilities—such as memory, attention, and reasoning—that results in full dependence on others for basic daily activities) and required partial/moderate assistance (helper does less than half the effort) with eating. During an observation and concurrent interview on 12/10/2025 from 12:50 PM to 1 PM in the Dining Room, Resident 81 was observed sitting in his wheelchair at one dining table while another resident was being assisted with meal by CNA 8. Resident 81 was observed coughing for 2 to 3 seconds, with phlegm coming out of his mouth and saliva dripping on to his chest and clothing. The CNA 8 at the same table did not respond to his cough. A few minutes later CNA 2 was observed approaching Resident 81 speaking in soft low voice. Meanwhile, CNA 8 was observed picking up another resident's tray from the table without saying anything to CNA 2. When asked why she did not acknowledge Resident 81's cough, the unidentified CNA stated that she was feeding another resident and could not check on Resident 81. CNA 2 stated that she was supposed to check Resident 81 and should have noticed the phlegm and cleaned him. During an interview on 12/10/2025 at 1:30 PM with the Director of Staff Development (DSD), the DSD stated that any staff in the same room, especially at the same table, was supposed to check the resident when they hear them cough regardless of assigned staff. DSD also stated that CNA 2 was supposed to assist cleaning Resident 81 before heading somewhere instead of leaving drooling. The DSD stated per facility policy, all residents have the right to be assisted with attention to safety, comfort, and dignity. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated December 2016, the P&P indicated the facility shall treat all residents with kindness, respect, and dignity. During a review of the facility's P&P titled Resident Rights dated December 2016, the P&P indicated that Federal and state laws guarantee certain basic rights to all residents of this facility, including to be treated with respect, kindness, and dignity. During a review of the facility's P&P titled Quality of Life – Dignity dated February 2020, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. The P&P further indicated that residents are treated with dignity and respect at all times. The facility culture is one that supports and encourages humanization and individuation of residents. This begins with the initial admission and continues throughout the resident's facility stay. During a review of the facility's P&P titled Assistance with Meals, dated March 2022, the P&P indicated that the residents who cannot feed themselves will be fed with attention to safety, comfort and dignity such as not standing over residents while assisting them with meals. During a review of the facility's P&P titled Assistance with Meals dated March 2022, the P&P indicated that all dining room residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity.

Based on interview and record review, the facility failed to ensure continuous communication and collaboration for Resident 34's overall medical management between Physician 1 (Attending Physician), Physician 2 (Wound Care Specialist, physician who specializes in Wound Care and management), Physician 3 (Dermatologist, physician who specializes in skin care and management), and Physician 4 (Oncologist, physician who specializes in cancer and cancer management). This failure resulted in the breakdown of communication and collaboration between Resident 34's physicians which led to the lack of direction for Resident 34's overall medical care and management. Cross Reference F697 Findings: During a review of Resident 34's admission Record (AR), the facility admitted Resident 34 on 12/2/2023 and readmitted Resident 34 on 11/22/2025 with diagnoses that include squamous cell carcinoma (skin cancer) of skin of other parts of face, open wound of right cheek and temporomandibular (area connecting jawbone to skull in front of the ears) and dementia (a progressive state of decline in mental abilities). The AR indicated Resident 34's responsible part was the Bioethics Committee (committee within the facility composed of the interdisciplinary team (IDT) including the Medical Director, Attending Physician, Nursing Services, Social Services, and other ancillary staff). During a review of Resident 34's Wound Assessment Report written by Treatment Nurse (TXN) 3, dated 12/2/2023, TXN 3 indicated Resident 34 had a right temple hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) sized 3 centimeters (cm) by 3 cm that was raised and dark colored. During a review of Resident 34's Minimum Data Set (MDS, a resident's assessment tool), dated 12/7/2023, the MDS indicated Resident 34's cognition (a residents thought process) was moderately impaired. The MDS indicated Resident 34 required moderate assistance (helper does less than half the effort) for activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) and required moderate assistance when transferring from a sitting to standing position and repositioning self in bed. The MDS indicated Resident 34 was not receiving a pain management regimen and denied pain. The MDS indicated the staff assessment for pain was blank and Resident 34's indicators for pain such as non-verbal sounds (such as groaning, gasping, or crying), vocal complaints (such as ouch or stop), facial expressions (such as grimacing, wincing, or clenched teeth or jaw), or protective body movements (such as guarding, bracing, or tensing a body part). The MDS did not indicate Resident 34 had any open lesions (an area of abnormal or damaged tissue caused by injury, infection, or disease). During a review of Physician 2's (Wound Care Specialist, physician who specializes in Wound Care and management) Surgical Notes, dated 4/9/2024, 4/16/2024, 4/23/2024, 4/30/2024, 5/7/2024, 5/14/2024, and 5/21/2024 Resident 34 had a left and right temporal wound. Physician 2 indicated Resident 34's left temporal wound was sized 3 cm by 3 cm with scant amount of serosanguineous (fluid mixed with blood and serum) drainage, unstable peri-wound (skin around the wound) and erythematous (inflamed and red) wound edge. Physician 2 indicated Resident 34's right temporal wound had increased in size from 7 cm by 7 cm to 8 cm by 8 cm with mild to scant amounts of serosanguineous drainage, unstable peri-wound, and friable (easily crumbled) wound edge on 5/21/2024. Physician 2 indicated that the recommended dressing was Betadine (antiseptic) solution cleanse and dry dressing. Physician 2 did not indicate in her 5/21/2024 Surgical Note the reason she stopped Resident 34's wound care consultation after 5/21/2024. During a review of Physician 3 (Dermatology)'s Visit Note, dated 5/16/2025, Physician 3 indicated Resident 34 had skin lesions (any area of skin that looks different from the surrounding skin), located on the left lateral forehead and the right lateral forehead. Physician 3 indicated these growths were asymmetric, bleeding, draining, growing, not healing, oozing, scaley, spreading, and tender and moderate in severity. Physician 3 indicated that Resident 34's skin lesions were interfering with grooming and catching on his clothing, and these skin lesions were red, swelling, and itchy. Physician 3 indicated Resident 34's plan of care was to refer Resident 34 to Physician 5 (Specialized Dermatologist who surgically removes skin cancer). During a review of Resident 3's Dermatopathology Report, reported on 5/21/2025, the report indicated Resident 34 had a left and right lateral forehead shaved biopsy that indicated squamous cell carcinoma with adnexal extensions. The report indicated these lesions extended to both peripheral margins and to deep margin. During a review of Resident 34's Nursing Progress Notes (PN), dated 6/17/2024 timed at 12:32 PM, the PN indicated Physician 3 recommended Resident 34 to be referred to Physician 4 (Oncologist physician who specializes in cancer care and management). During a review of Physician 4's New Visit note, dated 6/27/2024, Physician 4 indicated Resident 34 had high risk squamous cell carcinoma with multiple lesions on the left and right forehead and hands and arms which were large at 6 cm and 8 millimeters (mm, unit of measure) deep. Physician 4's plan of care indicated Resident 34 needed systemic treatment and would like to proceed with Cemiplimab (Immunotherapy treatment used to help increase the body's defense against cancer cells) 300 milligrams (mg, unit of weight) intravenous (medication delivered directly into the vein via a small catheter) every 3 weeks until Resident 34's intolerance or up to 24 months. During a review of Physician 4's Follow-up notes, dated 7/17/2024, 9/18/2024, 3/26/2025, 4/16/2025, 5/14/2025, 6/4/2025, 6/25/2025, 7/30/2025, and 12/3/2025, Physician 4 indicated Resident 34's CT (imaging) scan on 7/11/2024 indicated a right temporal scalp mass with the size 9.5 cm by 1cm and the right greater than left maxillary sinus (hollow space in the bones around the nose) polypoid (growth) lesions. Physician 4 indicated Resident 34's right forehead lesion was worsening, tumor was growing. During a review of Resident 34's Order Recap Report, order dated 10/4/2024 and discontinued in 2/25/2025, the order indicated Resident 34 had a Wound Consult and Follow up visit by Physician 2. During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34's cognition as severely impaired. The MDS indicated Resident 34 required maximal assistance (helper does most of the effort) with ADL cares and required supervision when transferring from lying to sitting position or from bed to chair. The MDS indicated Resident 34 was not receiving a schedule pain medication regimen, Resident 34 denied pain, and the staff assessment for Resident 34's indicators of pain was blank. The MDS did not indicate Resident 34 had any open lesions. During a review of Physician 4's Follow up note, dated 11/19/2025, Physician 4 indicated Resident 34 had a Stage 3 high risk squamous cell carcinoma of the skin. Physician 4 indicated Resident 34 had multiple lesions on the left and right forehead and the arms and legs. Physician 4 indicated to transfer Resident 34 to the emergency department for altered mental status, locally advances skin cancer mixed with infection, hypotension (low blood pressure), and tachycardia (increased heart rate). Physician 4 indicated her recommendations to the emergency department including a blood culture, wound culture, wound care consult, infectious disease consult, and broad-spectrum IV antibiotics. During a review of Resident Acute Care Hospital (GACH) 1 records, Physician 6's (Plastic Surgery, physician specializes in the reconstruction of defects affecting appearance or function) Consultation Note, dated 11/20/2025 was reviewed. Physician 6 indicated Resident 34 had signification ulcerative (open sore)/erosive (an aggressive breakdown and destruction of deeper tissue) squamous cell carcinoma to the face with a cancerous wound to the scalp and right eye. Physician 6 recommended to keep the wound clean and dry, and may be covered with xeroform dressing if the wound is draining, otherwise leave open to air. During an observation on 12/10/2025 at 10:09 AM in Resident 34's room, Resident 34 was observed lying on his back in bed with his face exposed. The right side of Resident 34's face had dried scabbing extending from the hairline on the right side of the forehead across the right temple, over the right eyelid, and towards the area before the right ear. Dried blood streaks were also noted across the bridge of the nose, down the right side of the face to the chin, and on Resident 34's top linen sheets. During an interview on 12/10/2025 at 3:30 PM with Licensed Nurse (LN) 4, LN 4 stated Resident 34 was admitted in 2023 with a small hematoma (a collection of blood outside of the blood vessel caused by a broken blood vessel) on the right side of his face/ LN 4 stated, Resident 34 was under the care of a Dermatologist in early 2024 but then Physician 4 (Oncologist) took over Resident 34's care in mid-2024. LN 4 stated, Physician 2 managed Resident 34's wound care on the right side of his face. During an interview on 12/11/2025 at 12: 03 PM with Physician 2 (Wound Care Specialist), Physician 2 stated she managed Resident 34 wound care at the beginning of 2024, and it was small in size but it was scabbed. Physician 2 stated, once she knew Resident 34 had a biopsy (medical procedure to remove a piece of tissue and be tested in a laboratory) and was under the care of a Dermatologist, I pulled myself off the case to prevent conflicting orders between herself and the Dermatologist. Physician 2 stated that Resident 34 has not been under her care since 2024. Physician 2 stated, that today (12/11/2025) was her first time providing care for Resident 34 since 2024, and stated, I saw him because I think he stopped his chemotherapy. During the same interview on 12/11/2025 at 12:10 PM with Physician 2, Physician 2 stated, Resident 34 refused treatment and measuring today (12/11/2025). Physician 2 stated, Resident 34's right temple and forehead wound does not look infected, just necrotic and friable (easily crumbled). Physician 2 stated, she would like to cauterize (seal) the friable edges to stop the bleeding. During the same interview on 12/11/2025 at 12:15 PM with Physician 2, Physician 2 stated that she would like to get a better idea from the Oncologist of what Resident 34's goal of care was. Physician 2 stated, in her experience, the cancer growth was like an iceberg. If it looks bad on the outside, it looks worst on the inside. Physician 2 stated, one of the complications of this type of cancer was Resident 34's [cancerous] growth will eventually cover the whole face. Physician 2 stated another complication was the possibility of the cancerous growth inside the body may grow large enough to push against the brain. During a concurrent interview and record review on 12/11/2025 at 12:30 PM with Physician 2, Resident 34's Order Recap Report from 2023 to 2025 was reviewed. Physician 2 stated, Resident 34's wound care treatments to cleanse the right and left temporal open wound with normal saline solution, pat dry, apply xeroform dressing and cover with abdominal pad and secure the bandage with an elastic bandage were not her physician orders. Physician 2 stated, it was in her experience and understanding Resident 34's right forehead/temple wound cannot heal with topical treatment. During an interview on 12/12/2025 at 2:00 PM with Physician 1, Physician 1 stated he was the Medical Director and Resident 34's Attending Physician. Physician 1 stated, Resident 34 was under the care of an Oncologist and not a Dermatologist because Resident 34 does not have a wound. He has cancer. Physician 1 stated, Resident 34 was under the care of an Oncologist, who monitored Resident 34's radiation therapy, chemotherapy, and wound care therapy. Physician 1 stated, Resident 34 does not have an open wound. He just has facial cancer. During the same interview on 12/12/2025 at 2:15 PM with Physician 1, Physician 1 stated Resident 34 was being seen by the Wound Care Specialist who does wound coverage under contract with the facility. Physician 1 stated, Resident 34 had a wound consult back in February 2025 but there was not much for the consult to do but clean and dress Resident 34's right forehead/temple wound. Physician 1 stated, Resident 34 was seen by the wound care team, and he (Physician 1) ordered the standard wound care for Resident 34 to keep the area clean and dry and covered as Resident 34 would allow. During an interview on 12/12/2025 at 2:20 PM with LN 4, LN 4 stated Resident 34 was referred to the Dermatologist in 2024 when his right forehead/temple area became an open wound, and LN 4 stated it was a wound because there was an opening between the skin and some drainage. LN 4 stated, she was not aware Physician 2 had pulled herself off [Resident 34's] case until yesterday [12/11/2025]. LN 4 stated that Physician 2 had told LN 4 that Physician 2 thought Resident 34 was under management of a Dermatologist since 2024. LN 4 stated, she had assumed Resident 34's skin and wound care management was under Physician 2 since 2024. During an interview on 12/12/2025 at 3 PM with LN 4, LN 4 stated, Resident 34 was under the facility's Bioethics Committee because he does not have any family members and was not capable of making decisions. LN 4 stated, the Bioethics Committee consisted of the DON, Social Services Director (SSD), the Attending Physician, and the Medical Director. LN 4 stated, the Bioethics Committee coordinated and managed all of Resident 34's medical care while in the facility. LN 4 stated, she would consider Resident 34's overall medical management as the lack of communication and collaboration between the Physician 1, Physician 2, and Physician 4. During an interview on 12/15/2025 at 11:38 AM with LN 6, LN 6 stated, she was not aware Physician 2 was not overseeing Resident 34's right forehead/temple wound. LN 6 stated, I thought [Physician 2] was overseeing Resident 34 because she would see the TXN round with Physician 2 around the facility and Resident 34 had a wound. During a concurrent interview and record review on 12/15/2025 at 12:15 PM with LN 6, Physician 2's Surgical Notes dated from 4/9/2024 to 5/21/2024 and Resident 34's Order Recap Report from 2023 to 2025 were reviewed. LN 6 stated, Resident 34 had a wound care consult ordered on 10/4/2024 and 2/28/2025. LN 6 stated, Physician 2's documented were from 4/9/2024 to 5/21/2024. LN 6 stated, Resident 34 did not have a Wound Care Consult from 5/21/2024 to 12/11/2025, because Physician 2 was here 4 days ago [12/11/2025] for Resident 34's newest Wound Care Consult order. LN 6 stated, a wound was defined as an opening in the skin with drainage. During a concurrent interview and record review on 12/15/2025 at 12:30 PM with LN 6, Physician 4's Follow-up notes dated 7/17/2024, 9/18/2024, 3/26/2025, 4/16/2025, 5/14/2025, 6/4/2025, 6/25/2025, 7/30/2025, and 12/3/2025 were reviewed. LN 6 stated, Physician 4 managed Resident 34's chemotherapy and oncology management, but Physician 4 did not indicate Resident 34's wound care management or pain management. During an interview on 12/15/2025 at 4:15 PM with the Director of Nursing (DON), the DON stated, Resident 34 had skin cancer and was under the care of the Oncologist. The DON stated, Physician 1 indicated Resident 34 does not have a wound, and stated do not expect it to be treated like a wound because Resident 34 has facial cancer. The DON stated, Physician 2 stated that Resident 34's right forehead/temple area was a wound because there was a break in the skin and draining. The DON stated that the facility's nursing staff had assumed Physician 2 was providing Resident 34 with wound care management because of the state of Resident 34's right forehead/temple wound. During a review of the facility's P&P titled Physician Services, dated 4/2013, the P&P indicated that the resident's attending physician participates in the resident's assessment and care planning, monitoring changes in the resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident.

Based on observation, interviews, and record reviews, the facility failed to ensure that Resident 34 received appropriate pain management for open wounds on the right and left temporal areas by failing to: 1. Monitor and document Resident 34's pain before, during, and after wound treatments on 5/5/2025, 5/26/2025, 7/24/2025, 8/23/2025, and from 12/1/2025 to 12/13/2025, in accordance with physician orders and the resident's care plan. 2. Reevaluate Resident 34's pain management and notify Physician 1 (Attending Physician) of the resident's refusal of wound care treatments due to pain and sensitivity in the right and left temporal wounds, as required by the facility's policy and procedure (P&P) titled Pain - Clinical Protocol and care plan for refusal of treatments. 3 Monitor and document the probable causes of each pain episode, including pain characteristics and relieving factors, every shift and as needed. The facility also failed to monitor, record, and report any signs and symptoms of non-verbal pain indicators, as outlined in the resident's pain care plan. These failures resulted in Resident 34 exhibiting both verbal and non-verbal signs of pain during activities of daily living (ADL) care and wound treatments. Consequently, Resident 34 experienced unnecessary pain, which negatively impacted his quality of life and overall well-being. Findings: During a review of Resident 34's admission Record (AR), the facility admitted Resident 34 on 12/2/2023 and readmitted on [DATE] with diagnoses that included open wound of right cheek and temporomandibular (area connecting jawbone to skull in front of the ears) area and squamous cell carcinoma of skin (skin cancer) of other parts of face. During a review of Resident 34's care plan (CP), dated 2/20/2025, the CP indicated Resident 34 experienced acute (short term) pain and chronic (long term) pain. The CP's interventions included to establish a pain management treatment plan, evaluate the effectiveness of non-pharmacological and pharmacological treatments, evaluate for pain, and evaluate for non-verbal indicators of pain. During a review of Resident 34's Order Recap Report, with an order date of 3/1/2025 and discontinued date 11/22/2025, the order indicated to administer Acetaminophen Oral Tablet 325 milligrams (mg, unit of weight), two tablets by mouth every six hours as needed for moderate to severe pain (4-10) on the numerical number scale (0/10 indicated no pain to 10/10 indicated the worse pain ever felt). During a review of Resident 34's Order Recap Report, with an order date 5/9/2025 and discontinued date 8/3/2025, the order indicated to monitor Resident 34's pain levels before, during and after treatment as needed and every evening shift. During a review of Resident 34's Order Recap Report, with an order date 5/3/2025 and discontinued date 6/3/2025, the order indicated Resident 34's right temporal wound care included to clean the right temporal open wound with normal saline solution, pat dry, apply betadine 10% solution and leave open to air every evening shift for 30 days and as needed for 30 days. During a review of Resident 34's Order Recap Report, with an order date 5/3/2025 and discontinued date 6/3/2025, the order indicated Resident 34's left temporal wound care included to apply Vitamin A and D ointment to the left temporal scab and leave open to air for 30 days and as needed for 30 days. During a review of Physician 3 (Dermatology)'s Visit Note, dated 5/16/2025, Physician 3 indicated Resident 34 had skin lesions (any area of skin that looks different from the surrounding skin), located on the left lateral forehead and the right lateral forehead. Physician 3 indicated these growths were asymmetric, bleeding, draining, growing, not healing, oozing, scaley, spreading, and tender and moderate in severity. Physician 3 indicated that Resident 34's skin lesions were interfering with grooming and catching on his clothing, and these skin lesions were red, swelling, and itchy. During a review of Resident 3's Dermatopathology Report, reported on 5/21/2025, the report indicated Resident 34 had a left and right lateral forehead shaved biopsy that indicated squamous cell carcinoma with adnexal extensions. The report indicated these lesions extended to both peripheral margins and to deep margin. During a review of Resident 34's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of May 2025, on the dates 5/5/2025 and 5/26/2025, was reviewed. The TAR, on 5/5/2025 to monitor pain level before, during, and after treatment, was left blank. The MAR, on 5/26/2025 for pain monitoring every shift, was blank. There was no documented evidence Resident 34 was premedicated or offered pain medications prior to the left and right open temporal wound treatment. During a review of Resident 34's CP, revised 6/26/2025, the CP indicated Resident 34 was at risk for pain related to right temporal wound. The CP's interventions included to monitor and document probable causes of each pain episode, to monitor/record the pain characteristics such as quality, severity, location, duration, aggravating factors, and relieving factors every shift and as needed, and to monitor/record/report any signs and symptoms of non-verbal pain such as changes in breathing, vocalizations (such as grunting, moaning), mood/behavior changes (such as increase irritability or restlessness), eye changes (such as wide/open or narrow/shut eyes or tearing), face expressions (such as grimacing or a worried look), and body changes (such as increase tension or rigidity). During a review of Resident 34's TAR for the month of July 2025, the TAR indicated to monitor pain level before, during, and after treatment every shift, for 7/24/2025 was blank. The TAR, on 7/24/2025, to provide right and left temporal open wound care, was also left blank. During a review of Resident 34's Order Recap Report, with an order date 8/3/2025 and discontinued date 9/3/2025, the order indicated Resident 34's right temporal wound care included to clean the right temporal open wound with normal saline solution, pat dry, apply xeroform dressing and cover with abdominal pain wrap, with roll bandage and secure with elastic comfort every evening shift for 30 days. During a review of Resident 34's Order Recap Report, with an order date 8/3/2025 and discontinued date 9/3/2025, the order indicated Resident 34's left temporal wound care included to clean the left temporal open wound with normal saline solution, pat dry, apply xeroform dressing and cover with abdominal pain wrap, with roll bandage and secure with elastic comfort every evening shift for 30 days. During a review of Resident 34's Order Recap Report, order date 8/3/2025 and discontinued date 10/6/2025, the order indicated to monitor Resident 34's pain before, during, and after treatment every evening shift. During a review of Resident 34's TAR for the month of August 2025, the TAR indicated to monitor for pain level before, during, and after treatment every shift, for 8/23/2025 was blank. The TAR, on 8/23/2025, to provide right and left temporal open wound care, was also left blank During a review of Resident 34's Order Recap Report, with an order date 9/3/2025 and discontinued date 10/4/2025, the order indicated Resident 34's right temporal wound care included to clean the right temporal open wound with normal saline solution, pat dry, apply xeroform dressing and cover with abdominal wrap pad dressing, with roll bandage and secure with elastic comfort every evening shift for 30 days. During a review of Resident 34's Order Recap Report, with an order date 9/3/2025 and discontinued date 10/4/2025, the order indicated Resident 34's left temporal wound care included to clean the left temporal open wound with normal saline solution, pat dry, apply xeroform dressing and cover with abdominal pain wrap, with roll bandage and secure with elastic comfort every evening shift for 30 days. During a review of Resident 34's Order Recap Report, with an order date 9/3/2025 and discontinued date 10/4/2025, the order indicated Resident 34's right temporal wound care included to clean the right temporal open wound with normal saline solution, pat dry, apply xeroform dressing and cover with abdominal pain wrap, with roll bandage and secure with elastic comfort every evening shift for 30 days. During a review of Resident 34's CP, dated 9/15/2025, the care plan indicated Resident 34 for refusal of treatment to his forehead lesions. The CP's interventions included to offer Resident 34 pain medication before care to reduce resistance to treatment and to suggest a less intrusive and alternative wound dressing. During a review of Resident 34's Order Recap Report, order date 10/6/2025 and a discontinued date 11/22/2025, the order indicated to monitor Resident 34's pain before, during, and after treatment everyday shift. During a review of Resident 34's Order Summary Report, a physician order, with the start date of 11/22/2025 indicated to give Hydrocodone-Acetaminophen (combination pain reliever to relieve moderate to severe pain) Oral Tablet 5-325 mg with instructions to give 1 tablet by mouth every 4 hours as needed for moderate pain (4 to 7 out of 10). During a review of Resident 34's Order Summary Report, a physician order with the start date of 11/22/2025 indicated an order to give acetaminophen oral Tablet 325 mg, two (2) tablets by mouth every 6 hours as needed (PRN) for moderate to severe pain (4 to 6 out of 10) based on the numerical pain scale. During a review of Resident 34's MAR and TAR for December 2025, there was no documented evidence of Resident 34's pain assessment before, during, and after treatment from 12/1/2025 to 12/9/2025, after the order was discontinued on 11/22/2025. There was no documented evidence Resident 34 was offered pain medications or premedicated for pain prior to the left and right open temporal wound treatment. During a review of Resident 34's Minimum Data Set (MDS, resident assessment tool), dated 12/5/2025, the MDS indicated Resident 34's cognitive (a resident's thought process) was severely impaired. The MDS indicated Resident 34 required maximal assistance (helper does more than half the effort) for ADLs such as bathing, dressing, and toileting. The MDS indicated Resident 34 was not receiving a pain management regimen and denied pain. The MDS indicated the staff assessment for pain was blank and Resident 34's indicators for pain such as non-verbal sounds (such as groaning, gasping, or crying), vocal complaints (such as ouch or stop), facial expressions (such as grimacing, wincing, or clenched teeth or jaw), or protective body movements (such as guarding, bracing, or tensing a body part). The MDS indicated Resident 34 had open lesions. During an observation on 12/10/2025 at 10:09 AM in Resident 34's room, Resident 34 was observed lying on his back in bed with his face exposed. The right side of Resident 34's face had dried scabbing extending from the hairline on the right side of the forehead across the right temple, over the right eyelid, and toward the area before the right ear. Dried blood streaks were also noted across the bridge of the nose and down the right side of the face to the chin. During another observation on 12/10/2025 at 11:35 AM with Treatment Nurse (TXN) 2 in Resident 34's room, Resident 34 was observed lying in bed with a blanket over his face. TXN 2 explained the right temporal wound care treatment to Resident 34 and stated wound care was important to prevent infection. Resident 34 refused the temporal wound treatment and stated No, I am okay. Thank you. TXN 2 offered Resident 34 pain medication prior to treatment, and Resident 34 agreed to receiving pain medication prior to treatment and agreed to receiving right wound care treatment after lunchtime. During another observation on 12/10/2025 at 1: 25 PM with TXN 2, in Resident 34's room. Resident 34 was observed lying in bed with a blanket over his face. TXN 2 offered to provide Resident 34's right temporal wound care and explained to Resident 34 the importance of performing his wound care was to prevent infection. Resident 34 refused the temporal wound treatment at this time. During an interview on 12/11/2025 at 12:10 PM with Physician 2 (Wound Care Specialist), Physician 2 stated, Resident 34's right forehead and temporal area looked of necrotic tissue (dead body tissue) and very friable (easily crumbled). Physician 2 stated, Resident 34 refused temporal wound treatment and measurements of the right side of his face on this day when he was at the resident's bedside, 12/11/2025. Physician 2 stated, Resident 34 did not explain why he refused care. Physician 2 stated, Resident 34 said no and swatted my hand away. During an interview on 12/11/2025 at 12:47 PM with Licensed Nurse (LN) 6, LN 6 stated, she was Resident 34's Charge nurse and last assisted TXN 3 with Resident 34's temporal wound care in August and September 2025. LN 6 stated, Resident 34 would complain and scream during these wound treatments. LN 6 stated she would hold Resident 34's hand to prevent him from removing the wound care dressing right away. LN 6 stated, Resident 34 would almost always remove the wound care dressing to the temporal area right away. LN 6 stated, Resident 34 did not like having his right forehead, temporal area, and upper cheek touched because it hurts him. LN 6 stated, she thought [Resident 34] received pain medication prior to wound treatment. During the same interview on 12/11/2025 at 12:50 PM with LN 6, LN 6 stated she did not know that Resident 34 had pain medication order for Hydrocodone-Acetaminophen available for pain management. LN 6 stated, she did not know when the order was placed and noticed the medication was placed as of today [12/11/2025]. LN 6 stated, the TXN was responsible for assessing Resident 34's pain levels prior to treatment, performing the wound care treatments, and reassessing Resident 34's pain levels during and after treatment. LN 6 stated that the TXN would tell the LN that Resident 34 was requesting pain medication, and it was the LN's responsibility to provide medication to Resident 34. LN 6 stated, Resident 34 was not pre-medicated prior to Physician 2 (Wound Care Specialist) performing wound care treatment. LN 6 stated, if she had pre-medicated Resident 34, then Resident 34 probably would not have refused Physician 2's wound care treatment. During a concurrent interview and record review on 12/11/2025 at 1:15 PM with LN 6, Resident 34's CoC evaluations were reviewed. LN 6 stated, there was no documented evidence Physician 1 was notified of Resident 34's refusal of temporal wound treatments. LN 6 stated, if Resident 34 refused wound treatments three (3) times, a CoC should be initiated. During an interview on 12/12/2025 at 10:31 AM with Certified Nurse Assistant (CNA) 3, CNA 3 stated, Resident 34 was very sensitive to the right side of his head and face being touched. CNA 3 stated, on shower days, Resident 34 did not want the water to touch his hair and face. CNA 3 stated, Resident 34 would only allow me to clean the left side of his face. CNA 3 stated, when she would clean the left side of Resident 34's face, Resident 34's body was relaxed and resident would let me clean the left side of his face from his forehead to his chin. CNA 3 stated, when she tried to clean the right side of Resident 34's face, Resident 34's body and face would be more alert and more guarded. CNA 3 stated, she would explain to Resident 34 she was cleaning the right side of his face, and Resident 34 would be more alert, defensive, and on guard, the closer she cleaned to his upper right cheek area. CNA 3 stated, when she was too close to his upper right cheek area, Resident 34 would scream and say ouch!. CNA 3 stated she reported Resident 34's pain to the charge nurse. During an interview on 12/12/2025 at 1:45 PM with Physician 1 (Attending Physician), Physician 1 stated that Resident 34 would refuse [wound care] treatment, and it was difficult to care for [Resident 34]. Physician 1 stated, he does not know when he was first notified of Resident 34's refusal for wound care treatment, but stated, I clearly know about [Resident 34's] refusal of care. During an interview on 12/12/2025 at 2:35 PM with LN 4, LN 4 stated Resident 34 would get upset and more agitated when someone tries to touch his face. LN 4 stated, Resident would push your hand away and would say no, no, no and leave me alone when staff gets close to [Resident 34's] face.LN 4 stated that Resident 34 does not ask for any pain management, but he will say something when someone touches his face. During an observation on 12/15/2025 at 11:10 AM in Resident 34's room with TXN 2 present, Resident 34 was observed lying on his left side with a blanket covering his face. TXN 2 stood on the right side of the bed, slightly outside Resident 34's line of sight, and asked if she could perform his wound care treatment while pointing to the wound on the right side of his face. TXN 2 explained to Resident 34 the importance of wound care, offered Resident 34 pain medication, and offered to come back and check again around 1:30 PM. TXN 2 asked Resident 34 why he kept refusing his treatments, and Resident 34 leaned his neck back slightly, turned the right side of his face away from TXN 2's hand, and stated, No thank you. Go away. During a concurrent interview and record review on 12/15/2025 at 11:20 AM with TXN 2, Resident 34's TAR was reviewed. TXN 2 stated, Resident 34's pain assessments before, during, and after treatment were missing from the TAR from 12/1/2025 to 12/13/2025. TXN 2 stated, it was important to assess Resident 34's pain before and after treatment to evaluate and re-evaluate if Resident 34's current pain management was effective or needed to be re-evaluated. During a concurrent interview and record review on 12/15/2025 at 11:55 AM with LN 6, Resident 34's MAR and TAR for December 2025 was reviewed. LN 6 stated that there was no documented evidence of pain management from December 1 to December 9, 2025. LN 6 stated, there was no documented evidence Resident 34 was premedicated prior to temporal wound treatments. LN 6 stated, it was important to assess Resident 34's pain levels before, during, and after treatment. LN 6 stated, it was important to assess Resident 34's pain prior to treatment and premedicating is important prior to treatment because treatments hurt. LN 6 stated, it was important to reassess Resident 34's pain after treatment to determine if the pain management was effective. During a concurrent interview and record review on 12/15/2025 at 4:41 PM with the Director of Nursing (DON), Resident 34's MAR and TAR for December 2025 was reviewed. The DON stated, there was no documented evidence Resident 34's pain was assessed before, during, and after temporal wound care treatments. The DON stated there was no documented evidence Resident 34 was premedicated prior to starting wound treatments. The DON stated, pain assessment included assessing the pain level, type of pain, location of pain, frequency of pain, description of pain, what aggravates the pain, and what relieves the pain. The DON stated that it was important to reassess pain after Resident 34's wound treatments to evaluate whether the current pain management was effective. During the same concurrent interview and record review on 12/15/2025 at 4:50 PM with the DON, Resident 34's CoC documentations were reviewed. The DON stated that there was no documented evidence of Resident 34's refusal for treatments. The DON stated that a CoC needed to be created if the resident refused treatment three times because the physician needed to be notified of the resident's refusal. The DON stated she could not recall if the facility's IDT had discussed Resident 34's pain issues and wound treatment refusals during the facility's IDT meetings. During a review of the facility's P&P titled Pain - Clinical Protocol, dated March 2018, the P&P indicated that the physician and staff will identify individuals who have pain or who are at risk for having pain which included a review of any treatments that the resident currently is receiving for pain including complementary and non-pharmacological interventions. The P&P further indicated that the nursing staff will assess each resident when there is onset of new pain or worsening of existing pain. The P&P indicated that staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. The P&P indicated the nursing staff will identify any situation or interventions where an increase in the resident's pain may be anticipated such as wound care. The P&P further indicated the physician will help identify causes of pain and help identify the extent of the underlying cause of pain. During a review of the same policy, Pain - Clinical Protocol, dated March 2018, the P&P indicated, the physician and staff will establish goals of pain treatment, and will reassess the resident's pain and related consequences at regular intervals. The P&P indicated that if the resident's pain is complex and not responding to standard interventions, the attending physician may consider additional consultative support. During a review of the facility's P&P titled Requesting, Reusing, and/or Discontinuing Care or Treatment, dated 5/2017, the P&P indicated that if a resident requests, discontinues, or refuses care or treatment, the unit manager, charge nurse or director of nursing services will meet with the resident to: determine why the resident is requesting, refusing, or discontinuing care or treatment. The P&P indicated that the healthcare practitioner must be notified of refusal of treatment.

Based on observations, interviews and record reviews, the facility failed to implement the facility ' s policy and procedure (P&P) titled, Smoking Policy-Residents, dated 8/2022, to ensure eight of eight sampled residents (Residents 2, 3, 9, 14, 18, 56, 67 and 136) who were smokers (residents who smoked cigarettes) had an environment free of accident hazards (risk) by failing to: 1. Provide supervision while smoking to Residents 2, 3, 9, 14, 18, 56, 67 and 136 when Resident 2, 3, 14, 18, 56, 67 and 136, were assessed by the facility as unsafe smokers, and when Resident 9 ' s smoking assessment was not completed by the facility. 2. Ensure Resident 9 was assessed for the level of supervision while smoking. 3. Ensure Resident 3 did not store cigarettes and lighters in Resident 3 ' s drawer. 4. Ensure Resident 14, who was assessed by the facility as unable to light tobacco [a preparation of the nicotine (a toxic colorless or yellowish oily liquid that is the chief active constituent of tobacco) rich leaves of an American plant, which are cured by a process of drying and fermentation for smoking or chewing safely, did not pass/share cigarettes with Residents 9, 56 and 136, and used Resident 67 ' s lighter to light cigarettes. 5. Ensure Receptionist (REC) 1 did not provide lit cigarettes and allowed Residents 9 and 14 to smoke unsupervised during nonscheduled smoking time. 6. Identify Residents 2, 9, 14, 18 and 136 as noncompliant with the facility ' s smoking policy when Residents 2, 9, 14, 18 and 136 smoked during nonscheduled smoking time. 7. Ensure Residents 3, 56 and 67 who were identified as non-compliant with facility ' s smoking policy, were not allowed by the facility to continue to keep cigarettes and lighters in Resident 3, 56 and 67 ' s possession. 8. Ensure a designated staff was scheduled to supervise the smoking patio area during the scheduled and nonscheduled smoking time. 9. Ensure the facility has a plan of action in place on how to care for residents who did not comply with the facility ' s smoking policy. These deficient practices had the potential for Residents 2, 3, 9, 14, 18, 56, 67 and 136 to be at risk for accidental burn, fire hazards that could affect the health, safety, wellbeing of residents, staffs, visitors and result in serious injuries, hospitalization and death. On October 22, 2024, at 3:32 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility ' s failure to prevent smoking hazards by not monitoring and supervising smoking activities for Residents 2, 3, 9, 14, 18, 56, 67 and 136. The facility also failed to safely secure/store lighters and cigarettes. On 10/24/2024 at 1:42 PM, the IJ was removed in the presence of the Director of Nurses (DON, who was covering and acting as the facility ' s Administrator), Quality Assurance Consultant 1, and Clinical Consultant 1 after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and while onsite at the facility, the surveyors verified/confirmed the facility ' s implementation of the IJ Removal Plan and the IJ situation was no longer present. The facility had a plan in place to supervise all smokers. The IJ Removal Plan dated 10/24/2024, included the following: 1. On 10/21/2024 at around 5 PM, Residents 3, 56 and 67 ' s two packs of cigarettes and lighter were taken from Residents 3, 56 and 67 ' s bedside drawers by the DON and kept in the locked drawer in the receptionist desk. 2. On 10/21/2024 at around 5 PM, Resident 67 was provided education by the Social Service Director (SSD), and the DON regarding facility staff keeping the smoking materials and Resident 67 would not smoke without any supervision by the facility staff. Resident 67 agreed to comply with the facility staff after discussion with Resident 67. The facility ' s receptionist would be the keeper of the smoking items and smoking materials. Only staff would have access to the keys of the smoking items. 3. On 10/21/2024 at around 5 PM, Resident 3 was educated by the SSD on the facility ' s smoking P&P including surrendering cigarettes and smoking materials to facility staff. 4. On 10/21/24 Residents 3 and 56 ' s Care Plans (CPs, a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) for smoking were updated by the licensed nurses indicating the interventions for Resident 3 and 56 to safety smoke, and the DON initiated additional CPs for Resident 3 and 56 ' s non-compliance with smoking per P&P. 5. On 10/21/2022 Resident 136 was transferred to the General Acute Hospital (GACH) and would be re-educated by the SSD or designee regarding the facility ' s smoking P&P including not giving and not receiving cigarettes from other residents. 6. On 10/22/24 the smoking attendants were provided education by the DON/Designee on the facility ' s smoking P&P regarding the importance of supervision and being on the designated smoking area during smoking schedule. No smoking attendant would be assigned as a smoking attendant without being educated on the importance of being at smoking area during smoking schedule. 7. On 10/22/24, the facility implemented dedicated smoking attendants to monitor smokers 24 hours a day during scheduled and nonscheduled smoking times. The Activities Director (AD)/designee was responsible to schedule the smoking attendants weekly or as needed. The dedicated smoking attendant would log the behavior of the identified non-compliant residents and would intervene accordingly if residents found to not following the facility ' s P&P such as smoking on nonscheduled times or having in possession smoking paraphernalia (any device used, intended for use, or designed for use in smoking) when inside or outside the facility. 8. On 10/22/2024, Residents 2, 9, 14, and 18 ' s CPs were updated to reflect smoking non-compliance. 9. On 10/22/2024 at around 6 PM, Resident 9 was re-educated regarding the facility ' s P&P for smoking including lighting cigarettes in the smoking area by the delegated smoking supervisor. 10. On 10/22/2024, around 6 PM, Residents 3 and 56 were provided education by the SSD about safety on smoking and not to smoke without any supervision by staff. 11. On 10/24/2024, Resident 14 was re-educated by the SSD regarding the facility ' s smoking P&P including not giving and not receiving cigarettes from other residents. 12. On 10/24/2024, REC 1 was provided a 1:1 (a direct encounter between 2 persons) in-service by the DON regarding the facility ' s new smoking P&P including supervision of smokers. 13. On 10/24/2024, the SSD and Interdisciplinary Team (IDT, a team of people from different disciplines who work together to improve patient/resident care) members initiated a discussion with all residents who smoke (not limited to Residents 3 and 56) regarding the facility ' s P&P on smoking and importance of adhering to the policy for safety. Residents 3 and 56 agreed on complying on 10/24/2024 per IDT discussion. 14. On 10/24/2024, the quality Assessment and Assurance Committee (QAA, committee established for the purpose of improving the safety and quality of health services) members with the medical director and administrator updated the smoking policy with the policy not limited to addressing supervision of smokers and indicating potential outcomes for the non-compliant smokers. 15. On 10/24/2024, the DSD/designee initiated an in-service to licensed, non-licensed staff and smoking attendants on the importance of ensuring supervision of smokers In-service to all staff would be continued until all smoking attendants that would l be scheduled were provided education on supervision. Total of 8 residents were observed non-compliant with the facility ' s smoking policy and procedure. The facility ' s census was 84 and there were 23 smokers. Findings: a. During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 6/23/2016 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow) and nicotine dependence, cigarettes (occurs when the resident needed nicotine and could stop using it). During a review of Resident 2 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 12/29/2023, the H&P indicated, Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s Order Summary Report (OSR), the OSR indicated on 12/16/2023, Resident 2 had a physician order that Resident 2 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 2 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/15/2024, the MDS indicated Resident 2 ' s cognition (ability to think, remember, and reason) was severely impaired, and Resident 2 needed supervision in walking 150 feet in a corridor or similar space. During a review of Resident 2 ' s Smoking and Safety (S&S), dated 8/15/2024, the form indicated Resident 2 was a tobacco user. During a review of Resident 2 ' s CP, titled Smoking, dated 8/27/2024, the CP indicated Resident 2 was at risk for hazard/injury (burns) related to smoking cigarettes. The interventions included for facility staff to provide frequent monitoring to Resident 2 during smoking times. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 10/10/2017 and readmitted on [DATE] with diagnoses that included hemiplegia [a condition that causes half of the body to be paralyzed (or unable to move)] and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (or a stroke, which is a medical emergency that occurs when blood flow to the brain is cut off) affecting right dominant side, and COPD. During a review of Resident 3 ' s OSR, the OSR indicated on 5/6/2024, Resident 3 had a physician order that Resident 3 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 3 ' s H&P, dated 5/8/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognition was intact. The MDS indicated Resident 3 was a tobacco user, and able to independently (resident completes the activity by themselves with no assistance from a helper) utilize the wheelchair to manually wheel at least 50 feet, make two turns or at least 150 feet in a corridor or similar space. During a review of Resident 3 ' s S&S, dated 9/6/2024, the S&S indicated Resident 3 had balance problems while sitting or standing, and required supervision during smoking breaks. The form indicated the goal was for Resident 3 to adhere to the facility ' s Tobacco/Smoking Policies. During a review of Resident 3 ' s CP titled, Smoking, dated 10/2024, the CP indicated Resident 3 was at risk for discomfort, shortness of breath (SOB, the feeling of not get enough air into the lungs) and injury related to smoking. The interventions included for facility staff to provide frequent monitoring, remind Resident 3 of smoking schedule, and reorient Resident 3 to the smoking area. During a review of Resident 3 ' s CP, tilted Non-Compliance with Smoking, dated 10/2024, the CP indicated Resident 3 was not following smoking schedule and was keeping/hiding smoking paraphernalia such as lighters, matches and at risk for injury related to smoking and non-compliance behavior. The interventions included for staff to conduct an IDT conference with Resident 3 and for facility staff to supervise designated smoking area. c. During a review of Resident 9's AR, the AR indicated the facility admitted Resident 9 on 6/24/2019 with diagnoses that included COPD, and arthritis [the swelling and tenderness of one or more joints (places where two bones meet, such as the elbow or knee)]. During a review of Resident 9 ' s OSR, indicated on 7/11/2019, Resident 9 had a physician order that Resident 9 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 9 ' s MDS, dated [DATE], the MDS indicated Resident 9 ' s cognition was intact, and Resident 9 was able to wheel the wheelchair at least 150 feet in a corridor or similar space. During a review of Resident 9 ' s S&S, dated 6/3/2024, the S&S indicated Resident 9 was a tobacco user and the CP ' s goal was for the resident to adhere to the facility ' s Tobacco/Smoking Policies. d. During a review of Resident 14's AR, the AR indicated the facility admitted Resident 14 on 1/13/2020 and readmitted on [DATE] with diagnoses that included COPD, and nicotine dependence, cigarettes. During a review of Resident 14 ' s OSR, dated on 5/30/2014, the OSR indicated Resident 14 had a physician order that Resident 14 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 14 ' s MDS, dated [DATE], the MDS indicated Resident 14 ' s cognition was intact, and Resident 14 needed supervision in walking 150 feet in a corridor or similar space. During a review of Resident 14 ' s S&S, dated 8/22/2024, the S&S indicated Resident 14 was a tobacco user. The form indicated Resident 14 was unable to light tobacco safely, and Resident 14 required supervision during smoking breaks. e. During a review of Resident 18's AR, the AR indicated the facility admitted Resident 18 on 7/6/2017 and readmitted on [DATE] with diagnoses that included COPD, and nicotine dependence, cigarettes. During a review of Resident 18 ' s OSR, dated 4/7/2023, the OSR indicated Resident 18 had a physician order that Resident 18 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 18 ' s MDS, dated [DATE], the MDS indicated Resident 18 ' s cognition was intact. The MDS indicated Resident 18 was a tobacco user and was able to utilize the wheelchair with supervision to wheel at east 150 feet in a corridor or similar space. During a review of Resident 18 ' s H&P, dated 4/4/2024, the H&P indicated Resident 18 had the capacity to understand and make decisions. During a review of Resident 18 ' s S&S, dated 8/14/2024, the S&S indicated Resident 18 was a tobacco user, and Resident 18 had balance problems while sitting or standing. During a review of Resident 18 ' s CP titled, Smoking, dated 8/16/2024, the CP indicated Resident 18 was at risk for hazards/injury (burns) related to smoking cigarettes. The interventions included for facility staff to provide frequent monitoring to Resident 18 during smoking times. f. During a review of Resident 56's AR, the AR indicated the facility admitted Resident 56 on 4/10/2024 with diagnoses that included nicotine dependence, cigarettes, and psychoactive substance (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) abuse. During a review of Resident 56 ' s OSR, dated 4/10/2024, the OSR indicated Resident 56 had a physician order that Resident 56 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 56 ' s H&P, dated 4/10/2024, the H&P indicated Resident 56 was a smoker, and had the capacity to understand and make decisions. During a review of Resident 56 ' s MDS, dated [DATE], indicated Resident 56 ' s cognition was intact. The MDS indicated Resident 56 needed supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) when walking 150 feet in a corridor or similar space. During a review of Resident 56 ' s CP titled, Smoking, dated 4/10/2024, the CP indicated Resident 56 was at risk for discomfort, SOB and injury related to smoking. The interventions included for staff to frequent monitoring Resident 56 while smoking, remind Resident 56 of smoking schedule, and to wear smoking apron. During a review of Resident 56 ' s Activity Participation Notes, dated 9/23/2024, the notes indicated Resident 56 was noncompliant with Smoking Policy and Procedure. The notes indicated Resident 56 smoked whenever and wherever Resident 56 wanted, and Resident 56 continued to supply cigarettes to other residents. The notes indicated Resident 56 declined to surrender smoking paraphernalia like lighters and cigarettes. During a review of Resident 56 ' s S&S, dated 10/16/2024, the S&S indicated Resident 56 was a tobacco user and was noncompliant with smoking times. g. During a review of Resident 67's AR, the AR indicated the facility admitted Resident 67 on 4/18/2024 with diagnoses that included COPD due to drugs, and nicotine dependence, cigarettes. During a review of Resident 67 ' s H&P, dated 7/5/2024, the H&P indicated Resident 67 had a smoking history, and had the capacity to understand and make decisions. During a review of Resident 67 ' s S&S, dated 7/25/2024, the S&S indicated Resident 67 was a tobacco user. The S&S indicated Resident 67 had balance problems while sitting or standing, and required supervision during smoking. During a review of Resident 67 ' s CP titled, Smoking, dated 7/5/2024, the CP indicated Resident 67 was at risk for discomfort, SOB and injury related to smoking. The interventions included for facility staff to provide frequent monitoring, reorienting Resident 67 to the smoking area, and offering smoking apron. During a review of Resident 67 ' s IDT Care Conference notes, dated 7/30/2024, the notes indicated the IDT met with Resident 67 regarding the smoking P&P. The notes indicated Resident 67 was re-educated and the resident agreed to comply with the smoking scheduled time. The notes indicated Resident 67 was reminded that any smoking paraphernalia should be surrendered to the activity staff, including cigarettes and lighters for safekeeping. During a review of Resident 67 ' s CP titled, Noncompliance with Smoking, dated 8/1/2024, the CP indicated Resident 67 did not follow the facility ' s smoking schedule. The CP indicated Resident 67 shared/passed only one cigarette and smoked the same cigarette with other residents. The CP indicated Resident 67 was at high risk for transmitting infection. The interventions included for facility staff to supervise designated smoking area, offer smoking apron every schedule smoking time to Resident 67, and notify Resident 67 ' s Medical Doctor (MD) about Resident 67 ' s non-compliance. During a review of Resident 67 ' s Activity Participation Notes, dated 9/23/2024, the notes indicated Resident 67 was noncompliant with Smoking P&P. The notes indicated Resident 67 smoked whenever and wherever she wanted. The notes indicated Resident 67 continued to supply cigarettes to other residents and declined to surrender smoking paraphernalia like lighters and cigarettes. During a review of Resident 67 ' s MDS, dated [DATE], the MDS indicated Resident 67 ' s cognition was moderately impaired. The MDS indicated Resident 67, needed supervision in walking 150 feet in a corridor or similar space. h. During a review of Resident 136's AR, the AR, indicated the facility admitted Resident 136 on 10/1/2024 and readmitted on [DATE] with diagnoses that included lack of coordination, drug induced secondary parkinsonism (condition that manifested by tremors, muscle stiffness and slow movement), and hypertension (high blood pressure). During a review of Resident 136 ' s H&P, dated 10/2/2024, the H&P indicated Resident 136 had the capacity to understand and make decisions. During a review of Resident 136 ' s MDS, dated [DATE], the MDS indicated Resident 136 ' s cognition was moderately impaired. The MDS indicated Resident 136 needed partial assistance (helper does less than half the effort) in walking at least 10 feet in a room, corridor, or similar space. During a review of Resident 136 ' s OSR, dated 10/17/2024, the OSR indicated Resident 136 had a physician order that Resident 136 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 136 ' s S&S, dated 10/17/2024, the S&S indicated Resident 136 was a tobacco user. The S&S indicated Resident 136 had balance problems while sitting or standing, and Resident 136 needed staff supervision during smoking hours. During a concurrent observation and interviews on 10/21/2024 at 10:34 AM with Residents 14 and 136 in the smoking area, Residents 14 and 136 were smoking during nonscheduled smoking time. The Smoking time/schedule sign were as follows: 8AM-9AM, 1PM-2PM, 6PM-7PM. Resident 136 stated, Resident 136 could smoke anytime he wanted. Resident 136 stated, Resident 14 gave Resident 136 cigarettes. Resident 136 stated, Resident 14 lit the cigarettes for Resident 136. Resident 14 stated, Resident 14 got the cigarettes and lighter from REC 1 at the front desk. During a concurrent observation and interview on 10/21/2024 at 10:46 AM with Resident 14, Resident 14 walked out of the facility ' s entrance door with a lit cigarette in Resident 14 ' s hand and smoked his cigarette approximately 10 feet away from the designated smoking area in the patio without any staff supervision. Resident 14 stated, he received the cigarette from REC 1. After smoking a cigarette, Resident 14 threw the cigarette butt on the ground and stamped on the lit cigarette with Resident 14 ' s right foot instead of disposing the lit cigarette in the designated smoking receptacle (container or device used to extinguish and dispose of cigarette waste). During an observation on 10/21/2024 at 11:10 AM in the smoking area, seven (7) residents including Resident 18 were smoking in the patio during nonscheduled smoking time without a staff supervising the residents. During an observation on 10/21/2024 at 12:05 PM in Resident 14 ' s room, Resident 14 was holding a full pack of cigarettes. During an observation on 10/21/2024 from 1PM to 2PM (scheduled smoking time) in the facility ' s designated smoking area, Residents 2, 9, 14, 18 and 136 were smoking without a staff supervising the residents. During an observation on 10/21/2024 at 3:09 PM (nonscheduled smoking time) in the patio, Resident 9 was smoking with no staff presented to supervise the resident. Resident 9 pointed to REC 1 and stated Resident 9 received his lit cigarette from REC 1 who was sitting at the front desk inside the facility. During a concurrent observation and interview on 10/21/2024 at 3:10 PM in the facility ' s designated smoking area with Resident 56, Resident 56 threw Resident 56 ' s cigarette butt behind the planter and took Resident 14 ' s cigarette after Resident 14 offered a lit cigarette to Resident 56. Resident 56 stated, Resident 56 had his own cigarette lighter since admission and Resident 56 kept the lighter in his pant pocket. During an observation on 10/21/2024 at 3:12 PM (nonscheduled smoking time) in the patio, Residents 2, 14, and 67 with five (5) other residents were smoking without any staff to supervise the residents. During a concurrent observation and interview on 10/21/2024 at 3:15 PM (nonscheduled smoking time) with Resident 67 and Resident 14 in the patio, Resident 67 was sitting on a wheelchair smoking with no staff supervision, Resident 67 ' s cigarette ashes dropped down on Resident 67 ' s clothes from the top part of Resident 67 ' s chest to the resident ' s waist. One blue cigarette lighter was observed on top of a napkin in Resident 67 ' s wheelchair ' s cup holder. Resident 67 stated, she usually smoked one to one and a half pack of cigarettes per day and Resident 67 could smoke anytime she wanted. Resident 67 stated, she kept a lighter within her possession since she was admitted to the facility. Resident 14 stated he used Resident 67 ' s lighter to light his cigarettes. During an interview on 10/21/2024 at 3:20PM with REC 1, REC 1 stated, the designated smoking area was right outside of the facility ' s entrance. REC 1 stated, he was assigned to give out lit cigarettes to the smokers and watched the residents smoke through the facility ' s glass door while sitting inside the facility. REC 1 pointed to a monitor on the right side of the front desk and stated, he could observe the smokers through the monitor but was not assigned to monitor the residents in the smoking area because he was assigned to do other tasks such as answer phone calls and watch the people coming in and out of the facility. REC 1 stated, REC 1 gave cigarettes to the residents whose names were on the smoking list. REC 1 stated, he was aware that Resident 3 and Resident 67 had their own cigarettes and lighters. REC 1 stated, he allowed Resident 3 and Resident 67 to keep their cigarettes and lighters because their families ' members had been supplying them with the smoking materials. During a concurrent observation and interview on 10/21/2024 at 3:43 PM with Certified Nursing Assistant (CNA) 4 in Resident 3 ' s room, there was one red lighter in the left corner of Resident 3 ' s bedside drawer. CNA 4 stated, the lighter was functional and should not be kept in Resident 3 ' s bedside drawer due to potential of fire hazard. During an interview on 10/21/2024 at 4 PM with CNA 3, CNA 3 stated no resident should keep the lighters or cigarettes. CNA 3 stated, Resident 14 and Resident 56 wanted to continuously smoke even during nonscheduled smoking time. During an interview on 10/21/2024 at 4:25 PM with the DON, the DON stated, it was the facility ' s policy not to allow residents to keep their cigarettes and lighters within their possession due to fire hazard and accidental burns. The DON stated, staff supervision during scheduled smoking time was essential to ensure the residents safely smoke their cigarettes without hurting themselves such as cigarette burn and burn from the cigarette ashes. The DON stated the facility resident ' s population included residents (unspecified) with behavior problems so staff supervision was required so that the residents would not fight or became aggressive during the smoking time. The DON stated the activity staff who was scheduled to observe and supervise in the smoking area was supposed to give out cigarettes and light the cigarettes for the residents. The DON stated, when a resident was noncompliant with the facility ' s smoking policy, she expected the previous AD (AD 1) to develop a CP and conduct an IDT meeting to address the resident ' s noncompliance. The DON stated AD 1 was no longer working for the facility since 10/10/2024 and the new hired AD (AD 2) should know how to take care of residents who were noncompliance with smoking policy. The DON stated, since AD 1 was no longer worked for the facility, no one oversaw the activity staffs to make sure the activity staffs were present during the scheduled smoking time or knew how to care for noncompliant residents. During a concurrent record review and interview on 10/21/2024 at 4:30 PM with the MDS Nurse (MDSN), Resident 56 ' s CPs including the CP tilted, Smoking, dated 4/10/2024, and Resident 56 ' s IDT records since admission on 4/10/2024 were reviewed. The MDSN stated, Resident 56 was known to be noncompliant with the facility ' s smoking policy because Resident 56 kept Resident 56 ' s cigarettes and lighter at his bedside drawer. The MDSN stated, the MDSN could not find any documented evidence that a CP related to noncompliance with smoking policy in Resident 56 ' s medical record (chart). The MDSN stated there was no IDT meeting conducted for Resident 56. During a concurrent review and interview on 10/21/2024 at 4:35 PM with the MDSN, Resident 3 ' s CP tilted, Noncompliance with Smoking, dated 10/2024, indicated Resident 3 was noncompliant with the smoking schedule time, Resident 3 kept/hid his smoking cigarettes, lighter, matches and Resident 3 was at risk for injury related to smoking and non-compliance behavior. The MDSN stated, the interventions included to conduct IDT conference with Resident 3. The MDSN stated, per record, no IDT meeting was conducted with Resident 3 since 9/23/2024. During a concurrent record review and interview on 10/21/2024 at 4:40 PM with the MDSN, Resident 67 ' s CP titled, Noncompliance with Smoking, dated 8/1/2024, and Resident 67 ' s progress notes titled, Activity Participation Notes, dated 9/23/2024, were reviewed. The MDSN stated, per record, Resident 67 had been keeping the cigarettes/lighters in Resident 67 ' s possession. The MDSN stated Resident 67 did not follow the facility ' s smoking schedule and Resident 67 shared her cigarettes with other residents in the facility since 7/30/2024. The MDSN stated Resident 67 ' s CP titled, Noncompliance with Smoking, dated 8/1/2024, was not revised, and IDT meeting was not conducted when Resident 67 was found to be noncompliant with smoking during nonscheduled smoking time, and when Resident 67 refused to surrender her cigarette/lighter and supplied cigarettes to other residents on 9/23/2024. During an interview on 10/21/2024 at 4:45 PM with Payroll Staff (PS) 1 in the presence of the DON, PS 1 stated, the PS 1 was in charge of staffing scheduling. PS 1 stated, AD 1 ' s last working date was 10/9/2024. PS 1 stated, when AD 1 left, nobody was assigned to cover for the AD 1 ' s role. During an interview on 10/21/2024 at 4:51 PM with the DON, the DON stated, for residents (Resident 2, 9, 14, 18 and 136) who were noncompliant with their smoking policy, the facility supposed to develop a CP followed by an IDT meeting to go over the noncompliant issue and offer solutions, interventions, suggestions and discuss with the residents for the plan of care. The DON stated, when Resident 67 continued to be noncompliant on 9/23/2024, the AD 1 supposed to review and revise the CP to find out why Resident 67 continued to be noncompliant and to offer a different solution or adjust the interventions based on the resident ' s specific needs. During an interview on 10/21/2024 at 5:03 PM with the DON, the DON stated, the facility did not provide any supervision during scheduled and nonscheduled smoking time on 10/21/2024. The DON stated the residents (Residents 2, 3, 9, 14, 18, 56, 67 and 136) who were smoking during nonscheduled smoking time were noncompliant with the facility ' s smoking policy. The DON stated, all of the facility ' s residents were at risk for burns and fire, especially those residents that required oxygen supplement in the facility. During an interview on 10/21/2024 at 5:22 PM with the Activity Staff (AS) 1, AS 1 stated, from 9 AM to 1 PM (nonscheduled smoking time), he was aware that some residents kept coming out to smoke with their own lighters and cigarettes. AS 1 stated, he had to let the residents smoke cigarettes as they wanted and did not know what to do. AS 1 stated, he was not at the smoking area to supervise the residents who smoked from 1PM to 2PM on 10/21/2024 because he was busy [TRUNCATED]

Based on observation, interview, and record review, the facility failed to prevent and respond to the elopement (an act of leaving a care facility or safe area independently without notifying anyone) of one of three residents (Resident 1), who had severely impaired cognition (a condition that significantly impacts a person's ability to learn, remember, think, and communicate, making it difficult or impossible for them to live independently), by failing to implement the facility's policy and procedures by: 1. Not assessing and identifying Resident 1 as at risk for unsafe wandering (aimlessly going to places) and elopement when the facility observed the resident wandering to other resident ' s room and front lobby as indicated in the facility ' s policy and procedure titled Wandering and Elopement. 2. Not providing adequate supervision to ensure Resident 1 who had fluctuating capacity to understand and make decisions, with diagnoses including, schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior) , HIV (Human Immunodeficiency Virus), dysphagia (difficulty swallowing) and lack of coordination was properly assessed for risk of wandering and elopement as indicated in the facility ' s policy and procedure titled Nursing- Wandering and Elopement. 3. Not conducting a thorough investigation on how Resident 1 eloped and exited the facility to prevent other residents at risk of elopement from eloping in the exit areas as indicated in the facility ' s policy and procedure titled Accidents and Incidents- Investigating and Reporting. 4. Not developing a care plan to ensure Resident 1 received interventions, monitoring, and supervision to prevent elopement and wandering to other resident ' s rooms as indicated in the facility ' s policy and procedure titled Nursing- Wandering and Elopement. 5. The facility did not implement CODE [NAME] (a code called out in the facility ' s paging system [microphone announce a message] to alert staffs and visitors that a resident is missing or eloped) immediately when the resident was found missing as indicated in the facility ' s policy and procedure titled Use of Wander Guard(Wander Guard-a set of equipment, consisting of a watch-like device worn by a person and a door alarm that is set off once the watch-like device gets in close proximity to the door alarm; used for the purpose of preventing a person from exiting an area) and Nursing Wandering and Elopement. As a result of these failures, on 9/16/2024 at around 1:15 PM, Resident 1 was discovered to be missing, exposing Resident 1 to extreme weather, medical complications, malnutrition (lack of sufficient nutrients in the body), and death. Resident 1 missed her daily medications, including psychoactive medication (medication to manage mental disorders) and antiviral medication (medication to manage viral diseases such as HIV). Resident 1 remained missing on 9/19/2024. On 9/17/2024 at 9:20 AM, the California Department of Public Health conducted an unannounced visit to the facility to investigate Resident 1 ' s elopement. On 9/17/2024 at 7:15 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the failure to prevent and investigate how Resident 1 eloped and other residents at risk for elopement from the facility. The facility ' s Administrator (ADM) and Director of Nursing (DON) were notified of the IJ situation on 9/17/2024 at 7:15 PM. On 9/18/2024 at 12:13 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 9/19/2024 at 5:33 PM, the IJ was removed in the presence of ADM and DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed during onsite the facility ' s implementation of the IJ Removal Plan and the IJ situation was removed. The IJ Removal Plan Dated 9/19/2024, included the following: Immediate action(s) taken for the resident found to have been affected included: On 9/16/2024 the facility initiated an investigation, notified law enforcement, residents responsible party, primary physician and CDPH. The facility contacted hospitals in the area to inquire if they have admitted the resident. Multiple staff members searched in the nearby areas including, parks, stores, shopping centers as well as neighboring areas. The facility will continue its efforts to search for the resident on a daily basis for 3 months which would include contacting law enforcement as well as local hospitals and additionally search the local area weekly for 3 months. Identification of other residents having the potential to be affected was accomplished by: On 9/16/2024, the DON immediately initiated a review making sure that all residents are accurately reassessed, monitored, and supervised residents at risk of wandering behavior and elopement. Residents at risk for elopement are monitored and their whereabouts always accounted for and only three residents were identified in this category of which two of them have a wander guard and one of them was on a one-on-one monitoring (one staff monitoring one resident) until a wander guard can be placed on her. On 9/18/2024 sliding doors in Rooms B and C were reported to be opening to a width that a person could pass through. On 9/18/2024 The maintenance supervisor immediately made appropriate adjustments by putting a stopper making sure the door does not open to a width that a person can pass through. On 9/18/2024 the maintenance supervisor assessed the rest of the facility and made sure that there were no possible exit doors or windows that residents with risk of elopement could exit from by making sure that the alarms that are on them are working and that if they were to be opened the staff would be alerted. Based on the facilities investigation it seems that the resident exited from the main lobby doors. Actions taken/systems put into place to reduce the risk of future occurrence include: A scheduled 24 hour receptionist is in place to monitor the front doors. Additional monitoring of residents every 2 hours by the assigned nurse and reviewed by the shift charge nurse. Additional staff monitor implemented at the outside entrance of the facility from 7 am to 7pm and an alarm that cannot be easily removed without special tools will be activated at the facility's front door from 7pm to 7am. The Maintenance supervisor/ Designee will conduct daily audits making sure that they are working. On 9/16/2024 the DON/ Designee initiated in-services on: How to accurately assess residents for risk of wandering behavior and elopement How to care for residents at risk for elopement, based on the elopement assessment the plan of care will be individualized How to monitor and supervise residents for wandering behavior and elopement to identify risk factors for each resident such as cognitive impairment, history of wandering and/or elopement and conducting elopement risk assessment upon admission quarterly and as needed. Ensuring residents at risk for elopement were monitored and their whereabouts were always accounted for, and a wander guard was placed on them or other measures such as a one on one monitoring. Staff respond promptly by the following: Charge nurse should be contacted right away and immediately do the following: Page Code Green. Assign staff members to search throughout the inside of the facility premises and search in the immediate outside vicinity. Verify whether or not the resident has gone out on pass or at an appointment. And immediately contact: Law enforcement, resident ' s family members, physician and CDPH (California Department of Public Health) within 2 hours. The maintenance supervisor was in serviced by the administrator on 9/18/2024 in regard to the importance of making sure all sliding doors are only opening enough that a person can't pass through it. The maintenance supervisor/Designee will conduct daily checks for 3 months on the sliding doors, ensuring they are only opening enough that a person can't pass through it. Inservice was conducted on 9/19/2024 to all supervisors in regard to properly investigating any incidents including interviewing staff, roommates, residents' family members or any other person that might be able to provide useful information. Monitoring of the Removal Plan include: Starting the week of 9/16/2024 the DON/ Designee will conduct weekly audit logs making sure that residents are being accurately assessed for the risk of wandering behavior and elopement, residents at risk for elopement are monitored and their whereabouts always accounted for every 2 hours. The Director of Staffing Development (DSD) will conduct weekly Audits by asking random staff on how to care for residents that have been found to be at risk for elopement and that staff are responding promptly by calling out Code green per the facilities policy and procedures. The administrator will review on a daily basis from Monday through Friday for 3 months the previous days log for the additional monitoring staff. The administrator will conduct weekly checks on resident room sliding doors for 3 months making sure that they are functioning properly. The Administrator will conduct weekly checks on the door alarms for 3 months making sure that they are working properly. A Quality Assurance Program Improvement- (QAPI measures set by the facility to improve delivery of care at the facility) has been initiated in regard to ensuring that there is a system in place for residents who are at risk or maybe at risk for elopement, Elopement risk assessments, and elopement management. The administrator will conduct a weekly review of all investigations for three months making sure that incidents are being thoroughly investigated and include Interviews of staff, roommates, residents' family members or any other person that might be able to provide useful information. The results will be reviewed by the QA for further evaluation and recommendation if necessary. Findings: 1. A review of Resident 1 ' s Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included lack of coordination, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and dysphagia (difficulty swallowing). A review of Resident 1 ' s History and Physical (H&P), dated 5/3/2024, indicated the resident has fluctuating capacity to understand and make decisions. The H&P also indicated Resident 1 has a diagnosis of HIV (Human immunodeficiency virus is a virus that attacks the body's immune system, specifically white blood). A review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 6/17/2024, indicated the resident has severe cognitive impairment. The MDS indicated Resident 1 can walk 150 with supervision (helper provides verbal cues and/or touching assistance). The MDS also indicated Resident 1 does not use any mobility devices such as a cane, walker, or wheelchair and did not exhibit wandering behavior. A review of Resident 1 ' s Change in Condition Evaluation form, dated 9/16/2024, timed at 4:07 PM, conducted with the Director of Nursing (DON), indicated on 9/16/2024 at 1PM, Certified Nursing Assistant (CNA) was doing rounds and she noticed that [Resident 1] is not in her room. She looked if the resident is in the front which she always frequented but nowhere to be found. A review of Resident 1 ' s Order Summary Report dated 9/17/2024, included the following orders: -Olanzapine (medication that affects mood and behavior) tablet 15 MG (milligrams - a unit of measurement) to give 2 tablets orally (by mouth) at bedtime for Schizophrenia [manifested by] delusions [as evidenced by] believing her food has been poisoned -Tivacay (Dolutegravir Sodium-medication used to treat HIV virus) oral tablet 50 MG to be given one tablet by mouth one time a day for HIV. A review of Resident 1 ' s Progress Notes from 6/3/2024 to 9/17/2024, indicated no documented evidence that staff implemented interventions to monitor, supervise Resident 1 with wandering behavior of going into other resident ' s room. A review of Resident 1 ' s plan of care indicated no documented evidence that the facility developed a plan of care and implemented interventions to monitor, supervise and prevent Resident 1 from wandering or eloping from the facility after the facility observed Resident 1 wander to other resident ' s room and wanders to the front lobby near the exit door that leads to a busy street. During an interview on 9/17/2024 at 11:15 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 usually sits in the front lobby, by the front exit. CNA 1 stated Resident 1 can walk by herself independently. CNA 1 stated the last time she saw Resident 1 was on 9/16/2024 at around 12 PM when Resident 1 was eating lunch inside of the resident ' s room. During an interview on 9/17/2024 at 11:32 AM with Receptionist (RP) 1, RP 1 stated Resident 1 was sitting by the front entrance in the lobby at around 11 AM to 11:30 AM on 9/16/2024 but did not notice Resident 1 leave the facility. During an interview on 9/17/2024 at 11:49 AM with RP 2, RP 2 stated he last saw Resident 1 sitting in the front lobby near the facility ' s entrance door at around 11 to 11:30 AM on 9/17/2024. RP 2 stated he did not see where Resident 1 went after 11:30 AM because it became busy, and visitors started coming in. During an interview on 9/17/2024 at 12:08 PM with CNA 1, CNA 1 stated she noticed Resident 1 was missing at 1:15 PM because she could not find Resident 1 in her room and the front entrance. CNA 1 stated she reported to Licensed Vocational Nurse (LVN) 1 that Resident 1 was missing at around 1:20 PM. During an interview on 9/17/2024 at 12:10 PM, with LVN 1, LVN 1 stated she knows it was the usual routine of Resident 1 to sit on the chair by the front entrance of the facility. LVN 1 stated she was notified by CNA 1 at around 1:15 PM to 1:30 P.M on 9/16/2024 that Resident 1 was missing. LVN 1 stated she informed CNA 1, CNA 2, and CNA 3 to look for Resident 1. LVN 1 stated she immediately checked the rooms, starting from rooms in her station LVN 1 stated after checking the rooms in her station ' s rooms, she checked the rooms in 2 other stations and the front lobby. LVN 1 stated when she could not find the resident, she informed the Director of Nursing (DON) at around 2PM on 9/16/2024. During an interview on 9/17/2024 at 12:12 PM, LVN 1 and CNA 1 both stated they panicked and forgot to announce the Code [NAME] into the facility ' s paging system. LVN 1 stated announcing code green a code used to alert all facility staff that a resident is missing or has eloped. During an interview on 9/17/2024 at 1:13 PM with CNA 2, CNA 2 stated he was verbally informed by LVN 1 that Resident 1 was missing at around 1:15 PM on 9/16/2024. CNA 2 stated Resident 1 usually wanders to other resident ' s room and bathrooms, on 9/16/2024 at 1:15 PM when she looked for the resident, she did not find the resident in the facility. During an interview on 9/17/2024 at 1:27 PM with CNA 3, CNA 3 stated she was informed by LVN 1 that Resident 1 was missing at around 1:30 PM. CNA 3 stated Resident 1 walks around the facility without any help from the staff. CNA 3 stated Resident 1 goes to other residents ' rooms but when she looked for the resident on 9/1/6/2024, she did not find the resident in the facility. During an interview on 9/17/2024 at 12:28 PM with the DON, the DON stated LVN 1 reported to her that Resident 1 was missing at around 2PM. DON stated her initial response was to go out of the facility to look for the resident. The DON stated she and LVN 1 drove around the facility ' s area and came back at around 3PM but did not find Resident 1. DON stated when she came back into the facility, and she informed the Administrator (ADM) that Resident 1 was missing, and reported the resident was missing to the police department. DON stated, Code [NAME] was never announced on the facility ' s paging system because she and the other staffs panicked. The DON stated announcing Code [NAME] was used by the facility to help spread information to all staff that a resident has gone missing and to potentially help in preventing the resident from going out and far from the facility ' s premises. During an interview on 9/17/2024 at 1:58 PM with CNA 1, CNA 1 stated Resident 1 can walk without any need for assistance or devices. CNA 1 stated Resident 1 was not under any supervision or monitoring because she is quiet and just walks slowly. During an interview on 9/17/2024 at 1:59 PM with LVN 1, LVN 1 stated Resident 1 was not under any supervision and monitoring for wandering and elopement. LVN 1 stated Resident 1 was not one of the three residents listed in the elopement binder to be at risk for elopement in the facility. LVN 1 stated residents that are at risk for elopement are listed in the elopement binder. During an interview on 9/17/2024 at 2:52 PM with Registered Nurse (RN) 1, RN 1 stated the facility has an elopement binder labeled, Elopement Risk Residents which has a list of resident's names that are at risk for elopement. RN 1 stated residents are added into the list based on the assessment of the resident by the nurse using the Elopement Evaluation form. RN 1 stated if the resident was assessed to have any risk factor, then the resident must be added into the list. RN 1 stated a resident who was at risk for elopement must have interventions put in place to prevent an elopement such as monitoring the resident ' s whereabouts and supervision. During a concurrent interview and record review on 9/17/2024 at 3PM with RN 1, Resident 1 ' s Elopement Evaluation form, dated 6/17/2024 and 9/16/2024 were reviewed. RN 1 stated the following questions were incorrectly answered No instead of answering Yes. -Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. -Does the resident wander. -Is the wandering behavior a pattern, goal-directed (an action taken with the specific intention of achieving a desired outcome). -Is the wandering behavior likely to affect the privacy of others. Score value or 1 or higher indicate Risk of Elopement. During a follow up interview on 9/17/2024 at 3:05 PM with RN 1, RN 1 stated the questions should have been answered yes and the score should be greater than one because Resident 1 frequently stays in the front lobby, walks around the facility, and even wanders to other residents ' rooms. RN 1 stated if the form was answered correctly, Resident 1 could have been assessed as a high risk for elopement and put on the list for residents at risk for elopement. RN 1 stated Resident 1 should have been monitored to prevent elopement. During another concurrent interview and record review on 9/17/2024 at 3:06 PM with RN 1, Resident 1 ' s Elopement Evaluation form, dated 9/16/2024, was reviewed. RN 1 stated she did identify Resident 1 as at risk for wandering and elopement because she followed the answers in the previous Elopement Evaluation form dated 6/17/2024 that indicated Resident 1 as not at risk for wandering and elopement. RN 1 stated because she evaluated the resident as not at risk for elopement, the staffs would not know that the resident was at risk for elopement. During an interview on 9/18/2024 at 10:01 AM with Director of Staff Development (DSD), DSD stated residents who wander around the facility aimlessly and have psychiatric (mental, behavioral, and emotional disorders) medical diagnosis like Resident 1 are at risk for elopement. DSD added residents with psychiatric illness like Resident 1 have tendency to go out if the doors are left open which can jeopardize the safety of the resident and other residents who have behavior of wandering if they are not monitored or supervised. During a concurrent interview and observation on 9/18/2024 at 2:14 PM with CNA 5, Room B and Room C were checked. CNA 5 stated Room B and Room C both have sliding doors that opens wide enough for a person to walk out to and leave the facility. CNA 5 stated any resident could go out of the sliding doors that leads to the back side of the building and elope. During a concurrent interview and observation on 9/18/2024 at 2:30 PM with DON, Room B and Room C were checked. DON stated Room B was next to Resident 1 ' s room and Resident 1 could have eloped through the sliding doors. DON stated there were no alarms after a resident has passed through the sliding doors that could have alerted staff that a resident was eloping. DON stated there are no locks to the gate outside the sliding doors that could prevent any resident from leaving the facility. DON stated the sliding doors of Room B and Room C were not supposed to open wide enough for a person to be able to walk out. During an interview on 9/18/2024 at 2:40 PM with Maintenance Supervisor (MS), MS stated the area outside the sliding doors of Room C and Room D do not have any alarms, sensors, or cameras that could notify staff if a resident was outside. MS stated the facility does not lock the gate outside of the sliding doors. A review of Resident 2 ' s Admission Record indicated the resident was originally admitted on [DATE], readmitted on [DATE], with diagnoses that included spondylosis (abnormal wear on the cartilage [flexible tissue that lines joints] and bones of the back) and dysphagia. A review of Resident 2 ' s H&P, dated 10/25/2023, indicated Resident 2 has the capacity to understand and make decisions. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had no cognitive impairment. During an interview on 9/18/2024 at 3:20 PM, Resident 2 stated Resident 1 mentioned to her that Resident 1 was anxious to go home. Resident 2 stated no one has asked her regarding Resident 1 who was missing. A review of Resident 3 ' s Admission Record indicated the resident was originally admitted on [DATE], readmitted on [DATE], with diagnoses that included fibromyalgia (a chronic condition that causes widespread pain and tenderness in the muscles and soft tissues of the body) and epilepsy (a chronic brain disorder that causes recurrent seizures, which are episodes of involuntary brain activity). A review of Resident 3 ' s H&P, dated 5/6/2024, indicated Resident 3 has the capacity to understand and make decisions. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 2 has no cognitive impairment. During an interview on 9/18/2024 at 3:23 PM, Resident 3 was interviewed. Resident 3 stated no one has interviewed her regarding Resident 1. Resident 3 stated she sees the resident wander around the facility. During a concurrent interview and record review on 9/19/2024 at 9:52 AM with ADM, ADM ' s written statement and the facility ' s investigation report were reviewed. ADM stated he and the DON did not interview residents to verify if Resident 1 had wandering behavior or if the resident verbalized wanting to leave the facility during the facility ' s investigation about Resident 1 ' s elopement. ADM stated residents should have been interviewed because they can be witnesses that could provide valuable information and it is basic to interview residents. ADM stated he and DON leads the investigation to Resident 1 ' s elopement. ADM added the investigation was not thorough because no resident interviews were conducted and he does not know the possible area where Resident 1 exited from the facility on the day the resident eloped because the doors that were possible exit doors were not checked until the surveyor informed him about the sliding doors that could be opened and used as exit. During an interview on 9/19/2024 at 10:01 AM with Social Services Director (SSD), SSD stated she was not instructed to interview any residents about Resident 1 ' s elopement. SSD stated she did not interview Resident 2 and other residents regarding Resident 1 ' s elopement. During a phone interview on 9/19/2024 at 11:05 AM with Medical Doctor (MD), MD stated the facility never contacted him to provide a physician orders to prevent Resident 1 from eloping. MD stated the facility did not consider Resident 1 as at risk for elopement. During an interview on 9/19/2024 at 12:54 PM with SSD, Resident 2 was interviewed concurrently with SSD. During the interview, Resident 2 stated Resident 1 has been verbalizing of wanting to go home. During an interview on 9/19/2024 at 2:39 PM with DON, DON stated Resident 1 ' s cognitive ability was not reliable because of her medical diagnoses of schizophrenia. DON stated it was risky that Resident 1 was walking around the facility without any supervision or monitoring. DON also stated the facility should have contacted the police right away for assistance when they could not find the resident in the facility, instead of driving outside before calling the police. DON added it was her booboo or mistake on instructing staff to copy the Resident 1 ' s previous elopement evaluation onto a new elopement evaluation form. During a concurrent interview and record review on 9/19/2024 at 2:39 PM with DON, Resident 1 ' s entire medical records were reviewed. DON stated there was no care plan developed for Resident 1 to prevent the resident from elopement. DON stated there was no documented evidence that staff monitored or intervened to prevent Resident 1 from eloping. DON stated Resident 1 ' s Elopement Evaluation, dated 6/17/2024, was not answered correctly. DON stated Resident 1 should have been one of the residents in the facility ' s elopement list. DON stated she admits the facility was at fault of Resident 1 ' s elopement because of not accurately assessing and identifying Resident 1 as at risk of elopement and not implementing any interventions to prevent Resident 1 from eloping. DON stated the facility could have used a Wander guard to prevent Resident 1 from eloping. DON stated Resident 1 ' s medical condition could worsen because Resident 1 has not received the scheduled medications while out in the facility since 9/16/2024 and the resident had not been found. A review of the facility ' s Elopement Risk Residents binder conducted with the DON on 9/19/2024 at 2:39 PM did not include Resident 1 on the list. During a concurrent interview and record review on 9/19/2024 at 5:12 PM with ADM, the facility ' s policy and procedure (P&P) titled, Accidents and Incidents- Investigating and Reporting, revised 7/2017, was reviewed. ADM stated the investigation should include witnesses and their accounts of the accident or incident. ADM stated residents are witnesses that could provide valuable information to the investigation. A review of the facility ' s job description for Director of Nursing Services undated, indicated it is the DON ' s responsibility to promote a safe environment within the facility, which includes fire and accident prevention. The job description also indicated the DON assumes responsibility for investigations of alleged abuse or unusual occurrence. A review of the facility ' s P&P titled, Use of Wander guard, dated 7/23/2021, indicated when a resident is wearing a Wander guard or wristband that transmitter attempts to exit a monitored doorway, an audible alarm sounds. The P&P indicated Wander guard may be used for residents who has impaired cognition & decision-making skills yet verbalizes of wanting to leave the facility without supervision. The P&P also indicated if a resident is noted missing, the nurse will call Code [NAME] and organize a search immediately. A review or the facility ' s P&P titled, Nursing- Wandering and Elopement, released 6/2018, indicated residents who are deemed to be high risk for elopement or wandering will have a photograph maintained in their medical record. The P&P indicated the facility will develop a plan of care considering the individual risk factors of the resident. A review of the facility ' s P&P titled, Safety and Supervision of Residents, revised 7/2017, indicated the facility shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated resident supervision is a core component to safety. The P&P indicated risk factors include wandering. A review of the facility ' s P&P titled, Elopements, revised 12/2007, indicated if an employee discovers a resident is missing, he/she shall initiate an extensive search of the surrounding area. The P&P also indicated if the resident is not located in the facility ' s building(s) and premises, he/she shall notify law enforcement. A review of the facility ' s P&P titled, Wandering and Elopements, revised 3/2019, indicated the facility will identify residents who are at risk for unsafe wandering and elopement, the resident ' s care plan will include strategies and interventions to maintain resident ' s safety. The P&P also indicated if a resident is missing, initiate a search of the building(s) and premises; and if the resident is not located, notify the administrator and director of nursing services, the resident ' s legal representative, the attending physician, law enforcement officials.

Based on observation, interview and record review the facility failed to put measures in place to ensure the safety of four out of five sampled residents (Residents 1, 2, 3, and 4) who were assessed as elopement (leaving a facility without notice) risk. The facility staff failed to supervise Residents 1, 2, 3, and 4, who had diagnoses of mental illness, impaired cognition, and were deemed at risk for elopement by failing to ensure: 1. Resident 1 who had a diagnosis of [CONDITION(S)] (mental illness that affects how a person thinks, feels, and behaves), and was assessed to be at risk for elopement (an act or instance of leaving a safe area or safe premises) and had a history of elopement in another facility, implemented the care plan interventions to check for placement and functioning of the wander guard every shift and provided visual checks every 30 minutes. Resident 1 eloped from the facility on 9/12/2020. 2. Resident 2 who had a diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and was assessed to be at risk for elopement, eloped from the facility on 2/25/2021. The facility failed to implement new/revised interventions to prevent Resident 1 from eloping from the facility. Resident 2 was later found admitted to the General Acute Care Hospital (GACH) emergency room (ER). The GACH ER records clinical impression indicated Resident 2 was confused, dehydrated, and had altered level of consciousness. 3. Resident 3 who had a diagnosis of [CONDITION(S)] and was assessed to be at risk for elopement, eloped from the facility on 6/28/2021. The licensed nurses did not have consistent and accurate elopement risk assessments to revise the resident's care plan and at-risk resident's whereabouts not being closely monitored by facility staff for Resident 3 from 3/2021 to 6/3/2021. 4. Resident 4 who had diagnosis of [CONDITION(S)] disorder (a condition where symptoms of both psychotic and mood disorders are present) had a care plan indicating Resident 4 was at risk for injuries secondary to elopement, but facility staff assessed the resident not at risk for elopement in the facility's Elopement Risk Tool, indicating inconsistencies in assessment posing the resident at risk for resident's whereabouts not being closely monitored by facility staff. Resident 4 had the potential for serious harm/injury from accidents, dehydration, and hunger while out alone in the community due to impaired cognition. 5. The facility's front door latched automatically for the door to completely close for the facility's wander guard system to activate an alarm (wander guard system tracks individuals within set borders to guarantee their protection). 6. The facility's wander guard system was consistent in triggering the facility's wander guard alarm system for one of two doors with the wander guard alarm that alerts staff when at risk for wandering/elopement when residents pass by or through the facility front doors. On 7/22/2021, during the testing of the facility's wander guard system, two newly opened wander guard transmitter bracelets did not consistently alarm and trigger the wander guard system. 7. The facility monitored the maintenance for one of two wander guard door alarm systems daily as indicated in the facility policy, except on weekends because the Maintenance Supervisor was not in the facility. These deficient practices resulted in Resident 1, Resident 2, and Resident 3's elopement from the facility and other potential newly admitted residents that would be assessed as elopement risk to elope from the facility. Resident 4 had the potential to elope from the facility by not having accurate elopement risk assessment and care plan interventions. This failure had the potential to result in lack of access to medications, hydration, food, shelter, and exposed the residents to serious injuries/harm from accidents if left out in the community. On 7/22/2021 at 6 PM, during an abbreviated survey, the Department of Public Health called an Immediate Jeopardy (IJ-a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), in regard to a faulty, inconsistent wander guard alarm system that notifies staff of Residents who are at risk for wandering and or elopement, to alarm when passing in and out of the facility's front door. During the investigation, the facility's broken front door did not latch to close when passing through, further contributing to the faulty functionality of the facility's alarm system, including inconsistent assessments and determination of the residents' elopement risks using the facility's elopement risk assessments, for Residents 1, 2, and 3, and the potential for other residents to elope from the facility, in the presence of the Administrator (ADM) and Director of Nursing (DON). On 7/24/2021 at 12: 31 PM, the Department of Public Health removed the IJ while onsite after the surveyor verified the facility implemented the Plan of Action (POA- a detailed plan to address findings) given by the ADM which included: a. On 7/22/2021 the facility revised the Elopement Risk Assessment (ERA) tool, which eliminated subjectivity in the assessment by using a score system. On 7/24/2021 the ERA was revised to for indicators of risk for elopement to be assigned different scores, which major indicators indicating higher scores. b. On 7/22/2021 three Registered Nurses were in serviced on the newly adopted ERA. The facility's ongoing effort to in-service all licensed nurses through 7/27/2021. c. A door monitor was position outside of the facility's front door on 7/22/2021 while the front door awaited repair. The facility's front door began repair on 8:54 AM on 7/23/2021. d. On 7/22/2021 the facility's Alarm system where automatically enabled without the need to enter a code. e. On 7/23/2021 the MS changed the antennas for the wander guard system for the front door and adjusted the frequency to increase the parameters for the wand guard allowing for the wander guard bracelet to trigger the alarm system on a wider range. f. On 7/23/2021 the facility revised their Wandering and Elopement Policy and Procedure with the inclusion of the process of elopement assessment Findings: 1. A review of Resident 1's Face Sheet indicated an admission to the facility on [DATE] with diagnoses of malnutrition (a condition that results from lack of sufficient nutrients in the body) and [CONDITION(S)]. A review of Resident 1's History and Physical (H and P) dated 7/11/2020 indicated the resident was assessed having fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a care area screening and assessment tool) dated 7/13/2020, indicated the resident had severe cognitive impairment. Resident 1 required supervision with set up only for bed mobility and eating. The MDS indicated Resident 1 required limited assistance (non-weight bearing support) with one-person physical assist for transfers, locomotion, and toilet use. Resident 1 required Extensive assistance (staff provide weight-bearing support) with one-person physical assist for personal hygiene. A review of Resident 1's Medication Administration Record (MAR) for September 2020 indicated the following information: a. [MEDICATION(S)] (treat high blood pressure and chest pain) 10 mg, one tablet by mouth daily (QD) for hypertension, hold for systolic blood pressure (SBP the top number, measures the force your heart exerts on the walls of your arteries each time it beats) less than 110 or heart rate less than 60. [MEDICATION(S)] was ordered on 7/27/20. b. [MEDICATION(S)] (used to treat certain mental/mood disorders) 2 mg one tablet by mouth at bedtime for [CONDITION(S)] manifested by paranoia thinking someone wants to poison him. [MEDICATION(S)] was ordered on 7/27/2020. A review of Resident 1's Physician Order dated 7/8/2020 indicated an order to apply a wander guard to the resident's wrist secondary to the resident being elopement risk. A review of Resident 1's Care Plan for Elopement/Wandering Risk, dated 7/27/2020 revised on 9/12/2020, indicated Resident 1's problems/concerns that included Elopement/Wandering Risk Assessment Score of 10 or greater due to intermittent confusion and ambulatory with/without device. The care plan also indicated a problem/concern of Elopement/Risk Assessment with a score that was left blank and further indicated Resident 1 had a status or condition that is a risk factor for elopement or wandering. The care plan included the following interventions: a. Apply wander guard bracelet to Resident 1. b. Check exit door alarms if functioning. c. Provide frequent visual checks, at least every 30 minutes if Resident 1 was noted with wandering episodes. During a concurrent interview and record review with the QA nurse on 7/22/2021 at 3:45 PM, Resident 1's Elopement Risk assessment dated [DATE] indicated Resident 1 verbalized statements about leaving, had a history of leaving the facility, and had a psychiatric diagnosis. The QA nurse stated she was the licensed nurse that evaluated Resident 1's elopement risk and did not know why she had indicated Resident 1 did not present as an elopement risk. The QA nurse stated the elopement risk assessment should have indicated Resident 1 was at risk for elopement and could not state why she marked Resident 1 not at risk. The QA nurse stated a care plan should had been revised and updated after the 8/27/2020 assessment to implement a revised care plan intervention. The QA nurse stated Resident 1 eloped from the facility on 9/12/2020. On 8/2/2021 at 12:53 PM, during a concurrent telephone interview and review of Resident 1's Care Plan for Elopement/Wandering Risk dated 7/27/2020 with revision date 9/10/2020 did not indicate new interventions to prevent wandering or eloping out of the facility. The Quality Assurance (QA) nurse stated the care plan did not indicate the status/condition that posed as a risk factor for Resident 1's elopement or wandering. The QA nurse stated Resident 1's specific status or condition mentioned in the care plan should have been indicated to identify Resident 1's risk for elopement. The QA nurse stated that the incorrect problem/concern was checked off on Resident 1's Elopement Care Plan. The QA nurse stated Resident 1's care plan for elopement did not identify new/updated interventions and could not state the reason a revision date of 9/10/2020 was initiated. A review of Resident 1's Elopement Risk assessment dated [DATE] indicated Resident 1 Based on assessment presented as an elopement risk. A review of Resident 1's Elopement Risk assessment dated [DATE] indicated Resident 1 Based on assessment presented as an elopement risk. A review of Resident 1's Elopement Risk assessment dated [DATE] indicated Resident 1 Based on assessment did not present as an elopement risk. A review of Resident 1's Elopement Risk assessment dated [DATE] indicated Resident 1 Based on assessment presented as an elopement risk. A review of Resident 1's Licensed Nurses (LN) Progress Note dated 7/16/2021 at 11:59 PM indicated Resident 1 was admitted to another Skilled Nursing Facility (SNF 2) from GACH on 7/16/2021. A review of Resident 1's Licensed Nurses (LN) Progress Notes from SNF 2 dated 7/20/2020 timed at 11 PM indicated Resident 1 was readmitted to SNF 2 on 7/20/2020 at 5 PM. The SNF 2's LN Progress Note indicated, on previous admission Resident 1 had left the facility through the main entrance that does not have an alarm while LVN's and CNA's were doing patient care. The SNF 2's progress note indicated facility staff were aware that Resident 1 was an elopement risk and additional help was requested from CNAs to supervise and monitor Resident 1. A review of Resident 1's care plan for Elopement dated 9/10/2020 indicated Resident 1 was at risk for injury secondary to elopement. The interventions included: a. Frequent visual checks b. Camera surveillance c. Security guard d. Every four hours head count e. Photographs at the reception, charts, and nurses' station. A review of Resident 1's Care Plan for Elopement/Wandering Risk revised on 9/12/2020 indicated there were no added interventions. Resident 1's care plan indicated intermittent confusion and ambulatory without device. A review of Resident 1's Situation, Background, Assessment, Recommendations (SBAR) Communication Form dated 9/12/2020, indicated Resident 1 eloped from the facility on 9/12/2020. The SBAR indicated at approximately 8:20 AM Resident 1 was unaccounted for (not known where they are) in the facility. The SBAR indicated search teams were sent out to locate Resident 1. By 2:19 PM on 9/12/2020, Resident 1 was still not located. A review of Resident 1's recapped Physician Orders for September 2020 indicated to check wander guard for placement and functioning every shift. The order date was 8/7/2020. The Physician orders indicated to apply wander guard bracelet to Resident 1's wrist to monitor resident episodes of attempting to get out of exit doors. The order date was 7/27/2020. 2. A review of Resident 2's Face Sheet indicated a readmission to the facility on [DATE] with diagnoses that included heart failure, [CONDITION(S)], and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory). A review of Resident 2's H and P dated 2/9/2020, indicated Resident 2 was assessed not having the capacity to understand or make decisions. A review of Resident 2's MDS dated [DATE], indicated Resident 2 required limited assistance with one-person physical assist for bed mobility, transfers, toilet use, and personal hygiene. The MDS indicated Resident 2 required supervision with set up only for eating. A review of Resident 2's MAR for February 2021 indicated the following information: a. [MEDICATION(S)] (used for the treatment of moderate to severe dementia in people with Alzheimer's disease) 10 mg one tablet by mouth two times a day (BID) for dementia. The order start date was 2/7/ . b. [MEDICATION(S)] (used to treat the symptoms of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] disorder and irritability) 2 mg tablet. Give one tablet by mouth (BID) for [CONDITION(S)] manifested by delusions (misconceptions or beliefs that are firmly held, contrary to reality.) The order start date was 2/7/2020. A review of Resident 2's Care Plan for Elopement/Wandering Risk developed on 2/7/2020, indicated Resident 2 was not at risk for elopement but had the status or condition that is a risk factor (no risk factors/condition indicated) for elopement or wandering. The care plan indicated to implement Elopement/Wandering interventions that included but not limited to the following: -Allowing resident to move around hallways safely. -Provide a sense of security. -Apply Wander guard bracelet. -Check with exit door alarms if functioning. -Provide frequent visual checks at least every 30 minutes if noted with wandering episodes. The same care plan (Elopement/Wandering Risk) had another handwritten date of 2/25/2021 that indicated Resident 2 eloped from the facility and a notification to Glendale Police Department (PD), California Department of Public Health (CDPH) and ombudsman was conducted. The care plan indicated Resident 2 was found at the General Acute Care Hospital (GACH) emergency room (ER). The care plan did not indicate changes made to the interventions for prevention of resident wandering or eloping out of the facility, from the previous care plan developed on 2/7/2020. During a concurrent interview and record review with the DON on 7/22/21 at 1:21 PM, the DON confirmed that Resident 2 did not have wander guard since Resident 2 eloped on 2/25/21 and the resident was discharged from the facility on the same day, when the police department (PD) found the resident at the GACH. The DON stated Resident 2 should have worn the wander guard as indicated in the care plan. During a concurrent interview and record review with Quality Assurance (QA) nurse on 7/22/21 at 1:23 PM, QA stated Resident 2 was readmitted to the facility on [DATE] and elopement risk assessment was done the same day. Resident 2's elopement risk assessment dated [DATE] indicated Resident 2 was at risk for elopement. During a concurrent interview and record review with the QA nurse, on 7/22/21 at 4:12 PM, the QA nurse stated Resident 2's Elopement and Wandering Care Plan dated 2/7/2020 indicated to apply wander guard bracelet. The QA nurse stated she could not find documented evidence that Resident 2's care plan intervention to apply wander guard was implemented prior to Resident 2's elopement on 2/25/2020. On 8/2/2021, at 1:05 PM, during a concurrent interview and record review of Resident 2's Care Plan for Elopement/Wandering Risk dated 2/7/2020 and revised on 2/25/2021, the QA nurse stated the care plan did not indicate the status/condition that posed as a risk factor for Resident 2's elopement or wandering. The QA nurse stated Resident 2's specific status or condition mentioned in the care plan should have been indicated to identify Resident 1's risk for elopement. The QA nurse stated the Care Plan should indicate a check mark or circle the corresponding specific interventions that applies to Resident 2, as indicated in the pre-made care plan. The QA nurse stated the care plan did not indicate new and revised interventions on 2/25/2021, to prevent further elopements from Resident 2. The QA nurse stated she did not know why the care plan interventions were not updated. A review of Resident 2's Elopement Risk Assessments for the Year 2020 indicated the following information: a. On 2/7/2020, the assessment indicated Resident 2 was an elopement risk. b. On 2/25/2020, the assessment indicated Resident 2 was an elopement risk. c. On 4/6/2020, the assessment indicated Resident 2 was an elopement risk. d. On 7/6/2020, the assessment indicated Resident 2 was not an elopement risk. e. On 9/14/2020, the assessment indicated Resident 2 was not an elopement risk. f. On 12/8/2020, the assessment indicated Resident 2 was not an elopement risk. g. On 12/10/2020, the assessment indicated Resident 2 was not an elopement risk. A review of Resident 2's SBAR Communication Form dated 2/25/2021 at 4:04 PM indicated Resident 2 was unaccounted for, during lunch time and Resident 2 was not present in the facility. The SBAR indicated the facility searched nearby vicinities and called the Police Department (PD) for assistance to search for Resident 2. The SBAR indicated Resident 2 was later found at a General Acute Care Hospital (GACH) emergency room (ER) on the same day, 2/25/2021. A review of the facility's Final Report for Unusual Occurrence regarding Elopement dated 3/2/2021, indicated that at approximately 2:35 PM Resident 2 was found in the GACH ER and admitted to the GACH at approximately 11:30 AM. Resident 2 was brought in by Emergency Medical Transport (EMT) after a call from a non-facility bystander. The report indicated that according to the GACH records, Resident 2 was dehydrated. The report indicated that Resident 2 was later transferred to a locked facility on 2/27/2021. 3. A review of Resident 3's Face Sheet indicated a readmission to the facility on [DATE] with diagnoses that included diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired), [CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and paranoid [CONDITION(S)]. A review of Resident 3's H and P dated 5/13/2021, indicated resident was assessed having the capacity to understand and make decisions. A review of the facility's elopement assessments conducted for Resident 3, for the Year 2021, indicated the following information: a. On 3/2/2021, the Elopement Risk Assessment form printed in the resident's chart indicated Resident 3 was not at risk for elopement. b. On 3/23/2021, the Elopement Risk Assessment form printed in the resident's chart indicated Resident 3 was at risk for elopement. c. On 5/5/2021, a review of another form of elopement risk assessment titled Elopement Risk Tool found in the facility's new electronic medical record system indicated Resident 3 was at risk for elopement. d. On 6/3/2021, the Elopement Risk Assessment form printed in the resident's chart indicated Resident 3 was not at risk for elopement. e. On 6/28/2021, a review of the Elopement Risk Tool found in the facility's new electronic medical record system indicated that on 6/27/2021 (no time indicated), Resident 3 left the facility without informing staff. The tool indicated Resident 3 presented with the following conditions: -Verbalized wishing to go home. -Packed their belongings. -Remained in close proximity to an exit door. -Displayed exit seeking behaviors. A review of the facility's Final Report for the Elopement of Resident 3 authored by the Administrator (ADM), dated 7/2/2021, indicated at approximately 10:30 PM on 6/27/2021, Resident 3 eloped from the facility. The report indicated Resident 3 was brought back to the facility by the PD on 6/28/2021 at 1:50 AM. The Report indicated that Resident 3 was transferred to the GACH for psychiatric evaluation on 6/28/2021 at 11:50 PM secondary to elopement and increased agitation. A review of Resident 3's Care Plan for elopement dated 3/3/21, Resident 3 was at risk for injuries secondary to elopement and revised on 3/23/21 indicated Resident 3 was walking around the facility packing belongings [sic]. The care plan interventions included: a. Assist in reorientation to room/ facility b. Inform of risk and consequences of leaving the facility. c. Monitor resident location with visual checks every two hours. d. Monitor behavior and mood pattern every shift. e. Notify Medical Doctor (MD) any changes noted. f. Camera surveillance g. Security guard h. Wander guard bracelet j. Every four hours head count k. Residents photographs at the reception, charts, and nurses' station. A review of Resident 3's Care Plan for Elopement dated 5/6/2021 and revised on 6/28/2021, indicated the resident was at risk for injuries secondary to elopement. The interventions included the following interventions: a. To monitor behavior and mood patterns every shift. b. Keep a hazard free environment. c. Notify MD any significant changes noted. d. Encourage activities of resident choices and preference. e. Resident 3 refused to wear a wander guard A review of Resident 3's Care Plan for Noncompliance developed on 5/14/2021 and revised on 6/28/2021 indicated Resident 3 refused wander guard. The Care Plan indicated the following approaches: a. Provide non-threatening and nonjudgmental environment, b. Avoid threats or arguing when giving care or dealing with noncompliance behaviors. c. Do not force resident to comply against their wishes. d. Change approach and record what approach is successful e. Report non-compliant behavior to MD and Responsible Party (RP). f. Encouraged resident to express feeling of anger, guilt, and frustration. g. Inform of risk and consequence of choices. h. Honor resident's refusal to blood sugar check. During an interview on 7/22/2021 at 1:20 PM, the DON stated Resident 3 was at risk for elopement based on the 5/5/2021 Elopement Risk Assessment. The DON stated when a resident of the facility is determined to be at risk for elopement, the facility staff must continue the resident monitoring. The DON stated Resident 3 had exit seeking behaviors and frequently attempted to go out of the facility. The DON stated a wander guard bracelet was ordered for Resident 3 on 6/28/2021, after the elopement incident, but Resident 3 refused to wear the wander guard bracelet. The DON could not find documented evidence what interventions were implemented when Resident 3 refused to wear the wander guard bracelet. During a concurrent interview and record review with the QA nurse on 7/22/21 at 1:23 PM, the QA nurse stated Resident 3 was readmitted to the facility on [DATE] and was discharged on [DATE]. Elopement risk assessment was completed on 5/5/21 and Resident 3 was assessed at risk for elopement. The QA nurse stated the licensed nurses did not have consistent and accurate assessments documented for the elopement risk assessments conducted for Resident 3 from 3/2021 to 6/2021. During a telephone interview and concurrent record review of Resident 3's Elopement/Wandering Risk Care Plan on 8/2/2021 at 2:09 PM, the QA nurse stated that Resident 3 had more than one episode of carrying her belongings in a clear plastic bag and walking around the facility with her belongings. The QA nurse stated Resident 3's care plans for 5/14/21 and 6/28/2021, did not indicate new interventions for Resident 3's new behavior exhibited. The QA nurse stated that Resident 3 refused to wear a wander guard bracelet. The QA nurse stated she could not find revised interventions implemented when Resident 3 refused to wear a wander guard. The QA nurse stated Resident 3's care plan did not indicate person-centered interventions to monitor and prevent Resident 3 from eloping from the facility. The QA nurse stated Resident 3 eloped on 6/27/2021. A review of Resident 3's MDS dated [DATE] indicated Resident 3 had moderately impaired cognition. Resident 3 required supervision with set up only for bed mobility, transfers, locomotion, eating, and personal hygiene. Resident 3 required limited assistance with one-person physical assist for dressing and toilet use. A review of Resident 3's MAR for June 2021 indicated the following information: a. [MEDICATION(S)] 5 mg one tablet BID for [CONDITION(S)] manifested by paranoia as evidence by thinking that she will be harm. The medication administration was at 9 AM and 5 PM. The medication start date was 5/5/2021. b. [MEDICATION(S)] (used to treat symptoms of Parkinsonism -condition that causes a combination of the movement abnormalities seen in [CONDITION(S)] disease - such as tremor, slow movement, impaired speech or muscle stiffness) 1 mg one tablet by mouth BID for extrapyramidal symptoms (EPS: drug-induced movement disorders). The medication start date was 5/13/2021. c. [MEDICATION(S)] (treat epileptic seizures) 600 mg one tablet by mouth every evening for mood stabilizer for [CONDITION(S)] disorder manifested by manic episodes. The administration time was 5 PM. The medication start date was 5/5/2021. d. [MEDICATION(S)] 300 mg one tablet by mouth twice a day, at 8 AM and 1 PM as mood stabilizer for [CONDITION(S)] disorder manifested by manic episodes. The medication start date was 5/5/2021. e. [MEDICATION(S)] 10 mg one tablet by mouth before sleeping for [CONDITION(S)] manifested by paranoia as evidence by thinking that she will be harm. The medication order start date was 5/5/2021. 4. A review of Resident 4's Face Sheet indicated an admission to the facility on [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)] disorder, and [CONDITION(S)] disorder (a mental disorder with symptoms can cause unpredictable changes in mood and behavior, resulting in significant distress and difficulty in life). During a review of Resident 4's Elopement Risk Tool found in the facility's new electronic record system dated 6/17/2021 at 5:55 PM, indicated Resident 4 was not at risk for elopement. A review of Resident 4's Care Plan developed for Elopement dated 6/17/2021, indicated the resident was at risk for injuries secondary to elopement that included the following interventions: a. To monitor resident location with visual checks at least every two hours. b. Secured doors. c. Frequent visual checks. d. Camera surveillance. e. Security guard. f. Every four hours head count. g. Resident photographs at Reception area, resident charts and Nurses' Station. A review of Resident 4's H and P dated 6/20/2021 indicated the resident was assessed having the capacity to understand and make decisions. A review of Resident 4's MDS dated [DATE] indicated Resident 4 had moderately impaired cognition. Resident 4 required limited assistance with one-person physical assist was required for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. Resident 4 required supervision with set up only for eating. During a concurrent interview and record review with the QA nurse, on 7/22/21 at 4:30 PM, the QA nurse stated Resident 4's Elopement Care Plan dated 6/17/202 indicated to implement interventions due to risk for elopement but the assessment did not indicate Resident 4 was at risk for elopement. The QA nurse stated she could not find documented evidence that Resident 4 could be at risk for elopement. The QA nurse stated the assessment should be aligned with a resident's care plan interventions. During a concurrent observation and interview with Receptionist (RCP) 1 on 7/13/21 at 11:01 AM, RCP 1 stated someone should always be sitting in the facility's front door by the lobby receptionist desk to closely watch the video camera monitor and monitor the front door. RCP 1 stated there is one receptionist assigned every eight-hours for 24 hours. RCP 1 showed the video camera on top of the desk where he could monitor the facility's hallway, side gates, and parking lot. RCP 1 stated Restorative Nursing Assistant (RNA) 1 usually take over during his 30-minute break. RCP 1 stated that today, 7/13/21, no one took over for his breaktime because no one was available. On 7/22/2021 at 10:53 AM, during a concurrent observation and interview, in the presence of the Maintenance Supervisor and Director of Nurses (DON), the facility's double doors located in the front lobby of the facility by the Receptionist Area, was not latching and closing automatically, after opening. During the same observation, the wander guard alarm system (a wander management solution for patient and resident safety to protect those at risk of elopement) attached to the facility's front door was tested , in the presence of the MS and DON, using two different wander guard bracelets. The wander guard system attached to the front door did not consistently trigger the alarm with each passage of the wander guard bracelet through the facility's front doors. Five attempts were conducted to go in and out of the facility's front door were conducted with the MS, with more than two attempts unsuccessfully triggering the wander guard alarm system. The MS stated the inconsistency in the alarm being triggered was due to the front double doors not completely latching closed. The MS stated that on 7/20/2021 (two days ago) he noticed the double doors does not automatically latch closed upon opening. The MS stated he had called the company of the wander guard system two days ago and stated they would come soon. The MS was unable to state when the company of the wander guard system would arrive. During a concurrent observation and interview with the Central Supply Staff (CS) on 7/22/21 at 10:56 AM, the wander guard system by the front door of the facility triggered an alarm when the surveyor wearing a wander guard entered the front lobby door coming from outside (coming back in) not vice versa. The CS stated MS needs to adjust the wander guard system antenna since the system had not been used for a long time. The CS stated currently there are no residents currently using a wander guard in the facility. During a concurrent interview and record review of the MS Logbook Documentation on 7/22/2021 at 10:57 AM, the Logbook indicated, 'Doors, Locks and Alarms: Test operation and doors. The Logbook indicated that a Resident Monitoring System was only present in the lobby (front double doors). The Logbook indicated the door alarms for the following loc

Based on observation, interview, and record review, the facility failed to limit charges on the personal funds of four of five sampled residents (Residents 1, 2, 4, and 5) by failing to: 1. Assess the personal needs of Residents 1, 2, 4, and 5 and determine the reasonable costs of items purchased in excessive amounts, prior to the facility staff purchasing items using the residents' funds without residents' or responsibility party consent to purchase such items. 2. Ensure Residents 1, 2, 4, and 5, who were unable to independently make medical and financial decisions, were not charged a an excessive amount of money for items that the residents did not request or consent to purchasing, such as, numerous amounts of clothing items, personal hygiene items, such as hair shampoo, conditioner, brush, deodorant, a twin bed sheet set, television, DVD player, and luggage. 3. Inform Residents 1, 2, 4, and 5 and/or their responsible party orally and in writing prior to purchasing items not requested by the residents, so the responsible parties could decide and consent to such purchases on behalf of the residents. 4. Involve a resident advocate in the decision-making process for Resident 5, who did not have a responsible party or family, prior to the facility staff purchasing items using the residents' personal funds. 5. Ensure Residents 1, 2, 4, and 5' personal funds used by the facility to purchase items were related to the necessary care for the residents. 6. Ensure Residents 1 and 5 were not charged for routine personal hygiene items covered under Medicaid or Medicare such as shampoo, conditioner, lotion, bodywash. 7. Ensure the responsible party of Resident 1, who did not have the capacity to make financial decisions, was notified orally and in writing, of the resident's intent to purchase a funeral insurance in the amount of $4,195 prior to its purchase. These deficient practices violated the residents' rights related to the misuse of residents' personal funds by the facility due to the absence of any requests and consents of the residents and/or the responsible parties and may result to psychosocial harm. On 7/24/21 at 12:34 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator and Director of Nursing (DON) regarding the facility's misappropriation of residents' property related to inappropriate spending on Residents 1, 2, 4 and 5's accounts and placing other residents (33 residents who were unable to make medical and financial decisions, 17 residents who had trust accounts with the facility, and four residents under the facility as representative payee) at risk for misappropriation of property. On 7/26/21 at 5:09 p.m., the IJ was lifted after the Administrator and the Vice President of Operations (VPO) submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the initial implementation of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the Administrator and VPO. The acceptable POA included the following: 1. The Trust Account Oversight Committee (TAOC), consisting of the Administrator, Business Office Manager (BOM), Social Services Director (SSD), Director of Nursing (DON), Director of Staff Development (DSD), and Accounts Receivable Consultant (ARC), was set up to ensure items and services to be purchased were essential and needed by the residents to achieve resident goals per care plan, not expensive, and would be reasonably priced. 2. The Social Services Department would collaborate with the Interdisciplinary Team (IDT) in completing the Personal Needs Care Plan of the residents. 3. The TAOC would involve the residents, responsible parties, and next of kin relatives) with regards to purchases/withdrawals from the residents' personal funds. 4. The TAOC would approve purchases first prior to the withdrawal from the residents' personal funds. 5. The TAOC would seek approval from the Bioethics Committee for residents without a decision-making capacity, responsible party, or next of kin prior to purchases against the residents' personal funds. The facility would include the Office of the Long-Term Care Ombudsman and/or representative of the California Association of Area Agencies on Aging as a member of the Bioethics Committee. 6. The TAOC would ensure no purchases would be made for items or services covered under Medicaid or Medicare. Cross Reference F571, F602, F568, F582, F584 Findings: 1. A review of Resident 1's Face Sheet indicated the facility initially admitted the resident on 9/20/19 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .). The Face Sheet indicated the responsible party was Responsible Party (RP) 1 and the third contact was Family Member (FM) 1. The Face Sheet indicated Resident 1 was discharged from the facility on 4/13/21. A review of Resident 1's Admission Nursing Assessment, dated 9/20/19, indicated the resident had existing short-term and long-term memory problems. A review of the Psychiatric Admission Note at General Acute Care Hospital (GACH) 1, dated 12/9/19, indicated Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Note indicated Resident 1 was oriented to self only, with impaired insight (deep understanding of a person or thing), judgment, and memory. A review of Resident 1's Resident Statement Landscape (financial statement itemizing posted transactions in the trust account) indicated the following: a. On 7/29/20, an amount of $1,865.48 was debited (deducted from the trust account as payment for services or goods) for Personal Needs Items and paid to Vendor 1. b. On 9/1/20, an amount of $1,285.27 was debited for Personal Needs Items and paid to Vendor 1. c. On 2/11/21, a withdrawal amount of $4,195 for Transfer to Burial with no payee. A review of Resident 1's Invoice amounting to $1,865.48, dated 7/24/20, indicated the purchase of the following: Cardigan sweater - 3 totaling in the amount of $135.00 Printed knit tops - 5 totaling in the amount of $120.00 Roll-tab sleeve blouses - 3 totaling in the amount of $105 Elastic waist denim pants - 3 totaling in the amount of $135 Fleece pants - 3 totaling in the amount of $84.00 Knit pants - 4 totaling in the amount of $104.00 Sport bras - 3 totaling in the amount of $36.00 White anklet socks - 4 totaling in the amount of $12.00 Colored anklets - 4 totaling in the amount of $20.00 Cotton briefs 10 - totaling in the amount of $55.00 Knit gowns - 3 totaling in the amount of $108.00 Ortho-lite leather Velcro shoes - 1 totaling in the amount of $65.00 Bootie slippers plush - 1 totaling in the amount of $45.00 AM/FM radio - 1 totaling in the amount of $65.00 Headphones - 1 totaling in the amount of $45.00 Twin bed set - 1 totaling in the amount of $125.00 Twin blanket - 1 totaling in the amount of $55.00 Zippered tote - 1 totaling in the amount of $85.00 Walker bag - 1 totaling in the amount of $35.00 Coloring books with supplies - 2 totaling in the amount of $50.00 Toiletry caddy - 1 totaling in the amount of $25.00 Scrunchies set of 4 - 2 totaling in the amount of $10.00 Brush - 1 totaling in the amount of $8.00 Body wash - 2 totaling in the amount of $12.00 Shampoo/conditioner - 2 totaling in the amount of $12.00 Lotion - 2 totaling in the amount of $36.00 Ladies deodorant - 1 totaling in the amount of $4.25 A review of Resident 1's Invoice amounting to $1,285.27, dated 8/31/20, indicated the purchase of the following items: Leather Velcro shoes - 1 totaling in the amount of $65.00 Mesh slip-on shoes - 1 totaling in the amount of $65.00 32-inch TV - 1 totaling in the amount of $299.00 Full motion wall mount - 1 totaling in the amount of $75.00 TV antenna - 1 totaling in the amount of $50.00 DVD player - 1 totaling in the amount of $59.00 Old Spanish movies - 5 totaling in the amount of $90.00 Luggage set - 1 totaling in the amount of $300.00 Coloring set - 1 totaling in the amount of $50 Shampoo/conditioner - 2 totaling in the amount of $12.00 Body wash - 2 totaling in the amount of $12.00 Ladies deodorant - 2 totaling in the amount of $8.50 Lotion - 2 totaling in the amount of $14.00 Body mist - 2 totaling in the amount of $30.00 A review of the Interdisciplinary Team Conference Record dated 10/26/20 indicated Resident 1 was alert but did not have the capacity to make own decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized screening and care-planning tool), dated 1/19/21, indicated the resident had moderate impairment in cognition (cognition (mental action or process of acquiring knowledge and understanding). A further review of Resident 1's clinical record indicated Memorial Guide documents, dated 1/28/21, for the purchase of a funeral policy detailing funeral prearrangements signed by Resident 1. The resident was charged in the amount of $4,195 by a third-party funeral insurance company for the policy. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Social Services Note, dated 4/15/21, indicated RP 1 spoke with SSD and was very upset because Resident 1 purchased this mortuary plan on 1/28/21. The Note indicated RP 1 wanted to cancel or null and void the contract. The Note indicated Resident 1 stated at the time of mortuary plan purchase, Anyway, it's a [sic] government funds, I want to purchased [sic] a mortuary plan for my untimely death which we have to face in reality. I don't want my daughters to have a headache once it happens. During an interview on 6/25/21 at 11:54 a.m., Registered Nurse (RN 1) stated Resident 1 was alert and oriented to self and/or time, depending on the days, but the resident was Very forgetful with periods of confusion. During an interview on 6/15/21 at 12:41 p.m., the Social Services Director (SSD) stated the Business Office would notify Social Services Department when a resident must, Spend down to maintain Medi-Cal eligibility and how much to Spend down. The SSD stated they would order clothes for the residents most of the time, or the facility would purchase a television or radio from Vendor 1, depending on the resident's wishes or preferences. The SSD stated they would assist with a purchase of a funeral policy insurance if the resident needed to, Spend down a large amount of monies. The SSD stated when he assisted Resident 1 in obtaining a funeral policy in January 2021, SSD thought Resident 1 did not have dementia and had fluctuating capacity to make decisions. The SSD stated RP 1 was upset after finding out Resident 1 purchased the funeral policy and stated that Resident 1 was confused and had dementia. The SSD stated he apologized for his mistake and offered to assist with the funeral policy cancellation. During a telephone interview on 6/25/21 at 1:10 p.m., the SSD stated he did not contact the RP 1 because the facility's Social Service Department would coordinate with the Nursing Department to determine the Resident 1's needs. The SSD stated RP 1 was not contacted or authorized to the purchases made from Vendor 1 and the funeral policy. During a telephone interview on 7/14/21 at 11:35 a.m., Family Member (FM) 1 stated the facility did not contact her regarding making any withdrawals from the Resident 1's trust account (personal funds). FM 1 stated during Resident 1's discharge from the facility, she was asked by Staff 1 where to address the check with the trust account remaining balance. FM 1 stated when she requested a copy of the trust account statements and questioned the remaining balance being less than expected, Staff 1 refused to give her a copy of the statements but told her Resident 1 purchased a, Burial plot (funeral policy insurance). FM 1 stated she was upset because Staff 1 told her RP 1 authorized the funeral policy purchase. FM 1 stated RP 1 also knew that Resident 1 wanted to be cremated and would not make any financial decisions or sign any documents without consulting RP 1 and FM 1. FM 1 stated when she asked Resident 1 if she had signed any paperwork, Resident 1 did not have any recollection of a funeral policy she had signed. FM 1 stated, Resident 1, Had always asked us [Resident 1's family members] what's the best thing she needed to do. Resident 1 always sought out family's opinion on something as if resident wanted us to make the decision for her. In addition, FM 1 stated the facility did not contact her regarding the resident's needs, including any lack of clothing items, despite the family being involved with Resident 1's care. FM 1 stated upon Resident 1's discharge from the facility, the resident came home with a lot of brand-new items she did not need. These items included a TV, TV wall mount, DVD player, 4-5 DVDs, coloring books, markers, luggage set, and clothes labeled with other residents' names. During a telephone interview on 7/14/21 at 12:27 p.m., RP 1 stated she did not recall signing any documents authorizing the facility to make all financial decisions on behalf of Resident 1. RP 1 stated the facility staff did not contact her for any withdrawals from Resident 1's trust account and prior to Resident 1's funeral policy purchase. During a telephone interview on 7/14/2021 at 2:04 p.m., the Administrator stated the SSD mistakenly assisted Resident 1, who was cognitively impaired, to purchase a funeral policy without consulting the responsible party and/or family members. The Administrator stated the staff had mistakenly acted and assumed the role as the Representative Payee (person or organization appointed by Social Security to receive Social Security income for anyone unable to direct the management of benefits, whose main duties included paying for the future and current needs of the beneficiary) when the facility purchased items from an outside vendor (Vendor 1) on behalf of Resident 1 without consulting RP 1 or FM 1. During a concurrent review of Resident 1's records, the Administrator stated, although RP 1 verbally consented to have Resident 1's social security income be directly transferred to Resident 1's trust account, there was no documented evidence that RP 1 authorized in writing to have the facility manage and be in full control of Resident 1's personal funds. During a telephone interview on 7/19/21 at 1:53 p.m., the Business Office Manager (BOM 1) stated routine personal hygiene items, such as, toothbrush, toothpaste, shampoo, comb, conditioner, deodorant, body wash, body mist, and lotion, must not be charged to the residents' trust account. BOM 1 stated purchases from Vendor 1 could be utilized for non-covered items like clothing items and funeral policy. BOM 1 stated prior to any withdrawal from the account, the resident, RP (in general), or a witness must sign a withdrawal slip to authorize a purchase. During a concurrent review of Resident 1's financial records, BOM 1 stated there was no documented evidence FM 1 or RP 1 were notified of the debited transactions and stated the following: a. Withdrawal Record for $1,865.48 - signed by Assistant BOM (ABOM) 2 (previous ABOM of the facility) b. Withdrawal Record for $1,285.27 - signed by ABOM 2 c. Withdrawal Record for $4,195 - signed by BOM 2 (previous BOM of the facility) During a telephone interview on 7/20/21 at 4:02 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 did not communicate any requests for new clothes, television, radio, or coloring books. CNA 1 stated the facility provides shampoo, conditioner, body lotion, and deodorant for the residents. CNA 1 stated Resident 1's family members would bring Resident 1 clothes and Resident 1 would get donated clothes from the facility. CNA 1 stated if a resident wanted a specific brand or product not provided by the facility, then the facility would purchase, or family would bring it. During a concurrent interview and review of Resident 1's letter from Social Security Administration, on 7/26/21 at 1:25 p.m., the Accounts Receivable Consultant (ARC) stated the facility was not the Representative Payee for Resident 1. Resident 1's letter from the Social Security Administration, dated 7/2/21, indicated Social Security Administration designated FM 1 to be Resident 1's Representative Payee. 2. A review of Resident 2's Face Sheet indicated the facility initially admitted the resident on 12/22/17 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated FM 2 as Resident 2's second contact and RP 2 as Resident 2's third contact. A review of Resident 2's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Minimum Data Set, dated dated [DATE], indicated the resident had severely impaired cognitive skills (core skills the brain uses to think, read, learn, remember, reason, and pay attention) for daily decision-making. A review of the Resident Statement Landscape indicated an amount of $499.79 debited from Resident 2's trust account on 5/13/21 and paid to Vendor 1. A review of Resident 2's Invoice amounting to $499.79, dated 5/11/21, indicated the purchase of the following items: Short-sleeved T-shirts - 5 totaling in the amount of $65.00 Long-sleeved shirts - 5 totaling in the amount of $75.00 Fleece pants - 6 totaling in the amount of $114.00 Pajama pants - 3 totaling in the amount of $102.00 Crew socks - 10 pairs totaling in the amount of $30.00 Blanket - 1 totaling in the amount of $34.00 Fleece blanket 50 x 60 - 1 totaling in the amount of $17.00 During a telephone interview and a concurrent review of Resident 2's financial records on 7/19/21 at 1:53 p.m., BOM 1 stated the Withdrawal Record amounting to $499.79 was signed by ABOM 1 (current ABOM of the facility). During a telephone interview on 7/23/21 at 10:06 a.m., RP 2 stated he was Resident 2's responsible party. RP 2 stated he was not informed of any withdrawals made from Resident 2's trust account, except for the funeral policy that he agreed to purchase for Resident 2. RP 2 stated he did not authorize the withdrawal for $499.79 for the resident's clothing and other miscellaneous items. During a telephone interview on 7/23/21 at 10:41 a.m., FM 2 stated RP 2 was Resident 2's responsible party and she was only contacted by the facility staff when they were unable to contact RP 2. FM 2 stated she had not received any quarterly statements from the facility and had not been notified of any withdrawals made from Resident 2's trust account. During an observation and interview on 7/24/21 at 9:26 a.m., Resident 2 was observed lying in bed. Upon interview, the resident was alert to person only. With Resident 2's consent, during an interview and concurrent observation of Resident 2's bedside cabinet, CNA 3 stated Resident 2 had eight (8) pairs of new socks, dark blue fleece blanket, two (2) pants, three (3) T- shirts, and four (4) long sleeved shirts. CNA 3 stated some staff take out clothes from Resident 2's cabinet for other residents' use without paying attention to the label on the clothes pertaining to whom they belong to. During another observation and interview on 7/25/21 at 11:56 a.m., inside Resident 2's room. Resident 2 was observed lying in bed. Resident 2 was able to state his first and last name and able to answer basic questions. Resident 2 was unable to state his location, situation, and the date. During an interview on 7/25/21 at 12:03 p.m., Licensed Vocational Nurse (LVN) 3 stated Resident 2 was able to engage in basic conversations with staff to address his basic needs. LVN 3 stated she did not know if RP 2 or FM 2 were consulted for Resident 2's personal needs as she would have entrusted to the SSD to contact the responsible party for any purchases. During an interview on 7/26/21 at 1:25 p.m., the ARC stated the facility was the Representative Payee for Resident 2. However, during a concurrent review of Resident 2's records, the ARC stated there was no documented evidence that Resident 2, RP 2, or FM 2 authorized in writing to have the facility manage and be in full control of Resident 1's personal funds. 3. A review of Resident 4's Face Sheet indicated the resident was initially admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated Resident 4's responsible party was RP 4. A review of Resident 4's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for decision-making. A review of Resident 4's Resident Statement Landscape indicated an amount of $1,969.72 was debited on 4/28/21 for Personal Needs Items and paid to Vendor 1. A review of Resident 4's Sales Order amounting to $1,969.72, dated 4/22/21, indicated the purchase of the following: Twin bed set - 1 totaling in the amount of $120.00 Fleece blanket 50x60 - wheelchair - 1 totaling in the amount of $35.00 Woven blanket throw - 1 totaling in the amount of $49.00 Luggage (suitcase) - 1 totaling in the amount of $300.00 Fleece jackets - 2 totaling in the amount of $130.00 Cardigan sweaters - 2 totaling in the amount of $100.00 Short-sleeved printed knit tops - 5 totaling in the amount $120.00 ¾ sleeved printed knit tops - 5 totaling in the amount of $125.00 Fleece pants - 5 totaling in the amount of $120.00 Knit pants - 5 totaling in the amount of $130.00 Knit pajamas - 5 totaling in the amount of $180.00 Knit gowns - 6 totaling in the amount of $156.00 Cotton briefs - 7 totaling in the amount of $38.50 Sports bras - 3 totaling in the amount of $36.00 Non-skid socks - 5 totaling in the amount of $70.00 During a concurrent observation and interview with CNA 2 on 7/24/21 at 8:49 a.m., inside Resident 4's room. Resident 4 was observed lying in bed, unable to make eye contact and to communicate when spoken to. Resident 4's bed was observed with bed sheets that were supplied by the facility. In the presence of CNA 2, there were no luggage observed inside Resident 4's room. Inside Resident 4's bedside cabinet were two (2) blankets, 12 clothing items in hangers. During a concurrent interview, CNA 2 stated Resident 4 always used the bed sheets supplied by the facility. During an interview, on 7/24/21 at 11 a.m., the SSD stated there were no other belongings for Resident 2 stored in the Social Services Storage Room, where all residents' excess personal belongings were stored. The SSD stated there was no documented evidence that Social Services Department coordinated with RP 4 regarding Resident 4's personal needs or obtained consent to make purchases on behalf of Resident 4's personal funds. The SSD stated the facility was the Representative Payee for Resident 4, so there was no need to inform RP 4 of purchases to the residents' personal funds. During a telephone interview on 7/24/21 at 11:15 a.m., RP 4 stated he was the responsible party for Resident 4. RP 4 stated he was not aware of the $1,969.72 charge against Resident 4's personal funds. RP 4 stated he was not asked by the facility staff of what personal needs items to purchase for Resident 4 using the residents' personal funds. During another interview and concurrent observation on 7/24/21 at 11:53 a.m., the SSD stated he did not know about the purchase of a $300-luggage for Resident 4 and there was no plan for Resident 4's discharge at any time. During a concurrent observation, the luggage with Resident 4's name indicated in the unopened and sealed box was found in the Social Services Storage Room. The SSD stated he did not know why Resident 4 would need a luggage at that time. During an interview on 7/26/21 at 1:25 p.m., the ARC stated the facility was not the Representative Payee for Resident 4 but had requested to be selected as the Representative Payee. The ARC stated the facility has not received a confirmation or denial response from Social Security Administration. The ARC stated there was no documented evidence that RP 4 authorized in writing to have the facility manage and be in full control of Resident 4's personal funds. 4. A review of Resident 5's Face Sheet indicated the resident was initially admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated Resident 5's responsible party was the Bioethics Committee (committee that is advisory in nature and available for consultation regarding such issues as end-of-life care, withdrawal of life support, and other healthcare dilemmas). A review of Resident 5's MDS, dated [DATE], indicated the resident had severe impairment in cognition. A review of Resident 5's MDS, dated [DATE], indicated the resident indicated the resident had severely impaired cognitive skills for daily decision-making and had short-term and long-term memory problems. A review of Resident 5's Resident Statement Landscape, indicated the following: a. On 7/8/20, an amount of $1,005.36 was debited for Personal Needs Items and paid to Vendor 1. b. On 4/15/21, an amount of $898.69 was debited for Personal Needs Items and paid to Vendor 1. A review of Resident 5's Invoice amounting to $1,005.36, dated 7/6/20, indicated the purchase of the following: Short-sleeved solid polo - 4 totaling in the amount of $80.00 Short-sleeved basic T-shirts - 4 totaling in the amount of $48.00 Jersey shorts - 4 totaling in the amount of $54.00 Fleece pants - 5 totaling in the amount of $95.00 Fleece crew tops - 3 totaling in the amount of $54.00 Knit PJ pants - 2 totaling in the amount of $50.00 Crew T-shirts - 3 totaling in the amount of $16.50 Fleece jacket - 1 totaling in the amount of $35.00 Fleece hoodie - 1 totaling in the amount of $36.00 Knit beanie - 1 totaling in the amount of $12.00 Leather Velcro tennis shoes - 1 totaling in the amount of $80.00 Low Strap - Leather Waterproof shoes - 1 totaling in the amount of $110.00 Fleece slip-on slippers - 1 totaling in the amount of $38.00 Crew socks - 7 pairs totaling in the amount of $21.00 Wheelchair bag - 1 totaling in the amount of $35.00 Boombox - 1 totaling in the amount of $70.00 Music CD - Spanish - 2 totaling in the amount of $36.00 Body wash - 1 totaling in the amount of $6.00 Shampoo/conditioner - 1 totaling in the amount of $6.00 Men's deodorant - 1 totaling in the amount of $4.25 Lotion - 1 totaling in the amount of $7.00 A review of Resident 5's Invoice amounting to $898.69, dated 4/13/21, indicated the purchase of the following: Short-sleeved solid polo - 5 totaling in the amount of $120.00 Short-sleeved basic T-shirts - 5 totaling in the amount of $65.00 Jersey shorts - 4 totaling in the amount of $72.00 Knit pants - 4 totaling in the amount of $116.00 Fleece pants - 4 totaling in the amount of $76.00 Fleece crew tops - 3 totaling in the amount of $54.00 Crew T-shirts - 5 totaling in the amount of $27.50 Flannel pants - 5 totaling in the amount of $125 Fleece hoodie - 1 totaling in the amount of $36.00 Fleece jacket - 1 totaling in the amount of $38.00 Crew socks - 7 pairs totaling in the amount of $21.00 Body wash - 2 totaling in the amount of $12.00 Men's deodorant - 2 totaling in the amount of $8.50 Lotion - 2 totaling in the amount of $14.00 Shampoo/conditioner - 2 totaling in the amount of $12.00 During an observation on 7/24/21 at 9:10 a.m., Resident 5 was observed sitting on the wheelchair outside of his room. Upon interview, Resident 5 was unable to state where his belongings were kept. Resident 5 was wearing a blue sweater, red shirt, blue pants, socks, and shoes. During a concurrent interview and observation of Resident 5's room with CNA 3, there were no clothes observed, except for a big bottle of shampoo and a pair of socks on the bedside table; one (1) pair of socks, one (1) blanket, and worn out (with minor tears and did not looked new) shoes inside Resident 5's closet. CNA 3 left the room and went to the Personal Belongings Storage Room. Upon CNA 3's return to the resident's room, CNA 3 brought an unopened bag containing Resident 5's unused clothes, labeled with Resident 5's name purchased through Vendor 1 (clothing labels indicated Vendor 1). CNA 3 stated she kept Resident 5's clothes in the Personal Belongings Storage Room to prevent other staff from getting them for other residents' use. CNA 3 stated Resident 5 was wearing new shoes, CNA 3 had bought with her own money as a birthday present. During an interview and concurrent observation with the SSD, on 7/24/21 at 10:40 a.m., Resident 5's boombox (a device typically capable of receiving radio stations and playing recorded music) was observed in an unopened and sealed box in the Social Services Storage Room. The SSD stated for residents under the Bioethics Committee as the RP, the residents' needs were determined by asking the assigned CNAs of the residents' personal needs and by inspecting the residents' room and closet by the SSD and the Social Services Assistant (SSA). During a telephone interview, on 7/24/21 at 10:51 a.m., the Administrator was asked who the members of the facility's Bioethics Committee were. The Administrator stated the members comprised of the facility's medical director, administrator, DON, and social worker. The Administrator stated he was not sure who the other members of the facility's Bioethics Committee and would need to check. During a telephone interview and a concurrent review of the facility's policy on Bioethics Committee (undated) on 7/24/21 at 10:59 a.m., the DON stated only facility interdisciplinary team (IDT) members were included in the Bioethics Committee. During an interview on 7/25/21 at 12:15 p.m., the Administrator stated the facility did not develop a care plan to identify and address the personal needs needed to achieve the resident-specific goals of Residents 1, 2, 4, & 5 prior to purchasing items and services using the residents' personal funds. The Administrator stated the facility would now create the care plan template for the personal needs of the residents. A review of the facility's policy and procedures, titled Management of Residents' Personal Funds, dated 4/2017, indicated should the resident elect to have the facility manage his or her personal funds, it must be authorized in writing by the resid

Based on observation, interview, and record review, the facility failed to ensure four of five sampled residents (Residents 1, 2, 4, and 5) were free from misappropriation of property (deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's or the resident representative's consent and regardless of their apparent value to others) by failing to: 1. Protect personal funds for Residents 1, 2, 4, and 5, who were unable to independently make medical and financial decisions, by using the residents' money to purchase items not being used by the residents such as blankets, bed sheets, luggage, television, DVD player, radio, etc., The newly purchased personal items purchased by the facility was not reflected in Residents 1, 2, 4 and 5's current Inventory Lists. 2. Prevent facility staff from purchasing a funeral insurance policy without informing responsible party (RP 1) of Resident 1. Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1, who did not have the capacity to make financial decisions, agreed to purchase a funeral insurance policy offered by the facility staff amounting to $4,195. 3. Protect the residents' personal funds by charging Residents 1, 2, 4, and 5 an excessive amount of monies for items not requested by the residents or their responsible parties, such as numerous clothing items and accessories that were unused and stored in a separate storage room in the facility. 4. Protect resident's personal funds by charging Residents 1 and 5 for Medicaid/Medicare-covered items, such as routine personal hygiene items such as hair shampoo, conditioner, lotion, body wash/soap, deodorant, brush, already provided by the facility. 5. Ensure Residents 1, 2, 4, and 5' personal funds used by the facility to purchase items were related to the necessary care and would address the needs of the residents. These deficient practices had the potential to result in the residents' (31 residents who were unable to make medical and financial decisions, 17 residents who had trust accounts with the facility, and four residents under the facility as representative payee) failure to exercise their rights to be free from financial abuse, theft, loss of property, and further misuse of personal funds and may result to the residents' psychosocial harm. On 7/24/21 at 12:34 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause psychosocial harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator and Director of Nursing (DON) regarding the facility's misappropriation of residents' property related to the inappropriate spending on residents' funds and placing current residents who were unable to make medical and financial decisions, had trust accounts in the facility, and residents who had the facility as representative payee, at risk for misappropriation of property. On 7/26/21 at 5:09 p.m., the IJ was lifted after the Administrator and the Vice President of Operations (VPO) submitted an acceptable Plan of Action (POA, immediate interventions to correct the deficient practices). The surveyor verified and confirmed the initial implementation of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the Administrator and VPO. The acceptable POA included the following: 1. The Trust Account Oversight Committee (TAOC), consisting of the Administrator, Business Office Manager (BOM), Social Services Director (SSD), Director of Nursing (DON), Director of Staff Development (DSD), and Accounts Receivable Consultant (ARC), was set up to ensure items and services to be purchased were essential and needed by the residents to achieve resident goals per care plan. The TAOC would review the residents' needs and costs of items prior to purchasing to avoid unnecessary and excessive costs. 2. On 7/25/21, the BOM and ARC started reviewing the charged items to the residents' trust accounts. By 7/30/21, the BOM and ARC would determine reimbursements to be made for items not part of the residents' care plans or items purchased without consent from the residents or the responsible party. The TAOC would ensure family members or next of kin would be informed of the results of audit by 7/30/21. 3. The TAOC would ensure that family members or next of kin would receive the quarterly statements with the BOM calling the family members/next of kin to validate receipt of statements and documenting in the residents' electronic medical records. 4. On 7/25/21, the Social Services Department started reviewing the inventory lists of the residents' belongings of those unable to make medical and financial decisions and identified missing items. By 7/30/21, the final report of audit would be submitted to the administrator in order to compensate the residents of any missing items, including those purchased using residents' personal funds. 5. On 7/25/21, the Administrator faxed an invitation to the Office of the Long-Term Care Ombudsman and representative of the California Association of Area Agencies on Aging to be a member of the Bioethics Committee for residents who do not have decision-making capacity and do not have a responsible party. Cross Reference to F571, F602, F568, F582, F584 Findings: 1. A review of Resident 1's Face Sheet indicated the facility initially admitted the resident on 9/20/19 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .). The Face Sheet indicated the responsible party was Responsible Party (RP) 1. A review of Resident 1's Admission Nursing Assessment, dated 9/20/19, indicated the resident had existing short-term and long-term memory problems. A review of the Psychiatric Admission Note at the General Acute Care Hospital (GACH) 1, dated 12/9/19, indicated Resident 1 had [CONDITION(S)] (severe mental disorder with loss of contact with external reality), and dementia. The GACH 1 Note indicated Resident 1 was admitted on a 72-hour hold for grave disability (condition in which a person with a mental health disorder is unable to provide for his/her basic personal needs). The Note indicated Resident 1 was oriented to self only, with impaired insight (deep understanding of a person or thing), judgment, and memory. A review of Resident 1's Resident Statement Landscape (financial statement itemizing posted transactions in the trust account) indicated the following information: a. On 7/29/20, an amount of $1,865.48 was debited (deducted from the trust account as payment for services or goods) for Personal Needs Items and paid to Vendor 1. b. On 9/1/20, an amount of $1,285.27 was debited for Personal Needs Items and paid to Vendor 1. c. On 2/11/21, a withdrawal amount of $4,195 for Transfer to Burial with no indicated payee. A review of Resident 1's Invoice amounting to $1,865.48, dated 7/24/20, indicated the purchase of the following items: Cardigan sweater - 3 totaling in the amount of $135.00 Printed knit tops - 5 totaling in the amount of $120.00 Roll-tab sleeve blouses - 3 totaling in the amount of $105.00 Elastic waist denim pants - 3 totaling in the amount of 135.00 Fleece pants - 3 totaling in the amount of $84.00 Knit pants - 4 totaling in the amount of $104.00 Sport bras - 3 totaling in the amount of $36.00 White anklet socks - 4 totaling in the amount of $12.00 Colored anklets - 4 totaling in the amount of $20.00 Cotton briefs 10- totaling in the amount of $55,00 Knit gowns - 3 totaling in the amount of $108.00 Ortho-lite leather Velcro shoes - 1 totaling in the amount of $65.00 Bootie slippers plush - 1 totaling in the amount of $45.00 AM/FM radio - 1 totaling in the amount of $65.00 Headphones - 1 totaling in the amount of $45.00 Twin bed set - 1 totaling in the amount of $125.00 Twin blanket - 1 totaling in the amount of $55.00 Zippered tote - 1 totaling in the amount of $85.00 Walker bag - 1 totaling in the amount of $35.00 Coloring books with supplies - 2 totaling in the amount of $50.00 Toiletry caddy - 1 totaling in the amount of $25.00 Scrunchies set of 4 - 2 totaling in the amount of $10.00 Brush - 1 totaling in the amount of $8.00 Body wash - 2 totaling in the amount of $12.00 Shampoo/conditioner - 2 totaling in the amount of $12.00 Lotion - 2 totaling in the amount of $36.00 Ladies deodorant - 1 totaling in the amount of $4.25 A review of Resident 1's Invoice amounting to $1,285.27, dated 8/31/20, indicated the purchase of the following items: Leather Velcro shoes - 1 totaling in the amount of $65.00 Mesh slip-on shoes - 1 totaling in the amount of $65.00 32-inch TV - 1 totaling in the amount of $299.00 Full motion wall mount - 1 totaling in the amount of $75.00 TV antenna - 1 totaling in the amount of $50.00 DVD player - 1 totaling in the amount of $59.00 Old Spanish movies - 5 totaling in the amount of $90.00 Luggage set - 1 totaling in the amount of $300.00 Coloring set - 1 totaling in the amount of $50.00 Shampoo/conditioner - 2 totaling in the amount of $12.00 Body wash - 2 totaling in the amount of $12.00 Ladies deodorant - 2 totaling in the amount of $8.50 Lotion - 2 totaling in the amount of $14.00 Body mist - 2 totaling in the amount of $30.00 A review of the Interdisciplinary Team Conference Record dated 10/26/20 indicated Resident 1 was alert but did not have the capacity to make own decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized screening and care-planning tool), dated 1/19/21, indicated the resident had moderate impairment in cognition (cognition (mental action or process of acquiring knowledge and understanding). A further review of Resident 1's clinical record indicated Memorial Guide documents, dated 1/28/21, for a purchase of a funeral policy detailing funeral prearrangements signed by Resident 1. The resident was charged in the amount of $4,195 by a third-party funeral insurance company for the policy. A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Social Services Note, dated 4/15/21, indicated RP 1 spoke with SSD and was very upset because Resident 1 purchased this mortuary plan on 1/28/21. The Note indicated RP 1 wanted to cancel or null and void the contract. The Note indicated Resident 1 stated at the time of mortuary plan purchase, Anyway, it's a [sic] government funds, I want to purchased [sic] a mortuary plan for my untimely death which we have to face in reality. I don't want my daughters to have a headache once it happens. During an interview on 6/25/21 at 11:54 a.m., Registered Nurse (RN 1) stated Resident 1 was alert and oriented to self and/or time, depending on the days, but the resident was, Very forgetful with periods of confusion. During a telephone interview and concurrent review of Resident 1's care plans on 6/25/21 at 12:55 p.m., the Director of Nursing (DON) stated Resident 1's care plan for cognitive loss or dementia was initiated on 12/6/19 and one of the interventions included Encourage decision-making, but limit choice to resident's ability level. During an interview on 6/15/21 at 12:41 p.m., the Social Services Director (SSD) stated the Business Office would notify Social Services Department when a resident must, Spend down to maintain Medi-Cal eligibility and how much to, Spend down. The SSD stated they would order clothes for the residents most of the time or the facility would purchase a television or radio, depending on the resident's wishes or preferences, from Vendor 1. The SSD stated they would assist with a purchase of a funeral policy insurance if the resident needed to, Spend down a large amount of monies. The SSD stated when he assisted Resident 1 in obtaining a funeral policy in January 2021, SSD thought Resident 1 did not have dementia and had fluctuating capacity to make decisions. The SSD stated RP 1 was upset after finding out Resident 1 purchased the funeral policy and stated that Resident 1 was confused and had dementia. The SSD stated he apologized for his mistake and offered to assist with the funeral policy cancellation. During a telephone interview on 6/25/21 at 1:10 p.m., the SSD stated for the purchases from Vendor 1, SSD did not contact the responsible party as social service department would coordinate with the Nursing Department to determine the resident's needs. The SSD stated RP 1 was not contacted or authorized the purchases made from Vendor 1 and the funeral policy. During a telephone interview on 7/14/21 at 11:35 a.m., Family Member (FM) 1 stated the facility did not contact her regarding making any withdrawals from the Resident 1's trust account. FM 1 stated when she requested a copy of Resident 1's trust account statements and questioned the remaining balance being less than expected, Staff 1 refused to give her a copy of the statements. FM 1 stated Staff 1 informed her that Resident 1 purchased a burial plot (funeral policy insurance). FM 1 stated she was upset because Staff 1 told her RP 1 authorized and signed the funeral policy purchase. FM 1 stated that Resident 1 wanted to be cremated and Resident 1 would not make any financial decisions or sign any documents without consulting RP 1 and FM 1. FM 1 stated when she asked Resident 1 if she had signed any documents, Resident 1 could not recall the funeral policy she had signed. FM 1 stated the facility did not contact her regarding the resident's needs, including any lack of clothing items, despite her being involved with Resident 1's care. During a telephone interview on 7/14/21 at 12:27 p.m., RP 1 stated she did not recall signing any documents authorizing the facility to make all financial decisions on behalf of Resident 1. RP 1 stated the facility staff did not contact her for any withdrawals from Resident 1's trust account and prior to Resident 1's funeral policy purchase. During a telephone interview on 7/14/2021 at 2:04 p.m., the Administrator stated the SSD mistakenly assisted Resident 1, who was cognitively impaired, to purchase a funeral policy without consulting the responsible party and/or family members. The Administrator stated the staff had mistakenly acted and assumed the role as the Representative Payee (person or organization appointed by Social Security to receive Social Security income for anyone unable to direct the management of benefits, whose main duties included paying for the future and current needs of the beneficiary) when the facility purchased items from an outside vendor (Vendor 1) on behalf of Resident 1 without consulting RP 1 or FM 1. During a concurrent review of Resident 1's records, the Administrator stated, although RP 1 verbally consented to have Resident 1's social security income be directly transferred to Resident 1's trust account, there was no documented evidence that RP 1 authorized in writing to have the facility manage and be in full control of Resident 1's personal funds. During a telephone interview on 7/19/21 at 1:53 p.m., the Business Office Manager (BOM 1) stated routine personal hygiene items, such as, toothbrush, toothpaste, shampoo, comb, conditioner, deodorant, body wash, body mist, and lotion, must not be charged to the residents' trust account. BOM 1 stated purchases from Vendor 1 could be utilized for non-covered items like clothing items and funeral policy. BOM 1 stated prior to any withdrawal from the account, the resident, RP (in general), or a witness must sign a withdrawal slip to authorize a purchase. During a concurrent review of Resident 1's financial records, BOM 1 stated there was no documented evidence FM 1 or RP 1 were notified of the debited transactions and stated the following: a. Withdrawal Record for $1,865.48 - signed by Assistant BOM (ABOM) 2 (previous ABOM of the facility) b. Withdrawal Record for $1,285.27 - signed by ABOM 2 c. Withdrawal Record for $4,195 - signed by BOM 2 (previous BOM of the facility) During a telephone interview on 7/20/21 at 4:02 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 did not communicate any requests for new clothes, television, radio, coloring books, or specific personal hygiene items. CNA 1 stated the facility provided shampoo, conditioner, body lotion, and deodorant for the residents. CNA 1 stated Resident 1's family members would bring Resident 1 clothes and Resident 1 would get donated clothes from the facility. During the same telephone interview, on 7/20/21 at 4:02 p.m., CNA 1 stated she was not aware of any special beddings, personal TV, radio, bags, or luggage for Resident 1 other than what were available at the facility. CNA 1 stated the assigned CNA for Resident 1 was responsible for the inventory of the resident's belongings. CNA 1 stated if additional belongings were brought in during the resident's stay, either the Social Services staff or the assigned CNA or LVN were responsible for updating the resident's inventory lists, indicating each item, quantity, and description. On 7/21/21 at 3:10 p.m., during a telephone interview and a concurrent review of Resident 1's inventory lists from 9/20/19 to 4/13/21, the Assistant Director of Nursing (DON) stated new resident items should have been added to Resident 1's inventory lists by the social worker or the assigned charge nurse. The ADON stated she signed the inventory list upon Resident 1's discharge on 4/13/21, but she only indicated 1 luggage and 1 TV and did not itemize each clothing item or equipment. The ADON stated it was important to fill out the inventory lists with the items, quantity, and description to ensure the facility protected the resident belongings upon admission until the discharge of the resident from the facility. During a concurrent interview and review of Resident 1's letter from Social Security Administration, on 7/26/21 at 1:25 p.m., the Accounts Receivable Consultant (ARC) stated the facility was not the Representative Payee for Resident 1. Resident 1's letter from the Social Security Administration dated 7/2/21, indicated Social Security Administration designated FM 1 to be Resident 1's Representative Payee. 2. A review of Resident 2's Face Sheet indicated the facility initially admitted the resident on 12/22/17 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated FM 2 as Resident 2's second contact and RP 2 as Resident 2's third contact. A review of Resident 2's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Minimum Data Set, dated dated [DATE], indicated the resident had severely impaired cognitive skills (core skills the brain uses to think, read, learn, remember, reason, and pay attention) for daily decision-making. A review of the Resident Statement Landscape indicated an amount of $499.79 debited from Resident 2's trust account on 5/13/21 and paid to Vendor 1. A review of Resident 2's Invoice amounting to $499.79, dated 5/11/21, indicated the purchase of the following: Short-sleeved T-shirts - 5 totaling in the amount of $65.00 Long-sleeved shirts - 5 totaling in the amount of $75.00 Fleece pants - 6 totaling in the amount of $114.00 Pajama pants - 3 totaling in the amount of $102.00 Crew socks - 10 pairs totaling in the amount of $30.00 Blanket - 1 totaling in the amount of $34.00 Fleece blanket 50 x 60 - 1 totaling in the amount of $17.00 A review of Resident 2's inventory lists provided by the facility, from 1/24/18 to present did not indicate that items purchased on 5/11/21 with the amount of $499.79 were added to the current inventory lists. During a telephone interview and a concurrent review of Resident 2's financial records on 7/19/21 at 1:53 p.m., BOM 1 stated the Withdrawal Record amounting to $499.79 was signed by ABOM 1 (current ABOM of the facility). During a telephone interview on 7/23/21 at 10:06 a.m., RP 2 stated he was Resident 2's responsible party. RP 2 stated he was not informed of any withdrawals made from Resident 2's trust account, except for the funeral policy that he agreed to purchase for Resident 2. RP 2 stated he did not authorize the withdrawal for $499.79 for the resident's clothing and other miscellaneous items. During a telephone interview on 7/23/21 at 10:41 a.m., FM 2 stated RP 2 was Resident 2's responsible party and she was only contacted by the facility staff when they were unable to contact RP 2. FM 2 stated she has not received any quarterly statements from the facility and has not been notified of any withdrawals made from Resident 2's trust account. During an observation and interview on 7/24/21 at 9:26 a.m., Resident 2 was observed lying in bed. Upon interview, the resident was alert to person only. With Resident 2's consent, during an interview and concurrent observation of Resident 2's bedside cabinet, CNA 3 stated Resident 2 had 8 pairs of new socks, dark blue fleece blanket, two (2) pants, three (3) T- shirts, and four (4) long sleeved shirts. CNA 3 stated some staff take out clothes from Resident 2's cabinet for other residents' use without paying attention to the label on the clothes pertaining to whom they belong to. During another observation and interview on 7/25/21 at 11:56 a.m., Resident 2 was observed lying in bed. Resident 2 was able to state his first and last name and able to answer basic questions. Resident 2 was unable to state his location, situation, and the date. During an interview on 7/25/21 at 12:03 p.m., Licensed Vocational Nurse (LVN) 3 stated Resident 2 was able to engage in basic conversations with staff to address his basic needs. LVN 3 stated she did not know if RP 2 or FM 2 were consulted for Resident 2's personal needs as she would have entrusted to the SSD to contact the responsible party for any purchases. During an interview on 7/26/21 at 1:25 p.m., the ARC stated the facility was the Representative Payee for Resident 2. However, during a concurrent review of Resident 2's records, the ARC stated, there was no documented evidence that Resident 2, RP 2, or FM 2 authorized in writing to have the facility manage and be in full control of Resident 1's personal funds. 3. A review of Resident 4's Face Sheet indicated the resident was initially admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated Resident 4's responsible party was RP 4. A review of Resident 4's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for decision-making. A review of Resident 4's Resident Statement Landscape indicated an amount of $1,969.72 was debited on 4/28/21 for Personal Needs Items and paid to Vendor 1. A review of Resident 4's Sales Order amounting to $1,969.72, dated 4/22/21, indicated the purchase of the following items: Twin bed set - 1 totaling in the amount of $120.00 Fleece blanket 50x60 - wheelchair - 1 totaling in the amount of $35.00 Woven blanket throw - 1 totaling in the amount of $49.00 Luggage (suitcase) - 1 totaling in the amount of $300.00 Fleece jackets - 2 totaling in the amount of $130.00 Cardigan sweaters - 2 totaling in the amount of $100.00 Short-sleeved printed knit tops - 5 totaling in the amount $120.00 ¾ sleeved printed knit tops - 5 totaling in the amount of $125.00 Fleece pants - 5 totaling in the amount of $120.00 Knit pants - 5 totaling in the amount of $130.00 Knit pajamas - 5 totaling in the amount of $180.00 Knit gowns - 6 totaling in the amount of $156.00 Cotton briefs - 7 totaling in the amount of $38.50 Sports bras - 3 totaling in the amount of $36.00 Non-skid socks - 5 totaling in the amount of $70.00 A review of Resident 4's most current Inventory List, dated 1/29/20, provided by the facility indicated the resident had two (2) blouses, (4) pants, and (4) sweaters. During a concurrent observation and interview with CNA 2 on 7/24/21 at 8:49 a.m., Resident 4 was observed lying in bed, unable to make eye contact and to communicate when spoken to. Resident 4's bed was observed with bed sheets that were supplied by the facility. In the presence of CNA 2, there were no luggage observed inside Resident 4's room. Inside Resident 4's bedside cabinet were two (2) blankets, 12 clothing items in hangers. During a concurrent interview, CNA 2 stated Resident 4 always used the bed sheets supplied by the facility. During an interview, on 7/24/21 at 11 a.m., the SSD stated there were no other belongings for Resident 2 stored in the Social Services Storage Room, where all residents' excess personal belongings were stored. The SSD stated there was no documented evidence that Social Services Department coordinated with RP 4 regarding Resident 4's personal needs or obtained consent to make purchases on behalf of Resident 4's personal funds. The SSD stated the facility was the Representative Payee for Resident 4, so there was no need to inform RP 4 of purchases to the residents' personal funds. During a telephone interview on 7/24/21 at 11:15 a.m., RP 4 stated he was the responsible party for Resident 4. RP 4 stated he was not aware of the $1,969.72 charge against Resident 4's personal funds. RP 4 stated he was not asked by the facility staff of what personal needs items to purchase for Resident 4 using the resident's personal funds. During another interview and concurrent observation on 7/24/21 at 11:53 a.m., the SSD stated he did not know about the purchase of a $300-luggage suitcase for Resident 4 and there was no plan for Resident 4's discharge at any time. During a concurrent observation, the luggage with Resident 4's name indicated in the unopened and sealed box was found in the Social Services Storage Room. The SSD stated he did not know why Resident 4 would need a luggage at that time. During an interview on 7/26/21 at 1:25 p.m., the ARC stated the facility was not the Representative Payee for Resident 4 but had requested to be selected as the Representative Payee. The ARC stated the facility had not received a confirmation or denial response from the Social Security Administration. During a concurrent review of Resident 4's financial records, the ARC stated there was no documented evidence RP 4 authorized in writing to have the facility manage and be in full control of Resident 1's personal funds. On 7/26/21 at 1:25 p.m., during a concurrent interview and review of the facility's letter from Social Security Administration (dated 2/8/21), ARC stated the letter indicated the facility applied to be Resident 4's Representative Payee with no confirmation or denial at the time. 4. A review of Resident 5's Face Sheet indicated the resident was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated Resident 5's responsible party was the Bioethics Committee (committee that is advisory in nature and available for consultation regarding such issues as end-of-life care, withdrawal of life support, and other healthcare dilemmas). A review of Resident 5's MDS, dated [DATE], indicated the resident had severe impairment in cognition. A review of Resident 5's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision-making and had short and long-term memory problems. A review of Resident 5's Resident Statement Landscape, indicated the following: a. On 7/8/20, an amount of $1,005.36 was debited for Personal Needs Items and paid to Vendor 1. b. On 4/15/21, an amount of $898.69 was debited for Personal Needs Items and paid to Vendor 1. A review of Resident 5's Invoice amounting to $1,005.36, dated 7/6/20, indicated the purchase of the following: Short-sleeved solid polo - 4 totaling in the amount of $80.00 Short-sleeved basic T-shirts - 4 totaling in the amount of $48.00 Jersey shorts - 4 totaling in the amount of $54.00 Fleece pants - 5 totaling in the amount of $95.00 Fleece crew tops - 3 totaling in the amount of $54.00 Knit PJ pants - 2 totaling in the amount of $50.00 Crew T-shirts - 3 totaling in the amount of $16.50 Fleece jacket - 1 totaling in the amount of $35.00 Fleece hoodie - 1 totaling in the amount of $36.00 Knit beanie - 1 totaling in the amount of $12.00 Leather Velcro tennis shoes - 1 totaling in the amount of $80.00 Low Strap - Leather Waterproof shoes - 1 totaling in the amount of $110.00 Fleece slip-on slippers - 1 totaling in the amount of $38.00 Crew socks - 7 pairs totaling in the amount of $21.00 Wheelchair bag - 1 totaling in the amount of $35.00 Boombox - 1 totaling in the amount of $70.00 Music CD - Spanish - 2 totaling in the amount of $36.00 Body wash - 1 totaling in the amount of $6.00 Shampoo/conditioner - 1 totaling in the amount of $6.00 Men's deodorant - 1 totaling in the amount of $4.25 Lotion - 1 totaling in the amount of $7.00 A review of Resident 5's Invoice amounting to $898.69, dated 4/13/21, indicated the purchase of the following: Short-sleeved solid polo - 5 totaling in the amount of $120.00 Short-sleeved basic T-shirts - 5 totaling in the amount of $65.00 Jersey shorts - 4 totaling in the amount of $72.00 Knit pants - 4 totaling in the amount of $116.00 Fleece pants - 4 totaling in the amount of $76.00 Fleece crew tops - 3 totaling in the amount of $54.00 Crew T-shirts - 5 totaling in the amount of $27.50 Flannel pants - 5 totaling in the amount of $125 Fleece hoodie - 1 totaling in the amount of $36.00 Fleece jacket - 1 totaling in the amount of $38/00 Crew socks - 7 pairs totaling in the amount of $21.00 Body wash - 2 totaling in the amount of $12.00 Men's deodorant - 2 totaling in the amount of $8.50 Lotion - 2 totaling in the amount of $14.00 Shampoo/conditioner - 2 totaling in the amount of $12.00 A review of Resident 5's most current Inventory List, dated 6/7/21, provided by the facility indicated the resident had 1 pair of jeans, 1 white shirt, a pair of shoes, and 1 pair of socks. During an observation on 7/24/21 at 9:10 a.m., Resident 5 was observed sitting on the wheelchair outside of the resident's room. Upon interview, Resident 5 was unable to state where his belongings were kept. Resident 5 was wearing a blue sweater, red shirt, blue pants, socks, and shoes. During a concurrent interview and observation of Resident 5's room with CNA 3, there were no clothes observed, except for a big bottle of shampoo and a pair of socks on the bedside tabl

Based on observation, interview, and record review, the facility failed to ensure behavioral health care and services were provided for one of two sampled residents (Resident 7) who have [CONDITION(S)] (means thinking about wanting to take own life), in accordance with the facility policy, by failing to: 1. Identify and address Resident 7's behavioral issue of verbalizing wanting to hurt himself ([CONDITION(S)]) and prevent the resident from harming oneself. 2. Develop and implement Resident 1's care needs on 5/28/2021 when Resident 7 was identified to have [CONDITION(S)] by Registered Nurse (RNS) 2 and prevent the resident from attempting to hang himself with a call light on 7/1/21 while residing in the facility. 3. Develop individualized interventions related to Resident 7's identified underlying issues by providing a comprehensive behavioral assessment of Resident 7's Social Service needs (an activity aiming to promote the welfare of others) that may have contributed to the resident's [CONDITION(S)]. The Social Services Designee (SSD) did not conduct a comprehensive assessment and behavioral follow up assessments of Resident 7's behaviors that included verbalization of wanting to hurt himself due to a failed relationship, a failed attempt to hang himself using a call light cord, and [CONDITION(S)] from 5/4/2021 to 7/29/2021. 4. To evaluate and alter the resident's environment (Resident 7's room) upon readmission back to the facility, on 7/12/2021 after the resident attempted to hang himself with a call light cord while residing in the facility on 7/1/2021. The same call light cord was observed on 7/28/2021 inside Resident 7's room at the resident's bedside. These deficient practices and failures had the potential to result in Resident 7's continued attempts of suicide and possible death, including other four residents identified with history of [CONDITION(S)] in the facility. The Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment, or death to a resident) situation on 7/28/2021 at 6:33 PM, in the presence of the Administrator (ADM) and Director of Nursing (DON). The ADM and DON were informed of the facility's failure to have systems in place to address Resident 7's [CONDITION(S)]. On 7/29/2021 at 3:34 PM the survey team verified the implementation of the acceptable Plan of Action (POA, a detailed plan) through observation, interviews, and record review. The ADM and DON provided an acceptable plan of action on 7/29/2021 and the POA was accepted on 7/29/2021. On 7/29/2021 at 3:52 PM the survey team confirmed the removal of the IJ and IJ was lifted in the presence of the ADM and DON. The facility's plan of action included: 1. Resident 7 was placed on one-on-one person monitoring (continuous observation) with a certified nurse assistant, on 7/28/2021 to monitor the resident's whereabouts and to ensure his safety and well-being. Resident 7's attending psychiatrist ordered to transfer the resident to the acute hospital for further evaluation. 2. The Interdisciplinary Team (IDT; a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) would continue to meet on a weekly basis to reassess Resident 7's concerns and psychosocial well-being and provide additional interventions as needed such as identifying possible causes of depression or suicidal thoughts, diversional activities, use knowledge of past interests and hobbies to engage, involve, and distract; reach out to friends and family members and involve in plan of care if possible; referral to pharmacist for medication regimen review as needed for [CONDITION(S)] medications; referral to registered dietitian, assess environmental safety such as use for plastic utensils versus silverware for meals, replace call bell as an alternative for call light system, full-room sweep to make sure it is free from objects that may be used for self-harm. 3. When Resident 7 is readmitted back to the facility (discharged to acute hospital on 7/29/2021), the facility's Behavioral Management Committee, which included the Quality Assurance Nurse, the Social Services Director, Activity Director, and Psychiatrist would review acute hospital's history and physical and progress notes, would assess Resident 7 utilizing the trauma informed assessment, and conduct interview to evaluate for psychosocial needs. Hourly Behavioral Monitoring Form will be initiated for 72 hours and licensed nurses would also monitor resident for any changes every shift for 14 days. Any changes in behavior in relation to suicidal ideation such as verbalization of depression, tearfulness and/or crying would be promptly reported to resident's attending psychiatrist and/or physician and/or psychologist for further orders and/or interventions for evaluation. 4. On 7/29/2021, the Clinical Resource Consultant conducted an in-service to the members of the Behavioral Management Committee regarding their role in reviewing the resident's acute hospital's history and physical and progress notes, assessing the resident utilizing the trauma informed assessments, and conduct interview to evaluate for psychosocial needs. 5. Person-Centered Care Plan (formal process that includes correctly identifying existing needs, as well as recognizing potential needs) was initiated on 7/28/21 for Resident 7 to reflect plan of care such as provision of 1:1 CNA, plastic utensils versus silverware for meals, call lights in the room where Resident 7 was located were removed on 7/28/2021 and replaced with a call bell as an alternative for call light system. Registered Nurse made a full room sweep to make sure it was free from objects that may be used for self-harm. Licensed nurses would observe resident's behavior upon admission, utilize facility's non-pharmacologic interventions if note, & focus on verbalization of suicidal ideation, suicide threats, and suicide attempts. 6. Social Services on 7/28/2021 initiated a re-visit for Resident 7 to address psychosocial support. The Social Service Director and Social Service Designee will provide psychosocial support daily. In-service was provided on 7/29/2021 by the Administrator and DON to the Social Services Director (SSD) and Designee regarding assessing resident's needs for psychosocial support and providing visits daily to reassess the resident. 7. On 7/28/21, licensed nurses were provided in-service education by the Director of Staff Development consultant on identification of residents with potential suicidal ideation and provision of interventions for resident safety. In-services will be completed by facility's Director of Staff Development by 8/4/2021. 8. Current residents of the facility identified by the licensed nurses who have history of suicidal ideation were reassessed by the licensed nurses on 7/28/2021. Per licensed nurses' assessment, four (4) of the identified residents have not had any of the following episodes as outlined in the residents' Suicide Risk Care Plan. 9. In-service was provided to Social Services Director and Social Services Designee today 7/29/2021 by the Administrator and Director of nursing regarding assessing resident's needs upon admission and identification of suicidal thoughts/ideation or depressive symptoms for psychosocial support and providing visits daily for 72 hours and as needed thereafter per Interdisciplinary Team and Licensed Nurses re-evaluation of the residents. Findings: A review of Resident 7's Face Sheet indicated the facility admitted the resident on 10/01/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/27/2021, indicated the resident had moderately impaired cognition (mental abilities such as memory and thinking skills). The MDS indicated resident needed supervision (provide resident oversight help) with bed mobility, transfer, walking, dressing, eating, personal hygiene, and toilet use. A review of Resident 20's History and Physical dated 5/13/2021, indicated Resident 20 had the capacity to understand and make decisions. A review of Resident 7's Social Services (SS) note dated 5/4/2021 indicated Resident 7 expressed his love for Housekeeping Staff (HK) 1, and stated HK 1 told the resident she misses him, and that resident wants to further the relationship and resident proposed to marry HK 1. The progress note indicated that SSD informed Resident 7 that facility does not allow anybody from facility staff to have inappropriate relationship with any of the residents. The SS note did not include a comprehensive assessment or psychosocial support offered to Resident 7 regarding the alleged (claimed) relationship between the resident and HK 1. A review of Resident 7's Social Services (SS) note dated 5/7/2021, indicated the facility's IDT discussed the alleged relationship with HK 1. The SS note indicated the allegation was denied by HK 1. A review of Resident 7's IDT Care Conference dated 5/26/2021 was conducted and attended by Registered Nurse (RNS) 1, RNS 2, SSD, and Activity Staff (AS) 3 about the alleged relationship between HK 1 and Resident 7. A review of Resident 7's care plan titled Alteration in Behavior dated 5/26/2021, indicated behaviors manifested by the resident included: Behavior #1 - thinking that Resident 7 had a romantic relationship with housekeeping staff (HK 1). Behavior #2 - Resident 7 thought that they break up [sic] and wanting to hurt himself. Behavior #3 - Negative statements. The care plan indicated interventions that included to observe and document the behavior every shift and report any changes to the physician. A review of Resident 7's Medication Administration Records (MAR) for July 2021, indicated the following behaviors were monitored: a. On 10/1/2020, for depression manifested by persistent verbalization of sadness every shift and tally. b. On 10/1/2020, for episode of depression manifested by persistent feeling of hopelessness every shift and tally. c. On 7/12/2021, for episode of [CONDITION(S)] (mental illness affects person's thinking, feelings, and behavior) manifested by delusion every shift. A review of Resident 7's IDT Care Conference dated 5/28/2021, attended by the Social Services Assistant (SSA), SSD, and the Director of Nurses (DON) indicated the IDT discussed the allegation between HK 1 and Resident 7. The IDT did not indicate a discussion about Resident 7's [CONDITION(S)] and verbalization. A review of Resident 7's Progress notes dated 5/28/2021 and authored by RNS 2, indicated Resident 7 was upset of the recent IDT meeting (5/28/2021) with the DON and SSD. The progress note indicated Resident 7 verbalized to the IDT staff that it is, Better to hang myself and. I wish I will [sic] just drop dead, but you know that wish does not always come true. The progress note indicated Resident 7 was notified of Psychiatrist 1's order to transfer Resident 7 to the acute hospital due to verbalization of suicidal thoughts. The progress note indicated Resident 7 refused to be transferred to the acute hospital. A review of Resident 7's SS Notes dated 7/1/2021 indicated the IDT members went to Resident 7's room to meet with the resident, but the resident responded, I am not feeling talking today [sic] to their visit. A review of Resident 7's SS Notes dated 7/1/2021, indicated Social Services Director (SSD) spoke with Psychologist 1. The SS note indicated that Psychologist 1 reported to the SSD that Resident 7 was a danger to himself due to Resident 7's roommate (Resident 20) stated that Resident 7 showed him the call light cord wrapped around his neck and planned to hang himself through the curtain rod or the water sprinkler if Resident 7 had the opportunity. A review of Resident 7's Situation, Background, Assessment, and Recommendation (SBAR) form dated 7/1/2021, indicated Resident 20 reported to a psychologist (Psychologist 1) that his roommate, Resident 7, wrapped the call light cord around his neck looking for a sprinkler and curtain rod to hang himself. The SBAR note indicated Resident 7 denied the allegation, stating Resident 7 was, Just teasing Resident 20. The report indicated the facility's IDT placed Resident 7 on one-on-one monitoring for suicidal ideation (on 7/1/2021). The SBAR note indicated Psychiatrist 1 was notified and ordered a 5150 hold (allows a qualified officer or clinician to involuntarily [against their will] confine a person who is deemed to have a mental disorder that makes him or her a danger to themselves or others) for Resident 7. A review of Resident 7's MD 1 Individual Psychotherapy Progress Notes dated 7/1/2021, indicated Resident 20 reported to Psychologist 1 that he had seen the Resident 7 wrap his call light cord around his neck. The progress note indicated Resident 7's risk factors as suicidal ideation and Psychologist 1 informed the facility staff of Resident 7's suicide attempt, on 7/1/2021. The progress note indicated that Resident 7 claimed the incident never happened, and Resident 20 was lying. A review of Resident 7's Nurses Notes dated 7/1/2021 to 7/2/2021, indicated the following information: a. At 7:21 PM, on 7/1/2021, Resident 7 continued to be on one-on-one monitoring for [CONDITION(S)]. The note indicated, no episodes noted of resident trying to wrap the call light cord around the neck. b. At 7:23 PM, on 7/1/2021, indicated that Psychiatrist 1 ordered a 5150 hold to Resident 7, due to danger to self for suicidal ideation. c. At 5:30 AM, on 7/2/2021, the nurses' note indicated Resident 7 continued to be on one-on-one monitoring for suicidal ideation and frequent visual checks were conducted for safety. d. At 11:37 PM, on 7/2/2021, the nurses' note indicated Resident 7 was transported via ambulance to the general acute care hospital (GACH) 1 for further psychiatric evaluation and treatment. A review of Resident 7's GACH 1 Mental Health Unit Crisis Team Evaluation form dated 7/2/2021, indicated Resident 7 met the criteria for 5150 due to suicidal ideation and active suicidal plan. The form indicated, Patient is experiencing depressive symptoms which are triggering suicidal ideation. A review of Resident 7's GACH 1 ED (Emergency Department) Physician Note dated 7/2/2021 timed at 9:04 PM, indicated Resident 7 was sent to GACH 1 for medical evaluation. The ED note indicated that Resident 7 was brought by the paramedics from the facility where resident tried to hang himself. The ED note further indicated Resident 7 now says that he did not try to hang himself and he is not suicidal, he apparently was making an attempt to hang himself in his bed in the emergency department [sic]. The ED note indicated Resident 7's diagnostic primary impression was Suicide attempt. The ED note indicated the plan for Resident 7 was to be admitted to the Psychiatric Unit. A review of Resident 7's Face Sheet indicated the facility readmitted back Resident 7 to the facility from GACH 1, on 7/12/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 7's Psychosocial Evaluation was conducted by SSD on 7/14/2021 at 12:32 PM. The psychosocial evaluation did not indicate an assessment or information about Resident 7's psychosocial/behavioral needs due to depression manifested by wanting to hurt himself or [CONDITION(S)]. During an interview on 7/28/2021 at 9:29 AM, Resident 7 was asked if he had any suicidal thoughts. Resident 7 stated, Not today, but they never completely go away. Resident 7 was asked if he had any current plan to commit suicide. Resident 7 stated, It happened recently three weeks ago .I am not thinking of killing my self today . It is woman problem. I am okay now. I don't know if that thoughts really go away. Resident 7 stated, The psychiatric hospital did not help me with my suicidal thoughts and the facility does not know that I tried. Resident 7 stated he was in his room during that time and was getting up into the nightstand. Resident 7 stated, I was standing, and I was pretty close. It happened a month ago and my roommate knew. During an interview and record review of Resident 7's progress notes and care plans from 5/1/2021 to 7/28/2021, on 7/28/2021 with RNS 2 at 10:45 AM, RNS 2 stated that on 5/28/2021, Resident 7 verbalized to the IDT staff that it was better to hang himself. RNS 2 stated that Resident 7 had an IDT meeting with the Administrator, DON, and SSD on 5/28/2021, but could not find documented evidence that the IDT care conferences (5/26/2021 and 5/28/2021), discussed Resident 7's [CONDITION(S)]. RNS 2 stated she took Resident 7's verbalization of suicidal thoughts seriously and notified Psychiatrist 1 of Resident 7's verbalization of [CONDITION(S)], on 5/28/2021. RNS 2 further stated upon record review, she could not find documented evidence that Resident 7's behavior monitoring of wanting to hurt/harm himself were implemented as indicated in the 5/26/2021 care plan. RNS 2 stated there was no one-on-one staff monitoring implemented, after Resident 7 made RNS 2 aware of his suicidal thoughts on 5/28/2021. RNS 2 stated she should have developed an individualized care plan for Resident 7, on 5/28/2021 that was specific to Resident 7's suicidal thoughts and ideations so the facility staff could monitor the behaviors. RNS 2 stated she should have recommended and asked Psychiatrist 1 for facility staff to conduct a one-on-one monitoring on Resident 7 on 5/28/2021. During an interview on 7/28/2021 at 10:45 AM, RNS 2 stated Resident 7 was sent to GACH 1 for psychiatric evaluation on 7/2/2021. RNS 2 stated that Resident 7's roommate (Resident 20) saw Resident 7 with the call light cord wrapped around his neck (on 7/1/2021). RNS 2 stated that Resident 7 expressed to Resident 20 that if he had the opportunity to hang himself, he would hang himself. RNS 2 stated that no one in the facility knew that Resident 7 had suicidal thoughts but a history of depression. RNS 2 stated the incident (suicide attempt) occurred on 7/1/2021. During an interview on 7/28/2021 at 10:45 AM, RNS 2 stated depression care plans were developed and Resident 7's behavior was monitored for depression but there was no suicidal monitoring implemented or documented upon readmission back to the facility, on 7/12/2021. During the same interview and record review with RNS 2, on 7/28/2021 at 10:45 AM, RNS 2 further stated Resident 7's progress notes, IDT notes, and care plans from 7/12/2021, when Resident 7 was readmitted back to the facility, did not have documented evidence that the facility's IDT conducted care conferences to discuss Resident 7's behavioral healthcare needs due to [CONDITION(S)] and develop appropriate person-centered care plans to ensure Resident 7's safety after being readmitted back from the acute hospital. RNS 2 stated that after Resident 7 came back from the acute hospital on 7/12/2021, Resident 7 seemed happy. RNS 2 stated the facility staff monitored Resident 7, but not particular for suicidal [sic]. During same interview, and record review with RNS 2, on 7/28/2021 at 10:45 AM, RNS 2 stated there were no documented evidence from Resident 7's progress notes, IDT notes, and care plans, how the facility staff monitored Resident 7's whereabouts and safety while in the facility. RNS 2 stated she could not find documented evidence that Resident 7 suicidal thoughts/ideations were monitored by facility staff upon readmission on 7/12/21 until the present day. RNS 2 stated Resident 7 should have an individualized care needs developed and implemented for the history of attempted suicide on 7/1/2021 and resident's suicidal thoughts/ideations that includes goals and interventions to protect and prevent the resident from harm. During another interview on 7/28/2021 at 3:55 PM, RNS 2 stated that in every readmission the facility staff must develop new individualized care plans (formal process that includes correctly identifying existing needs, as well as recognizing potential needs) for the residents. RNS 2 stated the facility provided monitoring for Resident 7 upon readmission on 7/12/2021 for 72 hours. RNS 2 stated the facility staff provides 72-hour monitoring for all residents' readmissions, regardless if the resident had [CONDITION(S)]. RNS 2 stated the facility staff should have monitored for Resident 7's whereabouts and behavior of suicidal thoughts and check on the resident every two hours upon readmission on 7/12/2021. RNS 2 stated upon readmission of Resident 7 the licensed nurse should have asked questions for [CONDITION(S)] such as if the resident was having thoughts of hurting himself, how resident was feeling, and if resident was feeling safe. RNS 2 stated that if Resident 7 verbalized [CONDITION(S)], the facility staff would conduct a one-on-one monitoring, call the attending physician, and develop a care plan. During a concurrent interview and record review of Resident 7's Social Services Notes and Evaluations from 5/1/2021 to 7/28/2021, on 7/28/2021 at 3:55 PM, SSD was asked about his role and the social services department's responsibilities when a resident had [CONDITION(S)]. The SSD stated he would refer the resident immediately for a psychological and psychiatric evaluation. The SSD stated that the SSD role is to prevent the resident from harming himself by talking to the resident, encouraging the resident to express feelings, and ask the specific underlying concerns about his [CONDITION(S)]. The SSD stated that he should document after each discussion/meeting with the resident. The SSD stated he could not find documented evidences from the SS notes and evaluations that the social services department (SSD or SSA) had fulfilled its roles and responsibilities in meeting the behavioral healthcare needs of Resident 7 due to history of suicidal attempt and ideations of Resident 7 from 5/4/2021 to 7/28/2021. The SSD stated he did not include, and touch based on Resident 7's suicidal thoughts when he conducted his psychosocial evaluation on the resident on 7/14/2021, two days after readmission to the facility (7/12/21). The SSD stated he did not develop a comprehensive care plan for Resident 7's behavioral healthcare needs to address any underlying issues related to a recent history of suicidal thoughts/ideations or Resident 7 wanting to hurt himself to ensure the resident's safety. During an interview on 7/28/2021 at 5:33 PM, Resident 20 stated Resident 7 called him over his bed and saw that Resident 7 had the call light cord wrapped around his neck. Resident 20 was unable to recall the exact date and stated it happened a few weeks ago. Resident 20 stated Resident 7 told him that he planned on hanging it around the curtain's rod and Resident 20 stated he told Resident 7 that the curtain rod would not hold his weight. Resident 20 stated that Resident 7 had been verbalizing hurting himself since they became roommates for two and half months. Resident 20 further stated I saw Resident 7 in his bed that day and the call light cord was wrapped around his neck. Resident 20 stated that Resident 7 wanted to kill himself because he was in love with a woman and the woman did not share the same feelings. During a concurrent observation and interview on 7/28/2021 at 5:40 PM, inside Resident 7's room, in the presence of Maintenance Staff (MS) 1, a long call light cord and overhead light cord still hanged by Resident 7's wall. MS 1 stated this was the same room Resident 7 had prior to the readmission, on 7/12/2021. MS 1 measured the length of Resident 7's call light cord and stated the call light cord was seven feet long. MS 1 stated the overhead light cord above the Resident 7's bed measured four feet and seven inches long. During another interview with Resident 7 on 7/28/2021 at 5:47 PM, Resident 7 stated his attempted suicide (7/1/2021) happened a few weeks ago (unable to state exact date) and Occupational Therapist Assistant (OTA) 1 caught him inside his room when he was in the middle of wrapping the call light cord around his neck. Resident 7 stated that he was getting ready to hang himself with the call light cord while standing on top of the dresser, when OTA 1 walked into his room. Resident 7 stated he dropped the cord to the other side of the curtain when OTA 1 walked into his room. Resident 7 stated OTA 1 saw him standing on top of the dresser, but OTA 1 did not see Resident 7 holding the call light cord. During the same interview, on 7/28/2021 at 5:47 PM, Resident 7 was asked if the facility staff had asked him about his suicidal thoughts, and Resident 7 stated Nobody ever believed me to begin with, they (facility staff) told me that I act like I am too smart to do that. Resident 7 stated that he had told facility staff for several weeks before that day (7/1/2021) when he was caught with the call light cord wrapped around his neck. Resident 7 refused to disclose who were the other facility staff he had verbalized his [CONDITION(S)]. Resident 7 added I learned by going psych world you don't tell anyone anything anymore. A review of a Physician's Telephone Order dated 7/28/2021 timed at 10:30 PM, indicated an order to transfer Resident 7 via 5150 hold to GACH 2 due to danger to self. A review of GACH 2's Mental Health Unit Crisis Team Evaluation Form dated 7/28/2021 timed at 10:31 PM, indicated Resident 7 was placed on 5150 hold and met criteria for suicidal ideation and being a danger to self. A review of GACH 2's Psychiatric 1's Consultation note dated 7/29/2021, indicated Resident 7 reported to Psychiatrist 1 that he was depressed, and suicidality would always be there. Psychiatrist 1's note indicated Resident 7 had a depressed mood with depressed affect, positive suicidal ideation, and positive for delusion of persecution (falsely believing that someone or others are going to harm or are already harming the person). The note indicated Resident 7 verbalized that he would always be suicidal but no specific plan how Resident 7 was going to harm himself. During a telephone interview on 7/29/2021 at 2:08 PM, OTA 1 stated that she worked with Resident 7 a few months ago in March and April 2021. OTA 1 stated on 5/28/2021 she found Resident 7 standing on the bed putting up a poster on the window. OTA 1 stated she told Resident 7 to get down. OTA 1 stated she did not see Resident 7 on top of the dresser and messing with call light cord. OTA 1 stated on the same time, that day (5/28/2021) Resident 20 informed OTA 1 that Resident 7 tried to hurt himself. OTA 1 stated she notified RNS 2. A review of the facility's undated job description for the Director of Social Services indicated the SSD would develop preliminary and comprehensive assessments of the social service needs of each resident and develop plans of care that identifies the problems/needs of the resident and the goals to be accomplished for each problem/need identified. A review of the facility's policy and procedure titled Behavioral Assessment, Intervention, and Monitoring Policy and Procedure revised on March 2019 indicated the following information: a. The facility would provide, and residents would receive behavioral health services as needed to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. b. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. c. The IDT would thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. d. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies would be implemented immediately if necessary, to protect the resident and others from harm. e. The care plan will be consistent incorporate findings from the comprehensive assessment and be consistent with current standards of practice. A review of the facility's policy and procedure titled Suicide Threats revised on December 2007 indicated the following information: a. Resident's suicide threats shall be taken seriously and addressed appropriately. b. Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. c. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. d. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plan accordingly, until a physician had determined that a risk of suicide does not appear to be present. e. Staff shall document details of the situation objectively in the resident's medical record.

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a mild to severe respiratory illness that spread from person to person) in accordance to the facility's Mitigation Plan (MP, plan to reduce loss of life and impact of COVID 19 in the facility) and facility's policies for five of five sampled residents (Residents 1, 2, 3, 4 and 5) by failing to: a. Dedicate licensed staff to the Yellow Zone (unit for residents who have been in close contact with known cases of COVID-19, newly admitted or readmitted residents, have symptoms of possible COVID-19 pending test results, and for residents with indeterminate tests and residents on [MEDICAL TREATMENT] (removing of waste, salt and extra water to prevent build up in the body for residents who have loss of kidney function)) and also to the Green Zone (a unit for residents who test negative and have no signs and symptoms of COVID 19) and that Licensed Vocational Nurses 1 and 2 (LVN 1 and LVN 2) did not provide care Residents 1, 2, 3, 4, and 5 in the Yellow Zone as well as residents in the Green Zone. b. Ensure Certified Nursing Assistant 1 (CNA 1) doffed (removed) the gown before exited from the isolation room and performed hand hygiene prior to entering the resident's room. CNA 1 doffed isolation gown outside a room in the common area and then reentered the room. c. Ensure a Registered Nurse (RN), who was working on the 7:00 a.m. to 3:30 p.m. shift, supervised the day to day clinical activities of the facility including to oversee the care of the residents in the Red zone to ensure that the highest quality of care is maintained at all times. d. Ensure the one of three sampled Certified Nurse Assistants (CNA 2) were screened for signs and symptoms of COVID-19 upon entering the facility building, and facility staff conduct screening audits to ensure COVID-19 compliance for staff entering and cross screening in the Red Zone. e. Ensure a licensed nurse continuously monitored the residents in the Red Zone when a Licensed Vocational Nurse (LVN 1) was on break. When the LVN 1 took a break, nobody covered for LVN 1. f. Ensure the Administrator conducted a root cause analysis for COVID-19 outbreak (OB) as the facility identified on 10/23/2020. These deficient practices had the potential to result in the spread of COVID-19 from Residents 1, 2, 3, 4, 5, and among the rest of the residents and staff that could result in severe respiratory illness, hospitalization and/or death. On 11/16/20 at 2:35 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) regarding the facility's failure to implement interventions to prevent the spread of COVID 19 infection that threatened the health and safety of the residents and staff. On 11/17/2020 at 3:04 p.m., the IJ was lifted after the facility submitted an acceptable plan of action (POA, interventions to correct the deficient practices), the survey team verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The survey team confirmed and removed the IJ situation in the presence of the Administrator, facility consultant and the DON. The facility's approved POA as follows: a. The facility will stagger the days of the Director of Staff Development (DSD) and the Infection Prevention Nurse (IPN, a professional who make sure healthcare workers and patients are doing all the things they should to prevent infections) to ensure seven days of coverage for infection control and prevention to readily address infection control concerns. b. An in-service was given by the DSD and IPN on 11/16/2020 regarding staff screening by having the outgoing charge nurse will screen incoming staff in the Red Zone. c. The facility will assign an RN in addition to the LVN in the Red Zone to ensure the Red Zone has continuous staff coverage when a licensed nurse takes a break. d. The facility will ensure that there are dedicated staff, both a licensed nurse and a CNA for the Yellow Zone. e. The facility designated an RN for the Red Zone to assess the COVID-19 confirmed positive residents for any change of condition. f. The facility completed the Root Cause Analysis on the recent outbreak of 10/23/20 and will be reviewed and updated monthly. Findings: a. A review of the facility's daily census dated 11/15/2020, indicated the facility's census was 72 residents. A review of the facility's Daily Survey for COVID-19 record indicated the COVID testing was conducted from 11/9/2020 an 11/11/2020 for the 89 staff and 36 residents in the facility. There were three staff and 11 residents were confirmed COVID-19 positive. During an interview with the Administrator and the Director of Nurses (DON) on 11/15/2020 at 6:50 p.m., they stated there are 21 residents in the Red Zone, 26 residents in the Yellow Zone, and 25 residents in the Green Zone. One resident with confirmed positive was transferred to the hospital on [DATE]. A review of Resident 1's Face Sheet (Admission Record) indicated the facility admitted the resident on 8/29/2017 and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Physicians Order dated 10/30/2020, indicated to admit Resident 1 for skilled nursing services secondary to possible exposure to Covid-19. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 9/20/2019 and was readmitted on [DATE], with [DIAGNOSES REDACTED].) and arthritis (joint pain and swelling). A review of Resident 2's Physicians Order dated 11/10/2020, indicated to admit Resident 2 for clinical observation secondary to exposure to Covid-19. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 10/6/2014 and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's Physicians Order dated 10/23/2020, indicated to admit Resident 3 for clinical observation secondary to exposure to Covid-19. A review of Resident 4's Face Sheet indicated the facility admitted Resident 4 on 9/11/2019 and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Physicians Order dated 10/23/2020, indicated to admit Resident 4 for clinical observation secondary to exposure to Covid-19. A review of Resident 5's Face Sheet indicated the facility admitted Resident 5 on 2/14/2019, with [DIAGNOSES REDACTED]. During an interview on 11/15/2020 at 11:45 a.m., LVN 1 stated she provides care to Residents 1 and 2 in the Yellow Zone and also the residents in the Green Zone. During an interview on 11/16/2020 at 2:05 p.m., LVN 1 stated that she was assigned to care for Residents 1 and 2 in the Yellow Zone, and the residents in the Green Zone. During an interview on 11/16/2020 at 2:10 p.m., LVN 2 stated that she was assigned to Residents 3, 4 and 5 in Yellow Zone, and the residents in the Green Zone. A review of the facility's COVID-19 Mitigation Plan with a revised date on June 18, 2020, indicated for the facility to dedicate staff to care for person under investigation pending results (residents in the yellow zone). Team red will only work exclusively to Red Zone, team yellow will work exclusively to Yellow Zone, and team green will only work exclusively to green zone. b. During an observation in the Red Zone on 11/15/2020 at 12:59 p.m., CNA 1 exited an isolation room and doffed (removed) the contaminated gown and gloves outside the room and re-entered the same room. CNA 1 did not perform hand hygiene after doffing and before re-entering the room. A concurrent interview was conducted; CNA 1 confirmed the isolation gown and gloves were doffed after exiting the isolation room. During a telephone interview on 11/30/2020 at 11:02 a.m., the IPN stated it was not proper procedure to doff Personal Protective Equipment (PPE, not limited to gowns, gloves, eye protection, gowns) outside of the room. The IPN stated the CNA 1 is not to doff PPE outside a resident's room next to the door. The IPN stated a trash can was next to the door so staff can doff and throw away contaminated PPE inside the room. The IPN stated the proper procedure is to doff by the door inside the room before exiting. The IPN stated the staff are to don before entering the room. A review of the facility's policy and procedure, titled Nursing Services Policy and Procedure, dated September 2010, indicated that gloves and isolation gown should be doffed inside the residents' room and discarded in a waste receptacle inside the resident room. A review of the facility's Mitigation Plan revised date of 6/18/2020 indicated the staff will doff all PPE and leave all dirty PPE in designated receptables, perform hand hygiene, and don new PPE for the area they are entering. A review of CDC Healthcare Workers Using Personal Protective Equipment (PPE) Removing PPE updated 8/19/2020, indicates to remove gloves, Remove gown. personnel may now exit patient room and perform hand hygiene. c. During an observation in the facility on 11/15/2020 at 11:30 a.m., one RN was working in the facility from 7:00 a.m. to 3:30 p.m. shift. There was no dedicated RN working in the Red Zone. During an observation on 11/15/2020 at 1:05 p.m., LVN 1, who was assigned in the Red Zone, took a lunch break. There was no licensed nurse relieved LVN 1 nor monitored the residents in the Red Zone. In a concurrent interview, LVN 1 stated we monitor ourselves when we start our shift, and no one covers for me when I take my breaks. LVN 1 stated the RN Supervisor only comes to the Red Zone if necessary. During an interview on 11/15/2020 at 4:00 p.m., the DON verified and stated no licensed staff monitors the residents in the Red Zone when an LVN is on break. During an interview on 11/15/2020 at 5:06 p.m., the Administrator stated there was no dedicated RN in the Red Zone. During an interview with the Administrator and the Director of Nurses (DON) on11/15/2020 at 6:50 p.m., they stated there are 21 residents in the Red Zone, 26 residents in the Yellow Zone, and 25 residents in the Green Zone. The DON stated the RN on duty was responsible to assess residents for changes in condition including COVID-19 related signs and symptoms, make rounds to monitor the residents for safety and special needs, and coordinate with the charge nurses and DON regarding any concerns. During an interview on 11/16/2020 at 1:58 p.m., the IPN stated the facility did not have a RN from 7:00 a.m., to 3:30 p.m. The IPN stated the Director of Nurses (DON) performed the roles of a DON and a Registered Nurse (RN) at the same time, and there was no second RN in the facility on 11/16/2020 from 7:00 a.m. to 3:30 p.m. shift. The IPN stated the facility did not have a dedicated staff in the Green Zone and Yellow Zone and will figure it out. A review of facility's Nursing Staffing Assignment and Sign-in Sheet on 11/16/2020 at 2:45 p.m., indicated that there was no RN on duty on 11/16/2020 from 7:00 a.m. to 3:30 p.m. A review of the undated Charge Nurse-RN job description, indicated the primary purpose of the RN job position is to provide direct nursing care to the residents and to supervise the day to day nursing activities performed by the certified nursing assistants. All care and supervision must be in accordance with the current federal, state, local standards, guidelines, regulations and laws that govern our facility. A review of the facility's RN Nurse Supervisor Job Description dated 6/07, indicates the purpose of this position is to supervise the day to day clinical activities of the facility to ensure that the highest quality of care is maintained at all times. A review of the facility's Director of Nursing Services Job Description dated 5/08, indicates the primary purpose of this position is to direct the overall operation of the nursing department and delivery of care to the residents of this facility, and as may be directed by the Administrator, and to ensure that the highest quality of care is maintained at all times. A review of the facility's Mitigation Plan revised date of 6/18/2020 indicated the facility has a staffing teams to limit the transmission including dedicated, consistent staffing teams, who only be assigned to care for COVID-19 positive residents. d. During an interview on 11/15/2020 at 1:19 p.m., CNA 2 stated she was assigned in the Red Zone, and that she checked and recorded her own temperature in the logbook at the beginning of her shift. During a concurrent review of the log dated 11/15/2020, the log did not reflect that staff in the Red Zone were checked nor documented the signs and symptoms (s/s, not limited to fever and other respiratory illness) of COVID-19. On a concurrent interview, CNA 2 stated, they were performing their own symptom checks. During an interview on 11/15/2020 at 4:45 p.m., the Administrator stated the staff cross-screened each other in the COVID unit (Red Zone) to limit COVID-19 exposure. The Administrator stated the staff should document their temperatures and signs and symptoms on the screening log. The Administrator stated they did not conduct audits of the screening log to ensure screening was done properly and staff are cleared before providing care to the residents. During an interview on 11/16/2020 at 2:22 p.m., the DSD stated the DON was also the RN and that the facility did not have another RN on duty on 11/16/2020 to oversee the care of the residents in Red Zone. The DSD stated the facility should have an RN Supervisor in the Red Zone during the 7:00 a.m. to 3:30 p.m. shift. During a telephone interview on 12/8/2020 at 8:47 a.m., the DON stated that the facility receptionist screens all staff and guests who enter the building for COVID-19 for symptoms not limited to cough, fever, travelling internationally, loss of taste/smell including checking temperatures. The DON stated the purpose for screening is to not allow anyone in the building with symptoms/signs of COVID-19. The DON stated the receptionist completes the screening form and then the staff and/or guest signs the form. The DON stated staff screening process in the Red Zone should be the same as in the lobby. The administrator stated nobody was reviewing the COVID-19 screening log prior to 11/16/20. A review of the facility's Mitigation Plan revised date of 6/18/2020 indicated the facility's IPN is responsible for overseeing the screening of all individuals and will maintain all records that all screening occurs. The staff assigned to the Red Zone shall be screened prior to the start of shift and utilized the screening tool. A review of SB 73 Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities updated 11/24/2020, indicated that Health Care Facilities (HCF) should: 1. Inquire about symptoms of COVID and do temperature checks of all Health Care Provider (HCP) prior to the start of working their shifts AND at the end of the shift. 2. Identify staff who can monitor sick staff with daily check-ins using telephone calls, emails, and texts. http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/#groupactivities. A review for Centers of Disease Control and Prevention (CDC) coronavirus disease 2019 updated 5/13/2020, indicates to screen and triage everyone entering a Healthcare Facility for signs and symptoms of COVID-19. Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 (fever or chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and or diarrhea). During an interview on 11/15/2020 at 4:30 p.m., the Administrator and the DON stated the RN on duty performed IPN duties in addition to direct residents' care. The Administrator and the DON were not able to answer questions related to COVID-19 staff screening, auditing, appropriate cohorting of residents and staff cohorting. Both the Administrator and the DON stated they will refer to the IPN, who was not in the facility and did not work the weekend of 11/15/2020. e. During an observation on 11/15/2020 at 1:05 p.m., LVN 1, who was assigned in the Red Zone, took a lunch break. There was no licensed nurse relieved LVN 1 nor monitored the residents in the Red Zone. In a concurrent interview, LVN 1 stated we monitor ourselves when we start our shift, and no one covers for me when I take my breaks. LVN 1 stated the RN Supervisor only comes to the Red Zone if necessary. f. During an interview on 11/15/2020 at 5:00 p.m., the Administrator stated, we have not done a root cause analysis due to COVID, trying to establish a baseline and we are seeing it started on 10/23/20 with a housekeeper and maintenance staff. The Administrator stated the housekeeper and maintenance staff cleaned the residents' rooms. During a telephone interview on 11/16/2020 at 1:00 p.m., the IPN stated she endorses infection prevention responsibilities to the RN Supervisor on days she is not working in the facility. The IPN stated the RN Supervisors have not received an Infection Prevention training. A review of the facility's Infection Control Coordinator Job Description dated 10/03, indicates the purpose of this position is to monitor infection control practices and outcomes, preventing the spread of disease/infection through appropriate identification, planning and training. A review of the facility's Director of Staff Development Job Description dated 5/08, indicates this position is to coordinate all education needs of all employees in accordance with Local, Federal and State regulations. A review of the facility's policy, titled Quality Assurance and Performance Improvement (QAPI) revised 2/2020, indicates that the facility will establish and implement performance improvement projects to correct identified negative or problematic indicators, establish systems through which to monitor and evaluate corrective actions, and the Administrator is responsible for assuring the facility QAPI program complies with Federal, State and local regulatory agency requirement.

Based on observation, interview, and record review, the facility failed to ensure a resident was supervised to prevent a choking incident for one of three sampled residents (Resident 1). Resident 1, who needed supervision with eating and was at risk for aspiration (the entry of material such as food or drink form the mouth into the throat or lungs) and choking, was not supervised after Resident 1 took the food from the unlatched food cart, ate, and swallowed the food. This deficient practice resulted in Resident 1 choked on the food that he took from the unlatched food cart. Resident 1 was observed clutching his throat, unable to speak, became unresponsive (no pulse and breathing) on [DATE], at 12:48 p.m. Resident 1 was put in bed, and chest compressions was provided until paramedics (medical emergency services) arrived at 12:55 p.m. The Paramedic suctioned food blockage to be able to provide ventilation by a bivalve valve mask (BVM, a hand-held device to provide ventilation to a resident who is not breathing). The blockage removed from Resident 1 was a bread-like food particle that was a peanut butter substance. Resident 1 was pronounced dead in the facility on [DATE] at 1:02 p.m. Findings: A review of Resident 1's Admission Records indicated the resident was admitted to the facility, on [DATE], and readmitted , on [DATE], with [DIAGNOSES REDACTED]. to perform everyday activities). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated [DATE], indicated Resident 1's cognitive skills (ability to think and process information) was severely impaired and needed limited assistance (resident involved in activity, staff provided weight-bearing support) with one-person assist for locomotion on/off unit, and transferring (how resident moves between surfaces including to or from bed, chair, wheelchair, and standing position). The MDS assessment also indicated Resident 1 needed supervision for eating. A review of Resident 1's Progress Notes, dated [DATE], indicated Resident 1 had dementia with behavioral disturbance, and was dependent on a wheelchair. A review of Resident 1's care plan, titled Cognitive Loss/Dementia, initiated on [DATE], indicated resident had a problem due to dementia, decision making skills were severely impaired, and had altered perception/awareness (process of becoming aware of something through the senses). The care plan approaches included for the staff to be aware of triggers creating negative responses such as hunger, thirst, or any action that could negatively affect the resident. A review of Resident 1's Physician order [REDACTED]. A review of Resident's 1's care plan, titled Mechanically Altered Diet, initiated on [DATE], indicated that Resident 1's problem was missing teeth, at risk for choking and aspiration, and required supervision in eating. The interventions included to assist with meals as needed, to monitor the resident's intake, and refer to Speech Therapy as needed. The interventions did not indicate how to supervise and monitor Resident 1, who was at risk for choking and aspiration when eating. A review of Resident 1's care plan, titled Dental Status, initiated on [DATE], indicated Resident 1 had the potential for dental disorder related to no natural teeth and at risk for difficulty chewing and choking. The interventions included provide diet as ordered, monitor tolerance of texture of food, monitor oral intake, and monitor for oral discomfort. A review of Resident 1's Nutritional assessment dated [DATE] completed by a Registered Dietitian indicated Resident 1 had chewing problem, required supervision, oversight, encouragement or cueing when eating, and he required set-up help with the meal tray. A review of facility's Daily Menu Guide, for serving dates [DATE], [DATE], and [DATE] indicated the mechanical soft diet was soft and bite size foods. A review of the facility's investigative summary report, dated [DATE], at 12:48 p.m., indicated Resident 1 was noted at the hallway by Station 3, and Certified Nursing Assistant 1 (CNA 1) saw the resident clutching his throat and unable to speak. The resident was turning blue. A staff member went to attend the resident immediately, charge nurse assessed the resident and announced Code Blue (indicates a medical emergency such as cardiac or respiratory arrest). Registered Nurse Supervisor (RNS) ran over to Station 3, and saw the staff doing [MEDICATION NAME] maneuver (a first aid procedure used to treat upper airway obstructions by foreign objects) in his wheelchair several times. A 911 (medical emergency telephone number) was called. Resident 1 was put in bed, and chest compressions was provided until paramedics arrived at 12:55 p.m. The Fire Department had suctioned Resident 1 and obtained soft bread-like food particle. The Charge Nurse (Licensed Vocational Nurse 1, LVN 1) felt the soft bread-like food particle. The next day, on [DATE] at 12:36 p.m., a facility staff spoke with the Paramedic at the Fire Department, who was present at the facility yesterday, when 911 was called for Resident 1. Per the Paramedic, the substance removed from the resident's throat through suction was a food particle that was a peanut butter substance. A review of the paramedic report, dated [DATE], indicated upon arrival at 12:56 p.m., Resident 1 was lying in bed in supine (flat on his back) position. Facility staff state that pt. (patient/resident) had an episode of choking followed by respiratory and [MEDICAL CONDITION]. Pt was seated in a wheelchair according to staff and moved to a bed where Cardiopulmonary Resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [MEDICAL CONDITION]) was initiated by staff. EMS (emergency medical services) visualization of the airway found blockage, and food was removed. The paramedic administered ventilation through a BVM. Resident 1 was assessed with [REDACTED]. Resident 1 was pronounced dead at 13:04 (1:04 p.m.). A review of Resident 1's Certificate of Death, indicated time of death was on [DATE] at 1:02 p.m., the immediate cause of death was cardiopulmonary arrest (respiratory and [MEDICAL CONDITION]). The secondary causes included acute [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]) and hypertension (high blood pressure). During an interview with the LVN 1 on [DATE], at 11 a.m., LVN 1 stated on [DATE], LVN 1 was at the nursing Station 3, when LVN 1 heard CNA 1 yelled for help. LVN 1 stated the time of day was lunch time. LVN 1 stated when she arrived to help, Resident 1 was in his wheelchair sitting in the middle of the hallway at Station 3. LVN 1 stated Resident 1 was blue. LVN 1 stated CPR was provided after [MEDICATION NAME] maneuver was unsuccessful. LVN 1 stated Resident 1 did not have a pulse. During a telephone interview with the CNA 1, on [DATE], at 11:20 a.m., CNA 1 stated, on [DATE] (unable to provide time) CNA 1 saw Resident 1 took some food from the unlatched food cart, and Resident 1 ate the food. CNA 1 then approached Resident 1 and instructed Resident 1 not to take food from the food cart. CNA 1 stated Resident 1 did not respond to him, and he saw Resident 1 wheeled himself towards nursing station. CNA 1 then moved the food cart away and put latch on it. Then, CNA 1 stated that he looked back at Resident 1 and saw him looking pale and was coughing like choking. CNA 1 wheeled Resident 1 to Station 3, and CNA 1 yelled out for help. During an observation of facility's lunch time, on [DATE] at 12:20 p.m., a CNA was noted to take food tray from the food cart in front of room [ROOM NUMBER] and left the food cart open unattended. Residents were observed passing by the unlatched food cart. During a telephone interview on [DATE], at 10:32 a.m., LVN 2 stated the food cart should be closed and latched at all times. During a telephone interview on [DATE], at 2:32 p.m. CNA 1 stated the food cart has latch and it should be latched at all times. CNA 1 stated in the past (unable to provide date), he saw Resident 1 took a sandwich from the nursing station. During an interview with the Director of Nursing 1 (DON 1) on [DATE], at 2:41 p.m., the DON stated that the facility failed to ensure Resident 1 received appropriate interventions for his dementia and choking risk that led him to choke and died . During an interview with DON 2 on [DATE], at 4:18 p.m., DON 2 stated for a resident, who was at risk for choking, the appropriate interventions included to supervise the resident when swallowing any food eaten and offer liquid. During telephone interview on [DATE], at 5:17 p.m., DON 2 stated that she reviewed the care plan for Mechanical Altered Diet and confirmed the interventions did not address how to supervise or monitor the resident who was at risk for choking. DON 2 stated the resident who was at risk for choking should be closely monitored while resident was eating, give time for resident to swallow, and remind the resident to eat slowly. A review of the facility's policy and procedure, titled Safety and Supervision of Resident, revised date on ,[DATE], indicated, Our facility will strive to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The staff shall use various sources to identify the risk factors for the residents that included medical history and observation of residents, and the MDS. The type and frequency of resident supervision may vary among residents and over time for the same residents. Resident supervision may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was not sexually abused as indicated in the facility's policy and procedure. Resident 1 alleged that Certified Nursing Assistant 1 (CNA 1) sexually assaulted, (unwanted sexual contact, including touching and molestation) and raped (unwanted penetration, whether that is oral, anal, or vaginal) her inside her room on her bed on 2/14/19 at approximately 4:30 a.m. This deficient practice resulted in the sexual abuse of Resident 1 and Resident 1 to have vaginal (female genital organ) and body pain, bloody vaginal discharge and [MEDICAL CONDITION] (thoughts one has about taking his or her own life); to feel fear; and admittance to the hospital for psychiatric stabilization. Findings: During an observation, on 2/26/19, at 2:21 p.m., Resident 1 was awake and sitting on the bed in General Acute Care Hospital 2 (GACH 2). Resident 1 had dark purplish discolorations on both of her inner thighs. During a concurrent interview, on 2/26/19, at 2:21 p.m., Resident 1 stated that on 2/14/19 at approximately 4:30 a.m., CNA 1 entered her room and he (CNA 1) pulled his penis (male genital organ) out from his pants and asked her (Resident 1) to touch his penis and to perform oral sex. Resident 1 stated CNA 1 separated her legs and touched her vagina three times with his finger. Resident 1 stated that she told CNA 1 to stop but CNA 1 did not stop. Resident 1 stated CNA 1 inserted his penis inside her vagina. During the interview, on 2/26/19, at 2:21 p.m., Resident 1 stated that CNA 1 was brutal and that she (Resident 1) had severe pain in her vagina and entire body after the incident (on 2/14/19). Resident 1 stated that CNA 1 did not use a condom (a thin rubber sheath worn on a man's penis during sexual intercourse as a contraceptive or as a protection against infection). Resident 1 stated that after CNA 1 raped her, she felt scared, sad, wanted to kill herself, and had pain (vaginal and body pain) and vaginal bleeding. Resident 1 stated that she called 911 (an emergency service) on 2/17/19 (three days after the incident) and reported the sexual assault to GACH 1. Resident 1 did not report the abuse to any facility staff. Resident 1 stated that she wanted to kill herself and that she was in GACH 2 on suicide watch (an intensive monitoring process used to ensure that a person cannot attempt to kill self). During a telephone interview, on 2/26/19, at 9:35 a.m., Detective 1 stated that CNA 1 told the police (on 2/17/19) that he (CNA 1) had sex with Resident 1 (on 2/14/19) and that he (CNA 1) acknowledged that he (CNA 1) knew that Resident 1 had a mental illness that could affect Resident 1's ability to consent for sex. During an interview, on 2/26/19, at 12:02 p.m., the Assistant Administrator (AADM) stated that the staffs were not allowed to have any type of sexual encounters with the residents. On 3/22/19 at 4 p.m., the AADM stated the facility learned about Resident 1's allegation against CNA 1 the morning after the police visited the facility (on 2/18/19) The AADM stated she interviewed the residents in the facility who were assigned to CNA 1 and none of the residents who were assigned to CNA 1 had experienced abuse from CNA 1. During an interview, on 2/27/19, at 1:40 p.m., CNA 1 stated that he was arrested and charged with dependent adult harm/rape (on 2/18/19) and that he was out on a $100,000 bail (property or money given as surety that a person released from custody or imprisonment will appear in court when ordered to do so). A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. anxiety disorders (feelings of panic and fear, restlessness, and uneasiness). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 2/7/19, indicated that Resident 1's cognitive skills (ability to think, understand, and reason) were intact and she required supervision for bed mobility, transfers, dressing, and personal hygiene. A review of Resident 1's Depression Care plan, dated 12/13/18, indicated that the resident had a [DIAGNOSES REDACTED]. The interventions included to talk to the resident calmly and provide care gently and carefully. A review of Resident 1's Behavioral Management Care Plan, dated 12/13/18, indicated that the resident had multiple psychoactive (drugs affecting the mind and behavior) and narcotic medications (drugs that dulls the senses, relieves pain, and induces sleep) that contain [MEDICATION NAME] (a drug that stimulates the senses) which could cause cumulative effect on resident's health. The interventions were to approach resident in a calm non-threatening manner; to speak in a calm voice; and to attempt to refocus the resident's behavior to something positive when the resident is exhibiting a behavior. A review of Resident 1's Departmental Notes, dated 2/17/19, and timed at 5:01 p.m., indicated that Resident 1 wanted to be transferred to the hospital because she had vaginal bleeding for three days and that Resident 1 was transferred to GACH 1 at 4:35 p.m. A review of Resident 1's Emergency Department (ED) Provider Notes from GACH 1, dated 2/17/19, and timed at 9:43 p.m., indicated that Resident 1 called 911 and presented to ED for evaluation of reported sexual assault and bloody discharge. The ED Provider Notes indicated that Resident 1's clinical impression was sexual assault of adult by bodily force by caregiver and that the resident was taken by the police to a designated Sexual Assault Response Team (SART) facility for further evaluation and forensic (scientific tests or techniques used in connection with the detection of crime) testing. A review of the police report, dated 2/17/19, indicated that CNA 1 stated that he and Resident 1 had sex on 2/14/19 (no time indicated) and that he did not use a condom. The police report indicated that CNA 1 admitted to ejaculate (the action of ejecting semen from the body) inside Resident 1. The police report indicated that CNA 1 was aware that all residents at the facility suffered from medical problems and that they were dependent adults. The police report indicated that the police placed CNA 1 under arrest for violation of Elder/Dependent adult abuse and rape. A review of Resident 1's Departmental Notes, dated 2/18/19, and timed at 3:13 a.m., indicated Resident 1 was returned to the facility. At 11:26 a.m., Resident 1 was transferred to GACH 2 for medical and psychiatric evaluation and that the resident did not want to return to the facility. A review of Resident 1's ED Physician Notes from GACH 2, dated 2/18/19, indicated the resident required multiple medications to de-escalate her agitation (a shaken state of emotions) and a sitter (someone who provides supervisory services to a health care patient who may present a danger to himself/herself or others) was placed at her bedside. Resident 1 was placed on 5150 involuntary (against her will) hold (to confine a person who is deemed to have a mental disorder that makes him or her a danger to themselves or others for 72 hours) and was admitted to the hospital for psychiatric stabilization. A review of the facility's policy and procedure titled, Reporting Abuse to Facility Management, with a revised date (MONTH) (YEAR), indicated that the facility did not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends or other individuals. The policy indicated that sexual abuse was defined as, but was not limited to, sexual harassment, sexual coercion, or sexual assault.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants 1 and 2 (CNAs 1 and 2) did not physically abuse one of three sampled residents (Resident 1) and that Licensed Vocational Nurse 1 (LVN 1), and the Director of Staff Development (DSD) did not neglect Resident 1. For Resident 1, on 8/22/17, between 2 a.m. and 3 a.m., while the resident was trying to open an emergency exit door, CNAs 1 and 2 physically attacked Resident 1. When Resident 3 reported to LVN 1 the witnessed incident, LVN 1 did not evaluate Resident 1 for injuries, did not provide nursing care, did not report the incident and injuries to Resident 1's physician, the nurse supervisor, the police, or call the paramedics (911) for Resident 1 to receive the needed medical care. As a result, Resident 1 did not receive medical treatment for [REDACTED]. The paramedics evaluated Resident 1 and transferred the resident to General Acute Care Hospital 1 (GACH 1) where the Physician diagnosed Resident 1 with a posterior (behind) dislocation of the left eye lens, left periorbital ecchymosis (black eye), nasal fracture (broken nose), and facial contusion (bruised face). Resident 1 was hospitalized for [REDACTED]. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool), dated 8/18/17, indicated Resident 1 had memory problems, and cognitive (ability to think and process information) impairment. The MDS indicated Resident 1 was unable to speak or walk, and the resident used a wheelchair for mobility. A review of Resident 1's Change of Condition Assessment form dated 8/22/17, timed at 4 a.m., indicated on 8/22/17 at 4 a.m., Resident 3 approached and showed LVN 1 a recorded video of CNA 2 hitting Resident 1. LVN 1 interviewed CNA 2 and informed CNA 2 to stay away from Resident 1 until the completion of the investigation. At 6 a.m., LVN 1 reported the incident and contents of the video to the Director of Staff Development (DSD). A review of the facility's final investigation report, dated 8/25/17, indicated the Social Service Director (SSD) reported the abuse allegation to the administrator on 8/22/17 at 10:30 a.m. and the administrator reported the incident to the Police Department on 8/22/17 at 11:30 a.m. A review of the Police Investigation Report, dated 8/22/17, indicated at 1:30 p.m., Police Officer 1 (PO 1) went to the facility to respond to an elder abuse allegation. PO 1 viewed the video from Resident 3, and the video showed CNA 2 punched Resident 1 multiple times in the face. Resident 1 fell out of his wheelchair, and CNA 2 started to kick the resident, CNA 2 then grabbed Resident 1 by the leg and dragged the resident across the floor. Resident 1 was able to hold on a rail for a few seconds, but CNA 2 continued to drag Resident 1 across the floor and out of view of the video. The report indicated Resident 3 reported to PO 1 that CNA 1 was also involved in assaulting Resident 1, but the video did not capture CNA 1. Resident 1 had a bruise to the left side of his face. PO 1 tried to interview Resident 1 but the resident was nonverbal. The investigation report indicated PO 1 called the Forensic Specialist to the scene to take photos of Resident 1's face due to the severity of the facial injuries, and the fire department to treat Resident 1's injuries. The paramedics transported Resident 1 to GACH 1 for further evaluation and treatment. A review of GACH 1 Emergency Department (ED) Summary, dated 8/22/17, indicated Resident 1 arrived at the ED at 5:12 p.m. with the chief complaint of alleged assault by the nursing home facility's staff. Resident 1's [DIAGNOSES REDACTED]. Resident 1 was discharged from GACH 1 on 8/24/17, to another facility as requested by Resident 1's family. During an interview, on 8/29/17 at 11 a.m., Resident 2 stated she saw the recorded video from Resident 3's cell phone showing CNA 2 punching Resident 1 who was sitting in a wheelchair. Resident 2 stated she felt sad seeing staff abusing an older person and was emotionally traumatized. Resident 2 stated she worried it could happen to her or other residents in the facility. On 8/29/17 at 12:10 p.m., during a concurrent observation and interview, Resident 3 stated on 8/22/17, she woke up at 2 a.m. to have a cigarette when she heard the alarm went off and saw Security Guard 1 checking the emergency exit door. Resident 3 stated she saw Resident 1 was sitting in the wheelchair, trying to go out of the facility and CNA 1 trying to get Resident 1 away from the emergency exit door. Resident 3 stated she saw CNA 1 pulling Resident 1's left earlobe and punching the resident's face. CNA 1 left the area right away before she was able to get the cell phone from her bag. Resident 3 stated CNA 2 walked in, started hitting and punching Resident 1. Resident 1 fell out from the wheelchair, but his hands were holding the handrail, CNA 2 pulled Resident 1's hands off the wall handrail and dragged Resident 1 by the legs into the resident's room. Resident 3 stated she had a video of CNA 2 punching Resident 1 in her cell phone, which she showed to LVN 1, but LVN 1 made excuses, saying Resident 1 was combative. LVN 1 did not report the incident to anyone. Resident 3 stated she was sad after she witnessed the incident and would never forget it even though the psychologist (someone who studies the human mind and emotions) provided psychological counseling (a skilled activity that involves assisting others in managing and resolving emotional, behavioral, and other personal challenges) to her on 8/23/17. Resident 3 cried during the interview. During a telephone interview, on 8/29/17 at 12:30 p.m., Police Officer 1 stated he arrested CNAs 1 and 2 on 8/28/17, and both CNAs were in police custody. On 8/29/17 at 1:10 p.m., during a telephone interview, Security Guard 1 (SG 1) stated he recorded the incident on 8/22/17 in his cell phone. SG 1 stated that night, he heard the alarm, and when he went to check the door alarm, he saw CNA 1 and CNA 2 hitting Resident 1. SG 1 stated he saw CNA 1 pulled Resident 1's left earlobe and punched the resident's left eye area. CNA 1 left the scene when he noticed SG 1 was recording them. SG1 stated he saw CNA 2 punched, kicked, and dragged Resident 1 into the resident's room. SG 1 stated he felt upset, angry, and heartbroken when he witnessed staff beating the resident. A review of the facility's undated policy and procedures titled Abuse Prevention Program, and Protection of Residents during Abuse Investigation, indicated residents have the right to be free from abuse by anyone including staff. The policy indicated the facility will immediately reassign the employee involved in the abuse allegation to duties not involving residents care or will suspend the employee until the Administrator has reviewed the findings of the investigation.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents, (Resident 1) was not physically abused. On 7/20/18 at 4:40 p.m., Certified Nursing Assistant 1 (CNA 1) hit Resident 1 on the face with the buckle of a gait belt (an assistive device used by caregivers to safely transfer residents from one position to another). As a result, Resident 1 sustained multiple red marks on the forehead and swelling to the right temple (side of the head behind the eyes) area. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE], and re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 4/5/18, indicated Resident 1 had severe cognitive (ability to think and reason) impairment and was dependent on staff for bed mobility, transfers, and personal hygiene. A review of the Situation, Background, Assessment, and Recommendation (SBAR) Communication form, dated 7/20/18, indicated CNA 2 reported to Registered Nurse 1 (RN 1) that CNA 1 hit Resident 1 with a belt. Resident 1 had red marks on the forehead and slight swelling on the right temporal area. A review of the Licensed Nurses Narrative Notes dated 7/20/18, timed at 10:30 p.m., indicated the police handcuffed CNA 1 and escorted out of the facility by two police officers. A review of the facility's Final Report, dated 7/23/18, indicated CNA 1 was terminated based on the witness statement, Resident 1's injuries, and CNA 1's confession that he snapped at Resident 1. On 8/2/18 at 11:17 a.m., Resident 1 was observed in bed screaming, No, no. There were no marks on Resident 1's forehead and the right temple area. In a concurrent interview, CNA 3 explained Resident 1 could not speak full sentences, the resident could only say no. During an interview on 8/2/18 at 12:12 p.m., CNA 2 stated on 7/20/18 at 4:40 p.m., he saw CNA 1 hit Resident 1's face three times with the metal buckle of the gait belt. During an interview on 8/2/18 at 12:46 p.m., RN 1 stated on 7/20/18 CNA 2 reported CNA 1 hit Resident 1 on the face with the gait belt. A review of the Police Report, dated 7/20/18, indicated Resident 1 had multiple fresh lacerations (cuts) across Resident 1's head. CNA 1 was willfully using the gait belt to whip Resident 1. CNA 1 was arrested and escorted to jail. A review of the facility's policy and procedure titled, Abuse Prevention Program, revised on 8/2006, indicated residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteer, and staff from other agencies providing services to the residents, family members, legal guardian, surrogates, sponsors, friends, visitors, or any other individual.

Based on observation, record review, and interview, the facility failed to: 1. Ensure one resident (Resident 1) out of 94 residents, was free from physical abuse by allowing staff to put a bed sheet around Resident 1's waist and tie it to the back of his geriatric recliner (large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility), because the resident kept getting up unassisted. 2. Ensure Resident 1 was free from involuntary seclusion by allowing staff to isolate him in his room clothed in only a diaper. Resident 1's room door was closed. These deficient practices resulted in Resident 1's seclusion and neglect, and put Resident 1 at risk for injury including the risk of death, by leaving him alone in his room with the door closed with a bed sheet around his waist tied to the back of the geriatric recliner. Findings: On January 23, 2017, an unannounced complaint investigation was conducted. During a tour of the facility at 3:10 p.m., accompanied by the Maintenance Supervisor (MS), the door to Resident 1's room was closed. Upon knocking and entering the room, Resident 1 was in a geriatric chair with a bed sheet around his waist and tied in the back of the chair. Resident 1 was moving his legs up and down as if he was riding a bicycle. There were no floor mats on the floor on either side of the resident's bed as per physician order. The bed did not appear to be in a low position. Resident 1 was only wearing a diaper, and no clothes. During this observation, Certified Nursing Assistant (CNA) 1 walked into Resident 1's room. During an interview CNA 1 stated she knew it was wrong, but Resident 1 kept getting out of bed. During an attempt to interview Resident 1, he was not answering the questions coherently. The interview was ended. CNA 1 then said, she had just arrived to work. Someone from the day shift must have tied Resident 1 to the geriatric chair. The incident was immediately reported to the Director of Nursing (DON). He suspended two CNA's that provided care for Resident 1 on the day shift, and started an investigation. According to the admission information, Resident 1 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. loss of consciousness), history of falling, [MEDICAL CONDITION] (severe brain disorder), dementia (decline in mental ability that interferes with daily life), and Alzheimer's (irreversible, progressive brain disorder). The Minimum Data Set (MDS a standardized comprehensive assessment of the resident's problems and conditions) dated November 24, 2016, indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 11 out of 15 possible points (moderately impaired). The MDS for Activity Preferences indicated it was very important to Resident 1 to have reading material, listen to music, do things with groups of people and go outside to get fresh air. The Interdisciplinary Team (IDT) Care Conference (A team of facility staff usually the department heads, the resident and/or the resident's responsible party who meet to discuss particular issues (such as fall prevention) regarding the resident and different ways to address the issues) notes dated January 11, 2017, indicated Resident 1 had frequent episodes of standing up unassisted, his wheelchair pad alarm kept sounding, and the resident's roommates were complaining about the loud sound of his alarm when he tried to get up unassisted. The note also indicated the CNA could not provide 1:1 care to the resident. The note did not explain why Resident 1's CNA could not provide 1:1 care. The IDT recommended the resident have a self-release belt. They communicated the recommendation to the resident's physician on the same date. A review of the physician's orders [REDACTED]. 1. Self release belt (a belt that can be removed by the resident) when up in a wheelchair to alert staff if the resident tries to get up unassisted dated January 11, 2017. This was to minimize episodes of falls due to Resident 1's impaired gait and balance, impaired cognitive ability, and poor safety awareness. 2. Low bed with bilateral (up on both sides), side rails, with floor mats on both sides dated January 18, 2017. According to the Change of Condition Assessment on January 14, 2017, at 11:15 p.m., Resident 1 was found on the floor next to his bed. The resident sustained [REDACTED]. Resident 1 was transferred to an acute care hospital emergency room (ER) for further evaluation of the laceration at 1:30 a.m. The ER report from the acute care hospital indicated Resident 1 had an unwitnessed fall. The physician was not sure if the resident lost consciousness. Resident 1 was admitted to the acute care hospital on January 15, 2017, following the ER visit. Resident 1 was readmitted to the SNF on January 18, 2017, and the physician's orders [REDACTED]. 1. Donepezil HCL 10 milligrams (mg) at bedtime for Alzheimer's. 2. [MEDICATION NAME] 5 mg every morning and every evening for [MEDICAL CONDITION]. 3. [MEDICATION NAME] Sprinkles 1500 mg at bedtime for [MEDICAL CONDITION] Disorder. (a mental condition that brings severe high and low mood and changes in sleep, energy thinking and behavior. 4. Resident 1 was to have a low bed with bilateral (both) quarter side rails up, a floor mat on both sides of the bed, and a pad alarm while in bed. The facility staff were to apply a non release belt (restraint belt that cannot be removed by the resident) when up in a wheelchair due to a history of falls, poor trunk control, impaired dynamic sitting balance (the ability to balance while moving or changing between positions), and general muscle weakness. A review of the Resident Care Plan for physical restraints dated January 18, 2017, indicated Resident 1 required physical restraint and to apply non release belt when he was up in his wheelchair. The approach/interventions included releasing the belt with direct supervision. The Care Plan for Fall Risk dated January 18, 2017, indicated Resident 1 was a high risk for falls. The approach/interventions included using a pad alarm (a pad placed under the resident that alarms/sounds when the resident tries to get out of bed unassisted). The History and Physical dated January 20, 2017, indicated Resident 1 did not have the capacity to understand and make decisions. According to the Skilled Daily Nurses Note dated January 23, 2017, Resident 1 was alert to his name and had short and long term memory problems and disorganized thinking. The notes also indicated Resident 1 required extensive assistance from staff for activities of daily living. During a second visit to the facility on [DATE], at about 3 p.m. Resident 1 was observed in the activity room in his wheelchair. The resident had a non-release belt on while sitting at a table participating in activities. During an interview on January 25, 2017, at 3 p.m., the registered nurse (RN 2) was asked why Resident 1 was restrained while he was sitting in the activity room around staff. According to RN 2 they tried everything and the resident still fell , so they had to restrain him.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) was provided supervision and assistance with eating, and received food in a form that was safe for him and as ordered by the physician. Resident 1, who had a swallowing problem, required supervision and assistance with eating, and was prescribed a pureed (mashed potato-like consistency) diet with thickened liquids (to prevent going to lungs), was given a whole banana for a snack. When left unsupervised, he choked on the banana and subsequently died at the facility Findings: On [DATE], the Department of Public Health received an Entity Report Incident indicating Resident 1 was found in distress with a peeled banana next to him. Facility staff began life saving measures and called 911. The paramedics arrived and continued the life saving measures. Resident 1 was pronounced dead by the paramedics on [DATE] at 11:16 a.m. According to the medical record, Resident 1 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. Resident 1 also had Parkinson's disease, a movement disorder that affects the arms, legs, and head, which gets worse over time. A review of Resident 1's physician orders [REDACTED]. A physician order [REDACTED]. A Comprehensive Resident assessment dated [DATE], indicated Resident 1 required assistance with eating. Duplicate care plans were developed [DATE], [DATE], and [DATE], for Resident 1's risk for weight loss and alteration in nutritional status due to broken and missing teeth, difficulty swallowing, and being on a therapeutic pureed (mashed-potato consistency) diet. The interventions included providing Resident 1 cueing and encouragement during meals, setting up the resident's food tray, assisting him and giving verbal cues. The resident was also placed on a special nutritional program, and staff were to ensure optimal positioning (sitting up-right when eating to promote safety); resident was on thickened liquids (pudding-like consistency). A care plan dated [DATE], indicated Resident 1 had a potential for respiratory distress related to acute respiratory failure manifested by shortness of breath, and distress. The intervention was to monitor the resident for abnormal breathing patterns and to positron him for optimum comfort. A care plan dated [DATE], indicated the concern of altered cognitive functioning manifested by impaired decision-making and the inability to understand others. He also had trouble focusing on what was being said. The interventions included frequent prompting and cueing during activities. An Interdisciplinary Team Conference dated [DATE], under nutritional support/weight management indicated Resident 1 was on a pureed no added salt diet with pudding-thick liquids. A history and physical examination [REDACTED]. The Medical Nutritional Therapy Recommendations or Comments dated [DATE], indicated Resident 1 was to get double portion at lunch time, and to provide pudding thickened liquids. A review of a Minimum Data Set (MDS - a resident assessment and care screening tool), dated [DATE], indicated Resident 1 was not able to perform his activities of daily living, which included eating, without significant physical assistance. The resident's swallowing problem was not identified on the MDS. The Interdisciplinary Weight Management care plan for Resident 1 dated [DATE], indicated the problem of altered nutritional status manifested by the resident's medical condition. The approach indicated to assist the resident with eating and tray set-up as needed. The feeding program was not indicated (selected) as an intervention on this care plan. The Nurses Notes dated [DATE], at 7:30 a.m., indicated Resident 1 was fed by a CNA (Certified Nursing Assistant) in bed with the head of the bed up at 45 degrees. The Notes also indicated Resident 1 was on aspiration precautions (to prevent inhaling of a liquids or objects into the lungs). The Notes indicated Resident 1 ate 100 percent of his food and had a good appetite. The Nurses Notes dated [DATE], at 10:45 a.m. indicated the Activity Director found Resident 1 in distress. The registered nurse (RN 2) was informed, went to the activities room and found Resident 1 grunting; there was an open banana located next to him on the table. A blind sweep (check of the mouth) was done and nothing was found. The resident became cyanotic (blue in color due to lack of oxygen) and the Heimlich maneuver (emergency procedure for dislodging/removing foreign particles from the mouth) was initiated. Resident 1 coughed out a small piece of banana. The Nurses Notes dated [DATE], at 10:50 a.m. indicated Resident 1 was unresponsive and transferred to the nearest vacant room, where life-saving measures of Cardio Pulmonary Resuscitation (CPR) were initiated. A licensed nurse called 911, and at 10:55 a.m., paramedics arrived and took over the CPR procedures. At 11:16 a.m., the paramedics pronounced Resident 1 expired. A statement written by Physical Therapist Assistant 1 (PTA 1), dated [DATE], indicated after walking together, Resident 1 asked for a banana. PTA 1 asked the Rehabilitation Technician (RT 1 ) if she would get a banana for the resident. RT 1 got PTA 1 the banana and PTA 1 placed the unpeeled banana on the table in front of Resident 1, who was sitting in the activity room. PTA 1 then left to look for personnel to help Resident 1 eat the banana because PTA 1 had to be in the Rehabilitation room. The Activity Director came and told PTA 1 Resident 1 was in distress, and when PTA 1 went to the activity room, he saw the Restorative Nursing Assistant (RNA 1) and the registered nurse (RN 2) performing the Heimlich maneuver on Resident 1. Resident 1 was unresponsive, and PTA 1 helped the nurses transfer Resident 1 to a bed; nurses started CPR and continued until 911 paramedics arrived and took over the CPR procedures. The written statement by RT 1 dated [DATE], indicated Resident 1 was getting physical therapy. After therapy, Resident 1 would occasionally ask for a banana, and as a positive reinforcement he would be given one. RT 1 stated PTA 1 asked her to go to the kitchen to get a banana for Resident 1, which she did, and gave the banana to PTA 1. The Interview Record written by Licensed Vocational Nurse 1 (LVN 1) on [DATE], at 2 p.m., indicated at around 10:50 a.m., he went to the dining room and saw Resident 1 with four staff performing the Heimlich maneuver. He assisted the staff in bringing the resident to the nearest vacant room. The resident was already unresponsive, pale, and not breathing. Before starting CPR, the staff checked Resident 1's mouth and found small chewed particles and saliva. The Interview Record written by Activity Director 1 (AD 1), dated [DATE], at 12:50 p.m., indicated at 10:10 a.m., Resident 1 was given coffee with thickener, and no cookies as part of his activity. At 10:20 a.m., a physical Therapy Technician came to pick up the resident for Rehabilitation in stable condition. At 10:40 a.m., Resident 1 was placed back in the activity room near the piano with a peeled banana. She also saw a little piece of banana on the floor. She went to ask Resident 1 how he was doing, and then he appeared to clear his throat three times. She indicated the resident's tongue was protruding through his lips. He was pale, his hands were on the table, but he was not gasping for breath. At 10:41 a.m., AD 1 called RN 2 who initiated an oral cavity (mouth) sweep and the Heimlich maneuver. Resident 1 was then transferred to a room, and CPR was initiated by RN 2 and LVN 1. An Interview Record written by a kitchen dishwashing staff, dated [DATE], at 2:00 p.m., indicated he was asked by therapy staff for a banana, and he gave the staff a banana. A review of the Notice/Record of Warning to Employee form dated [DATE], issued to PTA 1, verbally and in writing. indicated that because of the seriousness of his violation his employment at the facility was terminated as of [DATE]. In an interview with the MDS nurse while reviewing Resident 1's medical record on [DATE], at 1:20 p.m., she stated that Resident 1 was assessed with [REDACTED]. In an interview with the Dietary Services Supervisor on [DATE], at 1:40 p.m., he stated Resident 1 is on a special diet. He stated Resident 1 can have a banana but, we have to mush it. During an interview with PTA 1 on [DATE], at 4 p.m., he stated on the day of the incident he took Resident 1 to the activities room and set him at the table closest to the television. He put a peeled banana in front of Resident 1. At In an interview with the Director of Nurses or of Nurses held [DATE], she stated Resident 1 should never have been given a banana. In an interview with the Administrator on [DATE], at 5:35 p.m., she stated during her investigation of this incident, she found out the staff had given Resident 1 a banana for positive reinforcement. When asked when this occurred, she said she didn't know how many times this had occurred.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) was provided and received a therapeutic pureed (mashed potato-like consistency) diet in a form as ordered by the physician. Resident 1, who had a swallowing problem and was prescribed a pureed diet with thickened liquids, was given a whole banana for a snack. When left unsupervised, he choked on the banana and subsequently died at the facility. Findings: On [DATE], the Department of Public Health received an Entity Report Incident indicating Resident 1 was found in distress with a peeled banana next to him. Facility staff began life saving measures and called 911. The paramedics arrived and continued the life saving measures. Resident 1 was pronounced dead by the paramedics on [DATE] at 11:16 a.m. According to the medical record, Resident 1 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. Resident 1 also had [MEDICAL CONDITION], a movement disorder that affects the arms, legs, and head, which gets worse over time. A review of Resident 1's physician orders [REDACTED]. A physician order [REDACTED]. A Comprehensive Resident assessment dated [DATE], indicated Resident 1 required assistance with eating. Duplicate care plans were developed [DATE], [DATE], and [DATE], for Resident 1's risk for weight loss and alteration in nutritional status due to broken and missing teeth, difficulty swallowing, and being on a therapeutic pureed diet. The interventions included providing Resident 1 a diet as ordered. The resident was also placed on a special nutritional program, and staff were to ensure optimal positioning (sitting up-right when eating to promote safety). Resident 1 was also on thickened liquids (pudding-like consistency). An Interdisciplinary Team Conference dated [DATE], under nutritional support/weight management indicated Resident 1 was on a pureed no added salt diet with pudding-thick liquids. A history and physical examination [REDACTED]. The Medical Nutritional Therapy Recommendations or Comments dated [DATE], indicated Resident 1 was to get double portion at lunch time, and to provide pudding thickened liquids. The Nurses Notes dated [DATE], at 7:30 a.m., indicated Resident 1 was fed by a CNA (Certified Nursing Assistant) in bed with the head of the bed up at 45 degrees. The Notes also indicated Resident 1 was on aspiration precautions (to prevent inhaling of a liquids or objects into the lungs). The Notes indicated Resident 1 ate 100 percent of his food and had a good appetite. The Nurses Notes dated [DATE], at 10:45 a.m. indicated the Activity Director found Resident 1 in distress. The registered nurse (RN 2) was informed, went to the activities room and found Resident 1 grunting; there was an open banana located next to him on the table. A blind sweep (check of the mouth) was done and nothing was found. The resident became cyanotic (blue in color due to lack of oxygen) and the [MEDICATION NAME] maneuver (emergency procedure for dislodging/removing foreign particles from the mouth) was initiated. Resident 1 coughed out a small piece of banana. The Nurses Notes dated [DATE], at 10:50 a.m. indicated Resident 1 was unresponsive and transferred to the nearest vacant room, where life-saving measures of Cardio [MEDICAL CONDITION] Resuscitation (CPR) were initiated. A licensed nurse called 911, and at 10:55 a.m., paramedics arrived and took over the CPR procedures. At 11:16 a.m., the paramedics pronounced Resident 1 expired. A statement written by Physical Therapist Assistant 1 (PTA 1), dated [DATE], indicated after walking together, Resident 1 asked for a banana. PTA 1 asked the Rehabilitation Technician (RT 1 ) if she would get a banana for the resident. RT 1 got PTA 1 the banana and PTA 1 placed the unpeeled banana on the table in front of Resident 1, who was sitting in the activity room. PTA 1 then left to look for personnel to help Resident 1 eat the banana because PTA 1 had to be in the Rehabilitation room. The Activity Director came and told PTA 1 Resident 1 was in distress, and when PTA 1 went to the activity room, he saw the Restorative Nursing Assistant (RNA 1) and the registered nurse (RN 2) performing the [MEDICATION NAME] maneuver on Resident 1. Resident 1 was unresponsive, and PTA 1 helped the nurses transfer Resident 1 to a bed; nurses started CPR and continued until 911 paramedics arrived and took over the CPR procedures. The written statement by RT 1 dated [DATE], indicated Resident 1 was getting physical therapy. After therapy, Resident 1 would occasionally ask for a banana, and as a positive reinforcement he would be given one. RT 1 stated PTA 1 asked her to go to the kitchen to get a banana for Resident 1, which she did, and gave the banana to PTA 1. The Interview Record written by Licensed Vocational Nurse 1 (LVN 1) on [DATE], at 2 p.m., indicated at around 10:50 a.m., he went to the dining room and saw Resident 1 with four staff performing the [MEDICATION NAME] maneuver. He assisted the staff in bringing the resident to the nearest vacant room. The resident was already unresponsive, pale, and not breathing. Before starting CPR, the staff checked Resident 1's mouth and found small chewed particles and saliva. An Interview Record written by a kitchen dishwashing staff, dated [DATE], at 2:00 p.m., indicated he was asked by therapy staff for a banana, which he gave an unpeeled banana. On [DATE] at 3:00 p.m. an In-service meeting was held. The Licensed Occupational Therapist, Physical Therapist, and Rehabilitation staff were in-serviced on checking with nursing staff prior to giving any fluids and/or food to residents. Also a list of current residents receiving pureed diets were to be posted in the rehabilitation room. The Interview Record written by Activity Director 1 (AD 1), dated [DATE], at 12:50 p.m., indicated at 10:40 a.m., Resident 1 was placed in the activity room near the piano with a peeled banana. She also saw a little piece of banana on the floor. She went to ask Resident 1 how he was doing, and then he appeared to clear his throat three times. She indicated the resident's tongue was protruding through his lips. He was pale, his hands were on the table, but he was not gasping for breath. At 10:41 a.m., AD 1 called RN 2 who initiated an oral cavity (mouth) sweep and the [MEDICATION NAME] maneuver. Resident 1 was then transferred to a room, and CPR was initiated by RN 2 and LVN 1. A review of the Notice/Record of Warning to Employee form dated [DATE], issued to PTA 1, verbally and in writing. indicated that because of the seriousness of his violation his employment at the facility was terminated as of [DATE]. In an interview with the MDS nurse while reviewing Resident 1's medical record on [DATE], at 1:20 p.m., she stated that Resident 1 was assessed with [REDACTED]. In an interview with the Dietary Services Supervisor on [DATE], at 1:40 p.m., he stated Resident 1 is on a special diet. He stated Resident 1 can have a banana but, we have to mush it. During an interview with PTA 1 on [DATE], at 4 p.m., he stated on the day of the incident he took Resident 1 to the activities room and set him at the table closest to the television. He put a peeled banana in front of Resident 1. At In an interview with the Director of Nurses or of Nurses held [DATE], she stated Resident 1 should never have been given a banana. In an interview held [DATE], with the Director of Nurses she stated Resident 1 should never have been given the banana at all. In an interview with the Administrator on [DATE], at 5:35 p.m., she stated during her investigation of this incident, she found out the staff had given Resident 1 a banana for positive reinforcement. When asked when this occurred, she said she didn't know how many times this had occurred.

Based on observation, interview and record review, the facility staff failed to provide supervision, operable doors and/or door alarms, and assistive devices (Wanderguard - a mechanical system that alerts staff when a resident approaches by activating an alarm (brand name was Code Alert)), to prevent serious harm from accidents and injuries, by failing to: 1. Provide safety to three of three discharged sample residents (1, 2, 3) by securing exit doors with an operable Wanderguard system to prevent them from leaving the facility unsupervised; 2. Provide adequate supervision to 17 residents with known wandering or elopement risks, or dementia, to protect the residents from possible elopement, when the Wanderguard system and/or the door was inoperable; and 3. Ensure all exit doors with a Wanderguard system were activated and/or alarmed to protect all residents. There were 22 residents at risk for elopement or wandering from the facility. Three of three discharged residents (1, 2, 3), who were unable to care for themselves, eloped (left without supervision) from the facility. Two residents were located by law enforcement (1, 2); the third resident (3) has never been located. This deficient practice had no actual harm with the potential for serious harm that resulted in Immediate Jeopardy (IJ) to residents' health and safety. This deficient practice had the potential to affect all residents who may wander out of the facility, especially residents at high risk for elopement and have Wanderguard bracelets, and residents in the facility with dementia. (Dementia is a general term for a decline in mental ability severe enough to interfere with daily life, that can lead to possible injury). Findings: On August 12, 2015, at 7:35 a.m., the Department of Public Health received a complaint alleging a resident (1), wearing a hospital gown, walked out of the facility, and was reported missing. The resident was found entering a freeway (134 Glendale freeway) ramp. On August 13, 2015, at 9:40 a.m., a physical tour and observation of the skilled nursing facility (SNF) was conducted, accompanied by the Maintenance Supervisor (MS). The double doors designated as exit doors located on the North West (NW) side of the building were not latched, and the door handles were tied together with yellow caution tape. An exit alarm control unit used as a Wanderguard alarm system, was installed on the wall next to the door frame, but there was no power or signal indicating the alarm system was activated or operating. On August 13, 2015, at 9:50 a.m., during an interview, the MS stated the NW doors were, broken and needed to be fixed. He stated he was in the process of changing the door frames and tore the door down the day before (August 12, 2015). The MS stated the Wanderguard alarm system had been inoperable for the last two to three weeks. On August 13, 2015, at 9:55 a.m., the Maintenance Supervisor removed the yellow caution tape, and walked out the NW exit door to the back patio, which had a five foot block fence around it and an iron gate with a latch on it. The MS stated he had installed an alarm on the gate, which was supposed to alert nursing station 1 when the gate was opened. The MS proceeded to unlatch and open the gate, and waited seven (7) minutes to see if facility staff would respond to the supposed alarm. There was no response from staff. At 10:10 a.m., 15 minutes later, nursing station 1 was observed, but there were no staff present, and no alarm was heard at the nursing station to indicate the gate had been opened. When the MS was asked why the gate didn't alarm as he indicated it would, he didn't have an answer. Two of the five exit doors observed with the MS created a risk to residents with dementia and/or wandering residents. The North West (NW) exit door was tied shut with yellow caution tape. There was no alarm on the door, and the Wanderguard system was inoperable. The North East (NE) laundry door had an alarm and a Wanderguard system. However, according to the MS, staff would disalarm the system all the time when taking laundry barrels in and out of the door, so it wouldn't alarm. The lobby door had a Wanderguard system on it, but there was no regular alarm applied for general traffic. The East door exiting towards the busy main street had an alarm and a Wanderguard system. The South West door (where the gate is) had an alarm and Wanderguard system on it. On August 13, 2015, at 1:30 p.m., an interview and review of records was conducted with the Assistant Administrator (AA). She provided the List of Dementia Patients/Wanderers. There were 22 residents listed, some with dementia, some wandered, and some required Wanderguard bracelets (bracelet). Two residents were assessed as high risk for wandering out of the facility, seven residents were at high risk for eloping and required bracelets for safety, according to the AA. a1. On August 13, 2015, at 2 p.m., a review of the facility's incident report, written by and reviewed with the Assistant Administrator (AA), indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The report indicated Resident 1 wandered out of the facility on August 9, 2015 (no time indicated). A review of the police report dated August 9, 2015, at 5:30 p.m. indicated the police had received a call from a male stating he had observed a man by the 134 freeway that looked confused and disoriented. The police found Resident 1 at the freeway ramp, and according to the report, they returned Resident 1 to the SNF. During the interview with the Assistant Administrator (AA) while reviewing the report, she stated she had completed the incident report. When asked about Resident 1 ' s elopement on August 9, 2015, she said he was in his room, eating breakfast, and then he was gone. She stated they didn't think the resident would leave. They had not talked to the family to gather any personal information regarding Resident 1. She stated Resident 1 was a new admit and they had not had time to assess whether he required a bracelet or not. When the AA was asked about the process followed for determining whether a resident is an elopement risk or required a bracelet, she stated nursing staff assess if a resident is a high risk for elopement. Nursing then contacts the physician for an order for [REDACTED]. She proceeded to provide a full box of Wanderguard bracelets. A review of Resident 1's general acute care hospital (GACH) Psychiatric Evaluation dated August 5, 2015, indicated he had recently been hospitalized , and now returned to the emergency room (ER). The evaluation indicated Resident 1 was from a previous SNF (unknown), and indicated he was now in theER on a 5150 (involuntary 72-hour hold for evaluation) due to being a danger to others and was gravely disabled (person, due to mental disorder, is incapacitated or rendered unable to carry out the transactions necessary for survival or otherwise provide for his or her basic needs of food, clothing, or shelter); he was confused and disorganized, with difficulty processing his thoughts. Resident 1 had gotten increasingly hostile and aggressive and he had been hitting at other residents and his caregivers unprovoked. His impulse control and judgment were all impaired. The discharge criteria was that Resident 1 would not be homicidal, with discharge instructions to call 911 if he is feeling suicidal or homicidal; these instructions were signed by the resident. The GACH progress notes dated August 6, 2015, indicated Resident 1 had severe depression, dementia and psychosis, was awake and confused, and could not give a good history. A review of the SNF Comprehensive Resident assessment dated [DATE], upon admission at 2:40 p.m., with the IDON, indicated Resident 1 was ambulatory and independent, and the rest of the assessment was incomplete. Resident 1's Elopement Wandering Risk assessment dated [DATE], indicated a score of 7 (scoring 10 or above is high risk). According to the available information from the GACH, and Resident 1 ' s past and current mental status, the assessment was inaccurate and should have been 10 or more, indicating Resident 1 was a high risk for elopement and required a bracelet. There was no immediate or short-term care plan developed to incorporate the available GACH information to provide a safe environment and to prevent Resident 1 from eloping from facility. There was no indication the resident's primary physician was contacted to obtain an order for [REDACTED]. Prevention Program policy. According to Resident 1's SNF Psychotropic Assessment forms dated August 8, 2015, he was prescribed medications for aggression and combativeness, and for anxiety manifested by restlessness and agitation. His Self Administration of Medication Assessment dated August 8, 2015, indicated that he was not able to self-administer medications due to mentally disabled. The form also indicated Resident 1 was not alert and oriented to person, place, or time, and he is not physically able to administer the medications. This information was reviewed and verified with the interim Director of Nursing (IDON). She stated Resident 1's assessment information and care plan for immediate care should have been completed, but she could not locate any other information. The interim Director of Nursing (IDON) stated she was not employed when Resident 1 eloped on August 9, 2015. She stated the DON, administrator, staff developer, MDS (assessment) coordinator, and the registered nurse supervisor, had all resigned. Therefore they were not available for interviews. On August 14, 2015, at 2:30 p.m., during an interview with the certified nursing assistant (CNA 1), who was Resident 1's care giver the morning of August 9, 2015, he stated at 7 a.m. he went to drop off the breakfast tray for Resident 1. When he returned to pick up the tray at about 8 a.m., the resident was still there. CNA 1 stated about 10 min after he picked up the tray he heard staff yelling they could not locate Resident 1. Resident 1's room was closest to the lobby door and station 1. When asked if Resident 1 had given any indication he wanted to leave, CNA 1 said no. On August 14, 2015, at 10:30 a.m., during an interview with Resident 1's family member (FM), she stated she didn ' t know the resident was discharged from the hospital, and only found out when she called the hospital to visit Resident 1, on August 8, 2015. She was referred to the SNF, and when she called the SNF on August 9, 2015, she was informed that Resident 1 had already left the facility and was missing. She was very upset, and stated Resident 1 should have been discharged to a locked facility because he had always been in a locked facility. She stated Resident 1 had a tendency to wander, and she did not believe he was capable of making decisions. On August 14, 2015, at 11 a.m., the Administrator was interviewed regarding Resident 1 ' s GACH transfer information. He stated Resident 1 came from a locked facility and should have been sent to a locked SNF. He stated the GACH Facesheet was incorrect and indicated the GACH was Not Locked, and no one knew Resident 1 required a locked facility until the family notified them after Resident 1 had already eloped. The Nurses Notes dated August 9, 2015, indicated Resident 1 was missing from approximately 9 a.m. and was returned by police at 7 p.m. He was sent back to the GACH with no apparent injuries at 9:30 p.m., and the family was present. The notes indicated that it was requested to send the resident back to the GACH because this SNF was not a locked facility, and the resident may elope again, per family request. On August 14, 2015, at 9 a.m. during an interview with the police department (PD) regarding Resident 1, it was revealed that two other residents had eloped recently (2, 3). The PD stated they had been called to the facility on numerous occasions, either for elopements or for abuse cases. This information lead to the information and investigation into the elopements of Resident 2 and Resident 3. a2. On August 13, 2015, at 2:30 p.m., a review of Resident 2's clinical record with the IDON, indicated he was [AGE] years old, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician Progress Record dated May 15, 2015, indicated Resident 2 was confused. There was no indication that he was oriented to person, place, or time; he ambulated without assistance. The Elopement/Wandering Risk assessment dated [DATE] indicated Resident 2's Wanderguard bracelet was discontinued. On March 8, 2015, the assessment indicated he had intermittent confusion, but was not a risk for elopement. A review of Resident 2's Facesheet indicated a family member was his responsible party. A review of the Nurse's Notes dated June 1, 2015, indicated Resident 2 got a new order for out on pass with the responsible party for a court hearing. On June 14, 2015, at 11 p.m. the notes indicated Resident 2 was missing from the facility. He was last seen walking the halls around 10:30 p.m., as usual. The notes indicated the oncoming (11 p.m. to 7 a.m. shift) certified nursing assistant (CNA) saw Resident 2 at the freeway ramp. The resident was brought back to the facility by local law enforcement. A review of the Incident Report with investigation, dated June 14, 2015, at 11 p.m., written by a licensed vocational nurse LVN (no longer employed), was provided by and reviewed with the Assistant Administrator (AA), on August 19, 2015, at 11 a.m. The report indicated Resident 2 was last seen walking in the hallway between 10 p.m. to 10:30 p.m. During rounds at 11 p.m. the resident was noted missing, who managed to get out of the facility between 10:30 p.m. and 11 p.m. The charge nurse drove around the vicinity, but could not locate the resident. The report indicated that a CNA (CNA 2) thought she saw Resident 2 by the freeway on-ramp when she came to work around 11 p.m. The conclusion was that he managed to get out of the facility. There was no indication as to how the resident managed to elope from the facility, and there was no thorough investigation completed. The section for notifying the Department of the elopement was blank. There was no immediate care plan developed to incorporate the available GACH information to provide a safe environment and to prevent Resident 2 from eloping from the facility. There was no indication the resident's primary physician was contacted to obtain an order for [REDACTED]. Prevention Program policy. a3. On August 13, 2015, at 3 p.m., a review of Resident 3's GACH psychiatric unit History and Physical (H&P) dated August 1, 2015, was conducted with the assistance of the IDON. The H&P indicated Resident 3 was admitted to the psychiatric unit directly from another GACH. He had significant psychiatric decompensation and was gravely disabled (person, due to mental disorder, is incapacitated or rendered unable to carry out the transactions necessary for survival or otherwise provide for his or her basic needs of food, clothing, or shelter); he was depressed and was placed on a 5150 hold (involuntary 72-hour hold for evaluation). The Psychiatric Evaluation dated August 1, 2015, indicated Resident 3 had worsening aggression and combativeness, and was a danger to others. He was confused and disorganized, rambling from one topic to another; he wanted to leave the psych unit immediately. He had a flat affect (lack of emotional response), was depressed, and his impulse control and judgement were impaired. The GACH Psychiatric Aftercare Plan dated August 6, 2015, indicated Resident 3 was being discharged to the SNF for gravely disabled adult. There was no plan indicated because it was blank. The form was signed by the GACH discharge planner. Resident 3 was admitted to the SNF on August 7, 2015, with [DIAGNOSES REDACTED]. The Elopement/Wandering Risk assessment dated [DATE], indicated Resident 3 was assessed at high risk for elopement. There was no immediate care plan developed to incorporate the available GACH information to provide a safe environment and to prevent Resident 3 from eloping from facility. There was no indication the resident's primary physician was contacted to obtain an order for [REDACTED]. Prevention Program policy. A review of the Nurse's Notes dated August 8, 2015, at 6 a.m., indicated Resident 3 wanted to call the cab and leave to go home. The notes indicated the resident walked out of the facility towards the main street and that staff were unable to stop him. According to the IDON, as of August 13, 2015, Resident 3 had not been located. On August 13, 2015, at 4:30 p.m., a review of the Resident Census and Conditions of Residents form completed by the facility, under Mental Status, indicated: 57 residents had documented psychiatric [DIAGNOSES REDACTED]. receiving health rehabilitative services for mental illness. On August 14, 2015, at 11 a.m., an interview was conducted with the administrative staff including the new Administrator, Assistant Administrator (AA), Interim DON (IDON), and the new Staff Developer. It was stated they had no record of Resident 2 or Resident 3 eloping from the facility. There was no record that the elopements were reported to the Department of Health. The AA stated that staff are supposed to inform administration when a resident is missing or elopes from the facility. A review of the Incident Log from February 2015 to August 9, 2015, indicated no documented evidence that Resident 2 or Resident 3 were included on the log. The AA was asked how Resident 1 and 2 were able to elope from the facility without staff intervention, or how they got out of the facility. She stated they were not able to determine how the residents wandered out of the facility. The AA was asked why Resident 3 was allowed to leave the facility unassisted, or why staff didn ' t attempt to stop him from leaving. She stated they couldn ' t stop him. During the administrative interviews, training records were requested with regards to how to handle residents with behavioral problems, residents who were at a high risk for elopement or wandering, or dementia-related training. And, when requesting interviews with staff who were employed at the time of Resident 2's elopement, the administrative staff stated the DON, administrator, staff developer, MDS (assessment) coordinator, admissions coordinator, and the registered nurse supervisor, had all resigned, including the staff developer. Therefore interviews could not be conducted, and no training records were available to provide. There was also missing clinical information regarding the elopements of Resident 2 and Resident 3. , which could not be provided because of inability to locate the information. On August 14, 2015, at 11 a.m., the Administrator was asked what the protocol was for admitting residents with psychiatric [DIAGNOSES REDACTED]. He stated he was recently employed, and was still getting acquainted with the resident population. Three attempts were made to conduct an interview with the new admission coordinator (AC2), with the assistance of the Administrator, however AC2 was either not available or not there. On August 14, 2015, at 5 p.m., during a reinspection to ensure the facility's exit doors and alarm systems were operable, accompanied by the MS, the NE exit door Wanderguard system had been disarmed (by an unknown employee). When the MS attempted to reset the system, it wouldn't work. He stated the staff disabled the system all of the time when going in and out of the door with the laundry barrels; he stated this may be why it stopped working. The MS said it was the wiring, and began work on the system/door. At approximately 6:00 p.m., the NE and NW alarms/systems were operable. A review of the facility's policy and procedure dated May 2011, revised May 2014, titled Elopement Prevention Program , indicated residents identified at risk for elopement will have a plan of care implemented to maintain the highest practicable level of mobility and psychosocial well-being while maintaining the safety and security of the resident. Other interventions could include a Wanderguard bracelet, 1:1 (one to one) supervision, secured unit placement, family intervention, and environmental assessment.