Every finding on record at Height Street Skilled Care

Based on observation, interview and record review, the facility failed to:1. Maintain an environment free of accident hazards for four of 41 sampled residents (Resident 86, Resident 110, Resident 111, Resident 85) when Resident 86, Resident 110, Resident 111, Resident 85 were allowed to keep cigarette lighters in their rooms unsecured. This failure had the potential for residents who wandered to access the cigarette lighters and potentially start fires in the facility and jeopardizing the safety of all residents, visitors and staff members. 2. Follow their policy and procedure (P&P) titled, Elopement [when a resident leaves the facility premises without staff knowledge or permission] and Wandering [when a resident walks around aimlessly, unsupervised] when:a. The facility did not ensure wander guards (wearable device used to detect the resident's proximity to exit points) were checked weekly for placement, testing, and expiration dates for two of two sampled residents (Resident 92 and Resident 96). This failure had the potential to place Resident 92 and Resident 96 at increased risk for elopement.b. The facility did not monitor wandering patterns as indicated in the care plan for one of two sampled residents (Resident 92) who was at risk for elopement. This failure resulted in Resident 92 walking out to the facility parking lot unsupervised. Findings: 1. During a concurrent observation and interview on [DATE] at 12:11 p.m. with Social Service Director (SSD) in the outside smoking area, Resident 86 was sitting in her wheelchair, and SSD was sitting on a chair. Resident 86 had a cigarette lighter in her right hand. SSD removed the smoking apron and stated Resident 86 liked to keep her cigarette lighter and cigarettes with her all the time. During a concurrent observation and interview on [DATE] at 12:20 p.m. with SSD in Resident 86's room, Resident 86 had a red multi-purpose lighter on her wheelchair. SSD stated Resident 86 informed her that a male smoker resident gave her the multi-purpose red lighter. SSD stated Resident 86 had her cigarette lighter and cigarettes in her clear bag which she kept in her room unsecured. During an interview on [DATE] at 12:33 p.m. with SSD, SSD stated there were three more residents keeping their cigarettes and cigarette lighters with them. During a concurrent observation and interview on [DATE] at 12:35 p.m. with Resident 110 in Resident 110's room, there was a cigarette and a cigarette lighter in a plastic container in the nightstand drawer. Resident 110 stated there was no locked drawer to keep the cigarette lighter secured. During a concurrent observation and interview on [DATE] at 12:36 p.m. with Resident 111 in Resident 111's room, there was a cigarette and a cigarette lighter in a plastic container in the nightstand drawer. Resident 111 stated there was no locked drawer to keep the cigarette lighter secured. Resident 111 stated sometimes he would light cigarettes for other residents. During a concurrent observation and interview on [DATE] at 12:38 p.m. with Resident 85 in Resident 85's room, there was a cigarette and cigarette lighter in a plastic container on top of a cardboard box next to his bed and night stand drawer. Resident 85 stated there was no locked drawer to keep the cigarette lighter secured. During a concurrent interview and record review on [DATE] at 1:57 p.m. with Assistant Director of Nursing (ADON), Resident 86's Medical Record (MR), undated was reviewed. The MR indicated Resident 86 had her last smoking assessment completed on [DATE]. ADON stated smoking assessments were supposed to be completed quarterly. ADON stated there was no care plan to keep the cigarette lighter at bedside. During a concurrent interview and record review on [DATE] at 1:58 p.m. with ADON, Resident 110's MR, undated was reviewed. ADON stated there was no care plan to keep cigarette lighters and cigarette at bedside. During a concurrent interview and record review on [DATE] at 1:59 p.m. with ADON, Resident 111's MR, undated was reviewed. ADON stated there was no care plan to keep cigarette lighters and cigarette at bedside. During a concurrent interview and record review on [DATE] at 2 p.m. with ADON, Resident 85's MR, undated was reviewed. ADON stated there was no care plan to keep cigarette lighters and cigarette at bedside. During a review of facility's policy and procedure (P&P) titled, Smoking, dated [DATE], the P&P indicated, To respect resident/employee choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers.Policy.IV. Residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas.Procedure I. Smokers shall be identified at the time of admission.II. A licensed Nurse will complete the Smoking Assessment for residents who wish to smoke in PointClickCare. A. All smokers shall be assessed related to smoking safety at the time of admission and then at last quarterly as outlined by OBRA assessment timeframe.X. All smoking materials will be stored in a secure area to ensure they are kept safe. Based on the individual resident's Smoking Assessment, Facility Staff shall determine the most appropriate method of secure storage. A. Examples of secure areas include but are not necessarily limited to: i. Locked drawers or cupboards in the resident's room. ii. Locked box in a resident's room. Iii. Labeled box in a locked medication room and clearly identified with the resident's name and room number.XV. Residents are strongly encouraged not to share their smoking materials with any other resident, staff, family, and/or visitor(s). 2. a. During a review of Resident 96's admission Record (AR), dated [DATE], the AR indicated, DIAGNOSIS. UNSPECIFIED DEMENTIA (decline in mental abilities severe enough to interfere with daily life) . SCHIZOPHRENIA (chronic and severe mental disorder that affects how a person thinks, feels, and behaves) . ANXIETY DISORDER (excessive fear or worry that interferes with daily life) . PSYCHOTIC DISORDER (severe mental health condition that causes a person to lose touch with reality) WITH DELUSIONS (false belief that a person holds onto despite clear evidence that it is not true). During a review of Resident 96's Minimum Data Set (MDS – a resident assessment tool), dated [DATE], the MDS indicated on Section C (Cognitive Patterns), Resident 96 had severely impaired daily decision-making skills. The MDS indicated on Section P (Restraints and Alarms), Resident 96 was using a wander or elopement alarm daily. During a review of Resident 96's Order Summary Report (OSR), dated [DATE], the OSR indicated, Resident to wear wander guard stopwatch to alert staff of leaving unattended. During a review of Resident 96's Nursing Quarterly Assessment (NQA), dated [DATE], the NQA indicated, Resident 96 had an elopement risk score of 9 (at serious risk for elopement). During a review of Resident 92's AR, dated [DATE], the AR indicated, DIAGNOSIS. UNSPECIFIED DEMENTIA. During a review of Resident 92's MDS, dated [DATE], the MDS indicated on Section C, Resident 92 had severely impaired daily decision-making skills. The MDS indicated on Section GG (Functional Abilities), Resident 92 was able to walk at least 150 feet independently. The MDS indicated on Section P, Resident 92 was using a wander or elopement alarm daily. During a review of Resident 92's OSR, dated [DATE], the OSR indicated, Resident to wear wander guard stopwatch to alert staff of leaving unattended. During a review of Resident 92's NQA, dated [DATE], the NQA indicated, Resident 92 had an elopement risk score of 7 (at serious risk for elopement). During a concurrent observation and interview on [DATE] at 4:48 p.m. with DON in Resident 92's room, Resident 92 was not wearing her wander guard and then the ADON walked into Resident 92's room with a new wander guard. DON stated Resident 92's old wander guard was in her office and the wander guard had to be replaced because it had already been expired. During a concurrent observation and interview on [DATE] at 4:50 p.m. with DON in Resident 96's room, Resident 96 was wearing a wander guard with an expiration date of [DATE] on his left ankle. DON stated Resident 96's wander guard was expired and should have been replaced. During a concurrent observation and interview on [DATE] at 4:55 p.m. with DON in DON's office, there was a wander guard with an expiration date of [DATE] on DON's desk. DON stated this was Resident 92's old wander guard. During a concurrent interview and record review on [DATE] at 4:55 p.m. with DON, the facility's Wanderguard Weekly Check Log (WWCL), dated [DATE] was reviewed. The WWCL indicated, Resident 92's wander guard placement and skin were checked weekly. DON stated Resident 92's wander guard was not being checked for expiration date. DON stated Resident 96's wander guard was not being checked weekly for placement, testing and expiration date. DON stated Resident 92's and Resident 96's wander guards should have been checked for placement, testing and expiration date weekly. DON stated if a wander guard was used beyond the expiration date, it would place the resident at risk for elopement because of device failure. During a concurrent interview and record review on [DATE] at 1:03 p.m. with DON, the facility's Wander Management Transmitters (wander guard) User Guide (WMTUG), dated [DATE] was reviewed. The WMTUG indicated, Each transmitter is stamped with a warranty expiration date. WARNING: Using a transmitter beyond the printed expiration date can result in system failure and/or elopement. Weekly Testing The following testing is required for all transmitters in use on residents. 1. Test the operation of transmitters using the transmitter tester. NOTE: Never take a resident to a door to test their transmitter. 2. Visually inspect transmitters for damage or loose parts. 3. Verify that the warranty expiration date stamped on the transmitter has not expired. If the warranty period has expired, discard and replace the transmitter immediately. 4. Your facility must keep records of test and transmitter inspection. DON stated the WMTUG was not followed. b. During a review of Resident 92's Care Plans (CP), dated [DATE], the CP indicated, Problem. (Resident 92) is an elopement risk/wanderer r/t (related to) Impaired safety awareness. Interventions. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. During a review of Resident 92's Change in Condition Evaluation (CCE), dated [DATE], the CCE indicated, During shift exchange resident (92) was out in the parking lot Residents (Family Member [FM] 1) brought (Resident 92) in as (FM 1) was arriving at the facility at this time. During an interview on [DATE] at 12:24 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated he was the nurse assigned to Resident 92 on [DATE] morning shift (7 a.m. to 3 p.m.). LVN 3 stated during the change of shift rounds with LVN 2 on [DATE] around 2:50 p.m. to 2:55 p.m., Resident 92 was sitting on her bed in her room. LVN 3 stated he did not remember hearing the wander guard door alarm on [DATE]. LVN 3 stated there was no monitoring done for elopement and wandering for Resident 92. LVN 3 stated there should have been monitoring done for elopement and wandering for Resident 92 because they did not want Resident 92 to get lost and to wander outside the facility, placing her at risk for injuries and at risk for falls. During an interview on [DATE] at 3:03 p.m. with LVN 2, LVN 2 stated he was the nurse assigned to Resident 92 on [DATE] evening shift (3 p.m. to 11:30 p.m.). LVN 2 stated during the change of shift rounds with LVN 1 on [DATE], LVN 2 did not see Resident 92 in her room. LVN 2 stated on [DATE] at around 2:55 p.m., he saw Resident 92 walking in the hallway by the shower room towards the kitchen. LVN 2 stated after the change of shift rounds with LVN 1 on [DATE], LVN 2 was at the nurses station 2 when he heard the wander guard door alarm coming from the front lobby. LVN 2 stated he went to the front lobby and he recalled seeing nurses at station 1 (near the front lobby) when the wander guard door alarm was ringing. LVN 2 stated he saw Resident 92 and FM 1 walking at the facility parking lot back into the facility. LVN 2 stated he did not notice any other staff members attempt to search for Resident 92. LVN 2 stated he did not announce the code for a missing resident, and he did not hear anybody announce the code for a missing resident. During an interview on [DATE] at 10:56 a.m. with FM 1, FM 1 stated he found Resident 92 in the facility parking lot walking by herself. FM 1 stated when he brought Resident 92 back into the facility, the door alarm was ringing. FM 1 stated when they walked past the front lobby, he saw a male staff approaching them and the male staff turned off the door alarm. FM 1 stated he saw there were nurses at the nurses' station near the front lobby and nobody at the nurses' station asked him what happened. FM 1 stated he talked to the male nurse assigned to Resident 92 (LVN 2) and LVN 2 told him he did not know Resident 92 was gone because LVN 2 just got to the facility. During an interview on [DATE] at 11:17 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated she was the CNA assigned to Resident 92 on [DATE] evening shift (2 p.m. to 10 p.m.). CNA 3 stated she was not aware Resident 92 walked out to the facility parking lot by herself. CNA 3 stated she did not remember hearing the wander guard door alarm on [DATE]. During a concurrent interview and record review on [DATE] at 1:11 p.m. with DON, Resident 92's MR, undated were reviewed. The MR indicated, there was no documentation Resident 2's behavior pattern of wandering was monitored. DON stated there should have been monitoring of Resident 92's wandering to monitor if the behavior had increased or if there would be changes. During an interview on [DATE] at 1:15 p.m. with DON, DON stated on [DATE] when Resident 92 was found at the facility parking lot by FM 1, the facility staff's response time to the wander guard door alarm should have been more immediate. DON stated when the facility staff would hear the wander guard door alarm, they were expected to check all the exit doors, check for missing residents especially Resident 92 because she was the only resident with a wander guard who could walk. DON stated when a resident was identified missing, code green should have been announced. DON stated code green was not announced on [DATE] when Resident 92 got out of the facility. During a concurrent interview and record review on [DATE] at 1:15 p.m. with DON, the facility's P&P titled, Elopement and Wandering, dated [DATE] was reviewed. The P&P indicated, Purpose To enhance the safety of residents of the Facility. The resident's risk for elopement and preventative interventions will be documented in the resident's medical record. Response to Resident Elopement A. The facility Staff member who finds that a resident is missing will alert Facility Staff. B. The Charge Nurse will call CODE [NAME] and organize a search. Facility Staff will search areas of the Facility, including common areas, bathrooms, showers, outside areas. DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure:1. One of 41 sampled residents (Resident 86)'s medication was securely stored. This failure had the potential for medication to be accessed by unauthorized staff and residents.2. Medications were labeled for one of seven sampled residents (Resident 64) when Resident 64's insulin pen (a multi-use vial of medication to treat high blood sugar in the format of a pen which uses a needle for administration of the medication) was not labeled with Resident 64's identification. This failure had the potential for Resident 64 to use another resident's insulin pen or vice versa, placing Resident 64 and other residents at risk of the spread of blood/borne diseases (diseases spread through the blood). Findings: 1. During a concurrent observation and interview on 4/20/26 at 9:08 a.m. with Licensed Vocational Nurse (LVN) 3 in Resident 86's room, Resident 86 had methadone (controlled medication [high risk of abuse] used to treat opioid use disorder) 90 mg (milligram) found on the bedside table. There was a label on the bottle with Resident 86's name and methadone 90 mg dated 4/18/26 and had pink fluid in the bottle. LVN 3 stated methadone was given by the night shift nurse and the bottle still had 1 ml (milliliter) medication left. LVN 3 stated medication should not be left at bedside. During an interview on 4/21/26 at 3:09 p.m. with Resident 86, Resident 86 stated some nurses watch her take her medication and some of the nurses just leave the bottle with Resident 86 on the bedside table and she would take the medication unsupervised. Resident 86 stated on 4/20/26 a medication bottle was left on her bedside table, and she did not think she finished all the medication and just fell asleep. During a concurrent interview and record review on 4/22/26 at 10:04 a.m. with Director of Nursing (DON), Resident 86's Medical Record (MR), [undated] was reviewed. DON stated there was no care plan or self-administer assessment completed on Resident 86. DON stated Resident 86 could not store her medications at bedside and could not take medications unsupervised. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, Controlled Substance Storage, dated 1/2022, the P&P indicated, B. Schedule [II-V] medications and other medications subject to abuse or diversion are stored in a permanently affixed, [double-locked] compartment separate from all other medications or per state regulations.H. Controlled substances are not surrendered to anyone, including the resident's physician, other than releasing controlled medications for a resident. During a review of the facility's P&P titled, Medication Storage in the Facility, Bedside medication storage, dated 1/2022, the P&P indicated, Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once the self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. 2. During a concurrent observation and interview on 4/20/26 at 11:37 a.m. with LVN 4 in the hallway in front of nurses' station 1, LVN 4 stated she was going to administer insulin to Resident 64. LVN 4 retrieved an unlabeled insulin pen from the medication cart and stated it was Resident 64's insulin pen. The insulin pen had no resident identification. LVN 4 stated the label with Resident 64's identification had fallen off the insulin pen. During an interview with the DON on 4/27/26 at 1:25 p.m., DON stated insulin pens should be labeled with the resident's identification. During a review of facility P&P titled, Medication Ordering and Receiving From Pharmacy, dated 1/2022, the P&P indicated, Labels are permanently affixed to the outside of the prescription container.

Based on interview, and record review, the facility failed to implement a physician order for one of three sampled residents (Resident 10) when a Registered Dietician (RD) consult was not completed. This failure had the potential to negatively impact on Resident 10's nutritional status and overall health.Findings:During a review of Resident 10's Electronic Health Record (EHR), (undated), the EHR indicated, Resident 10 had a significant weight loss (more than 5 percent of body weight) within one month. On 3/1/26 Resident 10's weight was 184 pounds and on 4/3/26 Resident 10's weight was 166 pounds.During a review of Resident 10's Physician Progress Note (PPN), dated 4/6/26, the PPN indicated, The resident has experienced a 2-pound weight loss over the past month and a total of 17 pounds over the past six months.the degree of unintentional weight loss is clinically significant.Assessment and Plan.Order dietary Consult for comprehensive nutritional assessment.During a review of Resident 10's Order Summary (OS), dated 4/6/26, the OS indicated, there was a telephone physician order for an RD consult placed on 4/6/26.During a concurrent interview and record review on 4/22/26 at 10:14 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 10's EHR, (undated) was reviewed. The EHR indicated, Resident 10's most recent RD consult was completed on 8/22/25. LVN 1 stated Resident 10 should have had a RD consult completed for the physician order date 4/6/26. During an interview on 4/22/26 at 10:16 a.m. with Director of Nursing (DON), DON stated the RD should assess the resident within 24 hours of the consult order being placed. During an interview on 4/23/26 at 10:38 a.m. with RD, RD stated when physician's place an order for RD consult, facility staff are to call her to inform her about the consult. RD stated the consult should be completed within 7 days. RD stated there was currently no process in place of who was responsible for informing her of consult orders. RD stated she was not made aware of Resident 10's RD consult order until 4/22/26 by the DON. RD stated she did not complete Resident 10's nutritional assessment until she was notified of the consult on 4/22/26. During a review of the facility's policy and procedure (P&P) titled, Assessment and Management of Resident Weights, dated 1/2025, the P&P indicated, V. Significant Weight Change Management.the DNS [Director of Nursing Services] or licensed nurse will.ii. Notify the physician and dietician of significant weight changes.C. The registered dietician will: i. Complete a nutritional assessment and weight management recommendations in the medical record.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 6) head of bed was elevated to prevent aspiration (when food or liquid enters the airway or lungs instead of going into the stomach) while receiving enteral tube feeding (liquid nutrition is given directly into the stomach through a tube). This failure had the potential to result in serious harm, including aspiration pneumonia (lung infection that occurs when food or liquid enters the lungs), respiratory compromise (lungs unable to work well enough and can make breathing difficult) and death.Findings:During an observation on 4/21/26 at 3:37 p.m. in Resident 6's room, Resident 6 was lying in bed, with the head of bed (HOB) elevated at a 15-degree angle. Licensed Vocational Nurse (LVN) 2 was at bedside. LVN 2 connected Resident 6 to his enteral feeding. LVN 2 set the feeding pump rate to administer 60 milliliters (ml) per hour. LVN 2 left Resident 6's room after starting Resident 6's enteral feeding.During a concurrent observation and interview on 4/21/26 at 3:39 p.m. with LVN 2 in Resident 6's room, Resident 6 was lying in bed with the HOB elevated at a 15-degree angle. Glucerna (nutritional formula) was connected to Resident 6's enteral feeding pump and was being administered at a rate of 60 ml per hour. LVN 2 stated he was not sure how elevated Resident 6's HOB was. LVN 2 stated there was nowhere on Resident 6's bed to check the elevation. LVN 2 stated Resident 6's HOB should have been elevated to a 90-degree angle while he was receiving enteral feeding.During a concurrent observation and interview on 4/21/26 at 3:40 p.m. with Registered Nurse (RN) 1 in Resident 6's room, Resident 6 was lying in bed with the HOB elevated at a 15-degree angle. RN 1 stated Resident 6's HOB was not elevated properly to prevent aspiration. RN 1 stated the HOB was at an angle below 30 degrees. RN 1 stated Resident 6's HOB should have been elevated to a 50-degree angle during enteral feedings.During a review of Resident 6's Order Review History Report (ORHR), dated 4/22/26, the ORHR indicated, Glucerna 1.5 @ [at] 60 ml [per] hour x[times] 20 hours via enteral feeding pump. Start at 12 noon and stop @ 8 am.During a review of Resident 6's ORHR, dated 4/22/26, the ORHR indicated, Resident 6 had an active physician order dated 6/12/25 to Keep HOB 30-45 degree elevated or as tolerated to prevent aspiration.During a review of Resident 6's Care Plan Report (CPR), dated 6/13/25, the CPR indicated, [Resident 6] requires tube feeding r/t [related to] Dx [diagnosis] of Dysphagia [difficulty swallowing food].Interventions.The resident needs HOB elevated 45 degrees during and 30 minutes after tube feed.Policy and procedure requested for enteral tube feedings on 4/22/26, facility failed to provide.

Based on interview and record review, the facility failed to communicate with methadone (medication used to help people reduce or quit opiates [pain medication]) outside clinic when one of one sampled resident (Resident 86) was admitted to the hospital for overdose. This failure had the potential not to meet resident needs.Findings:During a concurrent interview and record review on 4/22/26 at 9:31 a.m. with Director of Nursing (DON) Resident 86's Transfer Form, dated 11/22/26 was reviewed. The Transfer Form indicated Resident 86 was transferred to hospital for low oxygen saturation (level of oxygen in blood), and oversedation. DON stated resident was transferred to hospital and Resident 86 had order for Narcan (to rapidly reverse an opioid overdose) and it was not administered.During a review of Resident 86's hospital discharge paperwork (HDP) dated 11/23/25, the HDP indicated, Diagnosis: 1. Accidental methadone overdose.During an interview on 4/23/26 at 1:20 p.m. with DON, DON stated there was no documentation indicating that the Methadone clinic was notified about Resident 86's condition. DON stated facility just set up a new system to communicate with the Methadone Clinic.During a review of facility's policy and procedure (P&P) titled, Referrals to Outside Services, dated 1/1/2025, the P&P indicated, II. The Director of Social Services is responsible for locating agencies and programs that meet the needs of residents, facilitating the execution of service provider contracts, and referring residents to existing contracted providers.

Based on observation, interview, and record review, the facility failed to administer medications according to physician orders for one of seven sampled residents (Resident 2) when Resident 2 had an order for the administration of one inhalation (drawing the medication into the lungs) of Breo Ellipta Inhalation Aerosol Powder (a medication to treat inflammation of the lungs) 200-25 MCG (micrograms-unit of measurement)/ACT (actuation - refers to a single spray, puff, or activation of an inhaler) and Resident 2 inhaled two doses of the medication. This failure resulted in Resident 2 receiving twice ordered the dose of Breo Ellipta Inhalation Aerosol Powder 200-25 MCG/ACT and placed Resident 2 at risk of medication overdose. Findings:During a concurrent observation and interview on 4/21/26 at 9:05 a.m. with Registered Nurse (RN) 2 in Resident 2's room, RN 2 stated she was going to administer the Breo Ellipta Inhalation Aerosol Powder 200-25 MCG/ACT to Resident 2. RN 2 removed the Breo Ellipta Inhalation Aerosol Powder 200-25 MCG/ACT inhaler from the box and handed it to Resident 2. Resident 2 inhaled one dose. RN 2 directed Resident 2 to inhale a second dose. Resident 2 inhaled a second dose. RN 2 returned the Breo Ellipta Inhalation Aerosol Powder 200-25 MCG/ACT inhaler to the medication cart. The administration instructions attached to Resident 2's Breo Ellipta Inhalation Aerosol Powder indicated one puff inhale orally daily (one time a day).During an interview on 4/21/26 at 10:05 a.m. with Director of Nursing (DON), DON provided Resident 2's Order Summary Report (OSR) (a list of Resident 2's active physician orders) printed 4/21/26 at 9:51 a.m. and stated it contained Resident 2's current physician medication orders.During a review of Resident 2's OSR printed 4/21/26 at 9:51 a.m., the OSR indicated, Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT . 1 puff inhale orally one time a day . Order Date 3/11/26 . Order Status Active. During a review of facility policy and procedure (P&P) titled, Medication - Administration, dated 6/1/17, the P&P indicated, Medication will be administered by a Licensed Nurse per the order of an Attending Physician.

Based on observation, interview, and record review, the facility failed to ensure effective communication for one of one sampled resident (Resident 3) with a hearing deficit, when a communication board was not utilized. This failure resulted in Resident 3's inability to understand the information conveyed.Findings: During a review of Resident 3's Diagnosis Report (DR), dated [DATE], the DR indicated, Resident 3 had a diagnosis of Conductive Hearing Loss [sound is unable to reach the inner ear due to blockages or structural deformities], Bilateral [both ears].During a review of Resident 3's Minimum Data Set (MDS-resident assessment tool), dated [DATE], the MDS indicated, Resident 3 had a Brief Interview for Mental Status (BIMS, 13 to 15 indicates intact cognition [thinking/memory], 8-12 indicates moderate impairment, 0-7 indicated severe impairment) score of 14.During an interview on [DATE] at 8:46 a.m. the surveyor utilized a whiteboard to communicate with Resident 3 due to Resident 3's hearing impairment. Resident 3 was able to understand and respond appropriately by writing their response on the whiteboard. When Resident 3 was asked if staff communicate with him using a whiteboard, Resident 3 responded in writing, No. Resident 3 was asked if he understands what staff are saying when they come into his room. Resident 3 responded in writing, No, they just talk and I can't hear them. Resident 3 was asked if this bothered him and how it made him feel. Resident 3 responded in writing, Yes and Mad.During an observation on [DATE] at 8:55 a.m. in Resident 3's room a staff member walked into the room and verbally told Resident 3 she would come back to change him when he was finished speaking to surveyor. Staff members used hand gestures like she was rubbing her arms and then left the room.During an interview on [DATE] at 8:56 a.m. Resident 3 was asked in writing if he understood what the staff member had verbally communicated to him. Resident 3 wrote No.During an observation on [DATE] at 11:27 a.m. in Resident 3's room, Certified Nursing Assistant (CNA) 1 brought Resident 3 an extra blanket. CNA 1 verbally asked Resident 3, Do you want the blanket one sided or double sided? Resident 3 gave a thumbs up. CNA 1 verbally asked Resident 3, Is that better? Resident 3 did not respond. CNA 1 verbally asked Resident 3, Are you ok? Resident 3 did not respond.During an interview on [DATE] at 11:29 a.m. Resident 3 was asked in writing if he had understood what CNA 1 verbally told him. Resident 3 responded in writing, No. Resident 3 wrote he wanted staff to use the whiteboard to communicate with him.During an observation on [DATE] at 11:39 a.m. in Resident 3's room, CNA 2 walked into the room and verbally asked Resident 3 if he was ready to get up for lunch.During an interview on [DATE] at 11:40 a.m. with Resident 3, Resident 3 was asked in writing if he understood what CNA 2 had verbally told him. Resident 3 wrote; no, he did not understand CNA 2.During an observation on [DATE] at 11:45 a.m. in Resident 3's room, CNA 2 entered Resident 3's room and verbally informed him that she was going to clean him up. CNA 2 verbally informed Resident 3 she was going to raise the bed and continued to speak to Resident 3. Resident 3 did not respond to CNA 2.During an observation on [DATE] at 12:03 p.m. in the dining room, Resident 3 was sitting at a table in his wheelchair. Resident 3 did not have a whiteboard or notepad available for communication. During a concurrent interview and record review on [DATE] at 1:50 p.m. with Director of Nursing (DON), Resident 3's Care Plan Report (CPR), dated [DATE] was reviewed. The CPR indicated, [Resident 3] has a communication problem r/t [related to] Hearing deficit, Oral deformity.requires communication board.Interventions.COMMUNICATION: Resident requires a communication board for people to write on as a form of communication.The resident is able to communicate by using communication board, by pointing at yes or no questions or by pointing at what is written on the board.The resident prefers communicating.use communication board). DON stated staff should be using the whiteboard or a note pad to communicate in writing with Resident 3. During a review of the facility's policy and procedure (P&P), titled, Resident Rights, dated [DATE], the P&P indicated, All residents have the right to a dignified existence, self-determination and communication.The facility must treat each resident with respect dignity and care for each resident in a manner.that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility will protect and promote the rights of the resident and provide equal access to quality care regardless of diagnosis, severity of condition, or payment source.Procedure.D. Be fully informed and participate in his /her treatment including being fully informed in a language that he or she can understand.During a review of the facility's P&P titled, Deaf or Hearing Impaired Resident Care, dated [DATE], the P&P indicated, To assist the resident in adjusting to the facility, reduce anxiety, and promote resident safety.II. Nursing staff will consider the following methods for communication based on the residents need: A. Pencil and paper.C. Communication Board.

Based on interview and record review, the facility failed to review and accurately complete the annual Pre-admission Screening Assessment and Resident Review (PASRR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for one of 18 sampled residents (Resident 38). This failure had the potential for Resident 38 to be placed in an inappropriate setting and not receive required services.Findings:During a review of Resident 38's admission Record (AR), dated 5/10/25, the AR indicated, Resident 38 has diagnosis of Dementia (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain), Schizophrenia (a chronic, severe brain disorder that causes individuals to interpret reality abnormally, characterized by disruptions in thought, perception, and emotion), and Auditory Hallucinations (the perception of hearing sounds-such as voices, music, or buzzing-in the absence of any external physical stimulus).During a concurrent interview and record review on 4/22/26 at 9:16 a.m. with Director of Nursing (DON), Resident 38's PASRR dated 2/11/25 was reviewed. The PASRR letter indicated, If the individual remains in the NF [Nursing Facility] longer than 30 days, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day. DON stated there should have been new PASRR submitted after 3/12/25.During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening and Resident Review (PASRR), dated 7/1/23, the P&P indicated, To ensure that all Facility applicants are screened for mental illness and/or intellectual disability and to ensure coordination with the appropriate state agencies, if indicated.

Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADL - tasks required for self care such as bathing, eating. dressing, transferring, toileting and continence) for one of 18 sampled residents (Resident 4) when nail care and shaving was not provided to a dependent resident. Findings:During a review of Resident 4's admission Record (AR), dated 2/24/26, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses including encephalopathy (dysfunction of the brain that alters brain function).During a review of Resident 4's Minimum Data Set (MDS-Resident assessment tool), dated 2/27/26, the MDS Section GG - Functional Abilities indicated, Resident 4 was dependent on staff assistance to complete personal hygiene (shaving, washing hands, fingernail trimming).During a review of Resident 4's Brief Interview for Mental Status (BIMS - cognitive assessment), dated 4/20/26, the BIMS score indicated, Resident 4's score was 9 (moderately impaired).During a review of Resident 4's Activities of Daily Living [ADL] Care Plan, dated 3/18/26, the ADL Care Plan indicated, Resident 4 had an ADL self-care performance deficit related to impaired balance, limited mobility and acute condition.During an observation on 4/20/26 at 9:35 a.m. in Resident 4's room, Resident 4 was lying in bed, awake and alert. Resident 4 opened his mouth and stringy dry saliva was stuck on his top lip and bottom lip and stated thirsty. Resident 4 had a scruffy unshaven beard approximately one quarter inch in length. Resident 4's fingernails on both hands were untrimmed with dark brown debris underneath his fingernails of his right hand.During a concurrent observation and interview on 4/20/26 at 11:05 a.m., in Resident 4's room with Assistant Director of Nursing (ADON), Resident 4 was lying in bed. Resident 4 stated to ADON that he was thirsty and wanted water with ice. ADON stated Resident 4 had untrimmed fingernails with dirt underneath his nails and had unshaven beard. ADON asked Resident 4 if he wanted to be shaved, and Resident 4 stated yes.During a review of the facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails dated 1/01/26, the P&P indicated, Nail care is given to clean and keep the nails trimmed.

Based on interview and record review, the facility failed to ensure treatments were administered as ordered by the physician for one of three sampled residents (Resident 6). This failure had the potential to result in Resident 6 developing skin breakdown.Findings:During a review of Resident 6's Nursing Quarterly Assessment (NQA), dated 2/26/26, the NQA indicated, Resident 6 had a Braden Skin Risk Score (used to assess a resident's risk for developing a pressure ulcer [damage to the skin usually over bony areas caused by prolonged pressure]) of 13 (score of 13-14 means at moderate risk for skin breakdown).During a review of Resident 6's Order Summary Report (OSR), dated 4/23/26, the OSR indicated, Resident 6 had a physician order for Calmoseptine ointment (used to protect and heal irritated skin) to be applied on his left and right buttocks, and perineum (area between the genitals and the anus) every two hours for skin maintenance.During a concurrent interview and record review on 4/23/26 at 11:59 a.m. with Treatment Nurse (TN), Resident 6's Treatment Administration Record (TAR), dated April 2026 was reviewed. The TAR indicated, there was no documentation Calmoseptine was administered to Resident 6 on 4/14/26 at 12 p.m., 2 p.m., 8 p.m., 10 p.m. TN stated if there was no documentation on the TAR, the Calmoseptine was not administered. TN stated if the Calmoseptine was not administered as ordered by the physician, it would put Resident 6 at risk for skin breakdown.During a concurrent interview and record review on 4/27/26 at 1:09 p.m. with Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Wound Management, dated 1/1/26 was reviewed. The P&P indicated, A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Implement a wound treatment per physician's order. DON stated the P&P was not followed.

Based on interview and record review, the facility failed to ensure:1. The licensed nurses notified the physician in a timely manner when one of four sampled residents (Resident 1) had a change of condition.2. The licensed nurses failed to administer a medication as ordered by the physician for one of four sampled residents (Resident 1).These failures resulted in Resident 1 having abdominal pain and going to the hospital due to delay in care.Findings:During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 2/11/26, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status) score of 8 (score of 8-12 means moderately impaired cognition).During a review of Resident 1's Change in Condition Evaluation (CCE), dated 2/21/26, the CCE indicated, CNA (Certified Nursing Assistant) informed CN (charge nurse) resident (1) has had 3 BMs (bowel movements) with diarrhea (passing loose, watery, or unformed stool three or more times in a single day) . Date and time of clinician notification: 02/21/2026 08:10. Recommendation of Primary Clinician(s): loperamide (medication used to treat diarrhea) 2mg (milligrams - unit of mass) Q8 (every eight hours) PRN (as needed).During a review of Resident 1's Alert Note (AN), dated 2/22/26, the AN indicated, Resident (1) requested to be sent out to (acute hospital) due to diarrhea and abdominal pain, informed NP (Nurse Practitioner), gave order to send resident (1) out.During a review of Resident 1's POC (Point of Care - CNA documentation) Response History (POCRH), dated February 2026, the POCRH indicated, on 2/9/26, Resident 1 had two episodes of loose stools at 5:50 a.m. and 1:30 p.m., on 2/10/26, Resident 1 had two episodes of loose stools at 5:18 a.m. and 1:59 p.m., on 2/11/26, Resident 1 had two episodes of loose stools at 5:55 a.m. and 9:34 p.m., on 2/12/26, Resident 1 had two episodes of loose stools at 4:44 a.m. and 9:06 p.m., on 2/13/26, Resident 1 had one episode of loose stool at 9:55 a.m., on 2/14/26, Resident 1 had two episodes of loose stools at 5:53 a.m., and 9:55 a.m., on 2/15/26, Resident 1 had one episode of loose stool at 5:36 a.m., on 2/16/26, Resident 1 had three episodes of loose stools at 12:11 a.m., 5:04 a.m., and 9:22 p.m., on 2/17/26, Resident 1 had one episode of loose stool at 5:59 a.m., on 2/18/26, Resident 1 had two episodes of loose stools at 9:59 a.m. and 9:37 p.m., on 2/19/26, Resident 1 had three episodes of loose stools at 1:13 a.m., 5:59 a.m., and 10:32 a.m., on 2/20/26, Resident 1 had four episodes of loose stools at 12:06 a.m., 5:24 a.m., 4:24 a.m., and 9:30 a.m., on 2/21/26, Resident 1 had one episode of loose stool at 1:41 p.m., and on 2/22/26, Resident 1 had one episode of loose stool at 5:27 a.m.During an interview on 3/9/26 at 3:05 p.m. with Director of Nursing (DON), DON stated it was considered a change of condition when Resident 1 had three episodes of loose stools within 24 hours.During a concurrent interview and record review on 3/9/26 at 3:15 p.m. with DON, Resident 1's Order Summary Report (OSR), dated 3/9/26, was reviewed. The OSR indicated, Loperamide HCl Oral Tablet Give 2 mg by mouth every 8 hours as needed for diarrhea. hold when no loose stool. Order Date. 02/21/2026. DON stated on 2/21/26, the licensed nurse notified the physician about Resident 1 having diarrhea and the physician ordered loperamide.During a concurrent interview and record review on 3/9/26 at 3:15 p.m. with DON, Resident 1's Medication Administration Record (MAR), dated February 2026, was reviewed. The MAR indicated, there was no loperamide administered for Resident 1 on 2/21/26 and 2/22/26. DON stated, the loperamide should have been administered for Resident 1 on 2/21/26 and 2/22/26 because Resident 1 continued to have loose stools on 2/21/26 and 2/22/26.During a concurrent interview and record review on 3/11/26 at 3:05 p.m. with DON, the facility's policy and procedure (P&P) titled, Change of Condition Notification, dated 6/1/17, was reviewed. The P&P indicated, The Licensed Nurse will notify the resident's Attending Physician when there is. a need to alter treatment. due to change of condition. The Attending Physician will be notified timely with a resident's change in condition. DON stated on 2/9/26 at 5:50 a.m., when Resident 1 started to have episodes of loose stools that continued on 2/10/26 at 5:18 a.m. (three episodes of loose stools within 24 hours), the physician should have been notified on 2/10/26 because this was a change of condition. DON stated the physician was notified of Resident 1's change of condition on 2/21/26 (11 days after Resident 1's change of condition on 2/10/26). DON stated there was a delay in treatment due to poor communication between the nursing staff.

Based on interview and record review, the facility failed to report an allegation of abuse for one of four sampled residents (Resident 1) within 24 hours. This failure resulted in delayed investigation of abuse and had the potential to place Resident 1 at risk for further abuse. Findings: During a review of Resident 1's admission Record (AR), dated 3/4/26, the AR indicated, DIAGNOSIS. UNSPECIFIED DEMENTIA (decline in mental ability such as memory, thinking or behavior that are severe enough to interfere with daily life) . ANXIETY (feeling of fear, dread, and uneasiness) . ALZHEIMER'S DISEASE (progressive, irreversible brain disorder that slowly destroy memory, thinking skills, and eventually the ability to perform simple tasks) . DEPRESSION (persistent feeling of sadness and loss of interest in activities) . COGNITIVE COMMUNICATION DEFICIT (difficulty with speaking, listening, reading, or writing caused by disrupted thinking skills) . NEED FOR ASSISTANCE WITH PERSONAL CARE.During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 12/4/25, the MDS indicated in Section C, Resident 1 was rarely/never understood, had a memory problem, and her cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated in Section GG, Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating.During a review of Resident 1's Change in Condition Evaluation (CCE), dated 2/26/26, the CCE indicated, CNA (Certified Nursing Assistant 1) reported witnessing resident's (Resident 1) sister (Family Member [FM] 1) slap resident (1) on her right side of face. Upon evaluation, resident (1) noted with green/yellow discoloration to right facial cheek.During a review of the facility's 5-Day Investigation Summary (FDIS) dated 2/26/26, the FDIS indicated, On 02/26/2026, CNA (1) reported that approximately three weeks prior (2/1/26) (CNA 1) allegedly observed (FM 1) strike the resident (1) during a feeding interaction. The CNA (1) acknowledged that (CNA 1) did not report the alleged (physical abuse) incident to administration at the time it occurred (2/1/26) . Investigation identified delayed reporting by CNA (1).During an interview on 3/4/26 at 10:43 a.m. with Administrator, Administrator stated CNA 1 reported the alleged physical abuse incident (FM 1 slapping Resident 1 on the face on 2/1/26) to the administration on 2/26/26. Administrator stated, Yes, we have a delay in reporting (alleged physical abuse incident [FM 1 slapping Resident 1 on the face on 2/1/26]) by the CNA (1), she (CNA 1) should have reported right away (2/1/26).During an interview on 3/6/26 at 1:48 p.m. with CNA 1, CNA 1 stated when she went to Resident 1's room to drop off linen on 2/1/26, CNA 1 saw FM 1 grab Resident 1's hair and slap Resident 1 back and forth on the face. CNA 1 stated CNA 1 reported the alleged physical abuse incident (FM 1 slapping Resident 1 on the face on 2/1/26) to Licensed Vocational Nurse (LVN) 1 immediately and LVN 1 told CNA 1 to shut up, to not say anything, and to mind our own business.During an interview on 3/6/26 at 2 p.m. with LVN 1, LVN 1 stated he did not remember what date it was when CNA 1 approached him, and CNA 1 told him Resident 1 was being aggressive. LVN 1 stated CNA 1 did not report to him the alleged physical abuse incident (FM 1 slapping Resident 1 on the face on 2/1/26).During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated 6/25/25, the P&P indicated, Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adults. The facility will report allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime. i. Immediately, by phone, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman. ii. No later than 24 hours after forming the suspicion - if the alleged violation. does not involve abuse and does not result in serious bodily injury. ii. Reporting requirements are based on real (clock) time, not business hours.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and Resident 3) were able to receive phone calls and outside confidential communication from services outside of the facility. This failure had the potential to violate Resident 2 and Resident 3's rights.Findings:During an interview on 12/18/25 at 3:45 p.m. with the Long-Term Care Ombudsman (LTCO), LTCO stated he has a hard time contacting residents at the facility by phone. LTCO stated at times the calls go unanswered and other times they will be sent to voicemail, he stated he cannot leave voicemail due to the nature of his work, he must keep communication confidential. LTCO stated on 10/31/25 he called the facility; the receptionist answered the call and then transferred the call to the nurses' station; the call went unanswered at the nurses' station and was delivered to voicemail. LTCO stated on 11/17/25 he called the facility three times, each time the receptionist would answer the call and then transferred the call to the nurses' station, the calls went unanswered at the nurses' station and were then delivered to voicemail. LTCO stated on 11/19/25 he called the facility three times, the calls were answered by the receptionist and then transferred to the nurses' station, the calls went unanswered at the nurses' station and were then delivered to voicemail. LTCO stated the residents' rights to have private and confidential communications are being violated.During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 11/19/25, the MDS indicated, Resident 2' s BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 14 (13 to 15 points indicates the resident has cognitive intactness).During an interview on 12/19/25 at 12:12 p.m. with Resident 2, Resident 2 stated he does not have a cell phone and receive calls via the facility phone. He stated he had been told by others that they had called him at the facility, but the calls do not get put through to him.During an interview on 1/26/26 at 10:58 a.m. Family Member (FM) 1, FM 1 stated during the hours of 8 a.m. to 4 p.m. she can get in contact with Resident 3 on the phone but after the receptionist goes home it is a nightmare, she stated she cannot get anyone on the phone.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 10/1/17, the P&P indicated, All residents have a right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. The Facility will ensure that the resident can exercise his or her rights without interference . Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. E. Privacy and confidentiality including the right to privacy in his/her specific oral, written, and electronic communications; . L. Use a telephone in privacy .

Based on interview and record review, the facility failed to provide a home medication list for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not to understand how and when to take his needed home medications. Findings: During an interview on 1/12/26 at 3:17 with Licensed Vocational Nurse (LVN) 1, LVN 1 stated upon discharge residents were provided with their medications, with a list of home medications with instruction on how to take the medication. LVN 1 stated the nurses educated the resident on the home medication list and instructions, once the education is completed, she has the resident sign the home medication list to prove the education was completed. During a concurrent interview and record review on 1/12/26 at 3:38 p.m. with Director of Nursing (DON), Resident 1's Discharge Instruction Form, (DIF) dated 12/8/25, was reviewed. The DIF, indicated, Resident 1's medications were provided at discharge, none were listed on Resident 1's DIF. The DIF, indicated See Attachment. DON confirmed no evidence Resident 1 received home medications list upon discharge. The facility's policy and procedure were requested on 1/27/26, 1/28/26 and 2/3/26 but none were received.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received all their personal belongings upon discharge. This failure had the potential for Resident 2 to have missing items upon discharge.Findings: During a review of Resident 2's admission Record, (AR) the AR indicated, Resident 2 was admitted on [DATE] and discharged on 12/1/25. During a review of Resident 2's Inventory List, (IL) dated 11/6/2, the IL indicated Resident 2 had two grey t-shirts and one white sheet upon admission. During a concurrent interview and record review on 1/12/26 at 3:38 p.m. with Director of Nursing (DON), Resident 2's IL, dated 11/6/25 was reviewed. DON stated there was no evidence that Resident 2 received his belongings upon discharge on [DATE]. During a review of the facility's policy and procedure (P&P) titled, Theft Prevention, revised 11/1/17, the P&P indicated, The facility is committed to preventing the misappropriation of resident property. The facility will exercise reasonable care for the protection of resident's property from theft and loss. II. Measures to secure Personal Property A. At the time of admission and discharge, Facility staff complete . Resident Inventory. i. Upon admission and upon request thereafter, the Facility provides the resident and/or his/her representative with a copy of the Resident Inventory. G. Upon the discharge . the facility provides the resident or his/her representative with a copy of the Resident Inventory and the resident's property and obtains a signed receipt from the recipient.

Based on interview and record review, the facility failed to follow the policy and procedure (P&P) on Psychotherapeutic Drug (medication used to treat mental health disorders) Management for one of ten sampled residents (Resident 1) when Resident 1:1. Was not provided non-pharmacological (without using medications) interventions when Resident 1 verbalized increased sadness.2. Was not monitored every shift for 72 hours after his Lexapro (antidepressant [medication that treat depression [persistent feeling of sadness and loss of interest]-Lexapro black box warning, which is the U.S. [United States] Food and Drug Administration [FDA] most serious warning for prescription drugs. The warning states that anti-depressants can increase the risk of suicidal thoughts [thoughts of ending one's own life] .) dosage was increased.These failures resulted in Resident 1 being found with several layers of clear tape (plastic) over his mouth, cloth (cotton fabric) around his neck and ankles, hands were tied together, a white string (multiple strands twisted together) was tied from his hands to his feet, and with no signs of life.Findings:During a review of Resident 1's admission Record (AR), dated 9/4/25, the AR indicated, Resident 1 was admitted to the facility on [DATE]. The AR indicated, DIAGNOSIS. PARAPLEGIA, INCOMPLETE (partial loss of function on the lower body) . MAJOR DEPRESSIVE DISORDER (mood disorder [mental health condition that primarily affects a person's emotional state] that causes a persistent feeling of sadness and loss of interest).During a review of Resident 1's Quarterly Minimum Data Set (MDS - an assessment tool), dated 8/21/25, the MDS indicated on section C (Brief Interview for Mental Status), Resident 1 had a score of 15 (cognitively intact [has sufficient mental capacity to think, learn, reason, and solve problems effectively]). The MDS indicated on section D (Mood), Resident 1 had no thoughts he would be better off dead, or of hurting himself in some way. The MDS indicated on section GG (Functional Abilities - capacity of an individual to perform tasks), Resident 1 had functional limitation in range of motion (limited ability to move a joint [part of the body where two or more bones meet to allow movement] that interferes with daily functioning) on both of his legs and was wheelchair bound (person requiring a wheelchair to get around). The MDS indicated, Resident 1 required set up or clean-up (resident completes the activity and staff assists only prior to or following the activity) assistance with lying to sitting on side of the bed, and chair or bed to chair transfer. The MDS indicated, Resident 1 required supervision or touching assistance with rolling left and right on bed and sitting to lying on the bed. The MDS indicated, Resident 1 was unable to stand and walk.During a review of Resident 1's Documentation Survey Report (DSR - ADL [Activities of Daily Living - basic self-care tasks needed to live independently] flowsheet), dated September 2025, the DSR indicated, on 9/1/25 night shift, CNA 1 documented Resident did not require assistance with lying to sitting on side of the bed, rolling left and right on bed, and sitting to lying on bed.During a review of Resident 1's Care Plan (CP - personalized, written document that outlines an individual's specific health conditions, needs, goals, and preferences), initiated and revised on 5/4/22, the CP indicated, Problem. (Resident 1) prefers to get up late and stay in bed. Interventions (any treatment or action that staff perform to enhance resident outcomes) . Check with resident for concerns and needs during rounds, med (medication) pass, activities, room visit. The CP indicated, Problem. (Resident 1) has history of unwanted sexual behaviors towards specific staff by exposing himself and touching himself in the presence of female staff. Interventions. Safety check during care (visualizing residents), rounds, med pass, room visit, activities. The CP indicated, Problem. (Resident 1) has a DX (diagnosis) of Major Depressive Disorder m/b (manifested by) verbalized increased sadness on 8/28/2025. Interventions. Lexapro. Monitor AD (Antidepressant): SIDE EFFECTS. Suicidal Ideations (thoughts of ending one's own life) . Monitor behavior m/b verbalization of sadness due to health related issues QS (every shift).During a review of Resident 1's Order Summary Report (OSR), dated 9/4/25, the OSR indicated, Lexapro Oral Tablet 20 mg (milligrams - unit of measurement) . Give 1 tablet by mouth one time a day for M/B verbalization of sadness due to health-related issues related to MAJOR DEPRESSIVE DISORDER. Order Date. 08/28/2025. Start Date. 08/29/2025.During a review of Resident 1's Medication Administration Record (MAR), dated August 2025, the MAR indicated, Resident 1 was administered Lexapro 15 mg once daily until 8/28/25 and was administered Lexapro 20 mg once daily starting on 8/29/25. The MAR indicated, Resident 1 was monitored for side effects of Lexapro (Dystonia [movement disorder causing the muscles to contract]: torticollis [stiffness of neck], Anti-cholinergic symptoms [dry mouth, blurred vision, constipation, urinary retention] Hypotension [low blood pressure], Sedation or drowsiness, Increased falls or dizziness [feeling faint or weak], Cardiac [referring to the heart] abnormalities, Anxiety [feeling of worry or nervousness] agitation [feeling of irritability], Blurred vision, Sweating/rashes, Headache, Urinary retention [unable to empty all the urine from the bladder] or hesitancy [difficulty urinating], Weakness, Appetite change or weight change, Insomnia [inability to sleep], Confusion, Tardive dyskinesia [Lip smacking or chewing, abnormal tongue movement, involuntary contraction of the arms or legs, rocking or swaying], Suicidal Ideations) every shift and there were no side effects noted for the month of August. The MAR indicated Resident 1 was monitored for episodes of verbalization of sadness and verbalization of nervousness every shift and there were no episodes noted for the month of August.During a review of Resident 1's Psychiatric (relating to mental illness) Consult (PC), dated 8/25/25, the PC indicated, Resident 1 was seen by the psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) with the objective, Verbal complaints of increased depression and anxiety due to decline in health and environment, keeps to self. The PC indicated the psychiatrist increased Resident 1's Lexapro to 20 mg once daily. The PC indicated Resident 1 had no suicidal ideation.During a review of Resident 1's Nurses Notes (NN), documented by Licensed Vocational Nurse (LVN) 1, dated 9/2/25 indicated, Notified by CNA (Certified Nursing Assistant) (3) at 0945 that resident (1) was unresponsive (does not respond to sound, touch, or pain). Responded to room resident (1) immediately. Resident (1) not breathing, no respirations (breathing), unresponsive to tactile stimuli (sensory input received through touch). Resident (1) had tape over his mouth and cloth around his neck and ankles. I noticed that his hands were tied together, and a string was tied from his hands to his feet. Called for assistance to room. Current code status (type of emergent treatment a person would or would not receive if their heart or breathing were to stop) DNR (Do Not Resuscitate). RN (Registered Nurse/Director of Nursing [DON]) assessed resident (1). No signs of life, no respirations, no pulse (regular beating of the heart that can be felt by touching certain parts of the body). Current code status DNR. BPD (Bakersfield Police Department) notified. MD (Medical Doctor) notified of resident status. Emergency contact notified. Nephew in Mexico notified of resident status. BPD and Emergency response onsite at 1008. Corners [sic] (an official who investigates violent, sudden, or suspicious deaths) arrived to pick up body at 1256.During a review of Resident 1's Death Record (DR), dated 9/2/25, the DR indicated, Resident 1's date and time of death was 9/2/25 at 9:58 a.m.During a review of Resident 1's Summary of Incident (SI), documented by Administrator, dated 9/4/25, the SI indicated, On September 2, 2025, at approximately 9:45 AM, staff (CNA 3) discovered resident (1) unresponsive in his bed. Emergency response protocols were initiated, and 911 (emergency response number) was called. Law enforcement and the coroner's office responded. The coroner ruled the death a suicide (act of intentionally causing one's own death), pending autopsy (medical examination of a body after death to determine the cause of death) results.During a review of Resident 1's County of [NAME] Certificate of Death (CKCD), dated 9/2/25, the CKCD indicated Resident 1's immediate cause of death was Neck Compressions (occurs when a mechanical force [push or pull that results from the direct physical interaction of objects] was applied to the front or around the neck).During an interview on 9/4/25 at 3:58 p.m. with DON, DON stated Director of Staff Development (DSD) called her into Resident 1's room on 9/2/25 at around 9:45 a.m. DON stated she saw Resident 1 in bed bound by his wrist, had a tape on his mouth, his face was swollen and had a cloth around his neck. DON stated she removed the tape (DON stated it was a white tape that may have been more than one piece, enough to cover his whole mouth) on Resident 1's mouth and he had gauze inside his mouth, he was not breathing. DON stated she loosened the cloth around Resident 1's neck, and Resident 1 was still not breathing. DON stated the cloth around Resident 1's neck looked like some type of cut up blanket. DON stated facility staff called 911, and BPD and the homicide team (unit in a police department that investigates deaths) came.During an interview on 9/10/25 at 2:10 p.m. with Treatment Nurse (TN) 1, TN 1 stated the tape on Resident 1's mouth on 9/2/25 was a surgical tape (medical adhesive tape used to attach bandages, gauze, and other dressings to the skin around wounds) but it was thicker, and the facility did not have this kind of tape. TN 1 stated on 9/2/25, Resident 1's both hands and feet were tied with white cloth that looked like a rolled up sheet.During an interview on 9/10/25 at 2:21 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse assigned to Resident 1 on 9/2/25 morning shift (6 a.m. to 2 p.m.). LVN 1 stated on 9/2/25, she did her rounds at the beginning of her shift at around 7 a.m. and saw Resident 1 covered with a thick multicolored (blue, green, and red) blanket over his head. LVN 1 stated she did not see anything unusual. LVN 1 stated Resident 1 would normally sleep with his blanket over his head, so LVN 1 assumed Resident 1 was okay. LVN 1 stated CNA 3 (first person to see Resident 1 on 9/2/25) would normally greet Resident 1 in the morning and when CNA 3 went to Resident 1's room on 9/2/25, CNA 3 found Resident 1 unresponsive at around 9:40 a.m. LVN 1 stated she was called into Resident 1's room and LVN 1 saw Resident 1 with a tape on his mouth (LVN 1 stated it was a clear tape that was about half an inch with a material thinner than a surgical tape), both hands were tied together with a white string that was tied down to his ankles, and both ankles were also tied together. LVN 1 stated Resident 1's blanket had holes at the end with a string tied up to the bed frame at the foot of the bed. LVN 1 stated there was also a white cloth tied around his neck. LVN 1 stated Resident 1 had a white string ( thicker than yarn with the same thickness of a shoestring) used to tie his hands and feet. LVN 1 stated CNA 2 was the CNA assigned to Resident 1 on 9/2/25 morning shift. LVN 1 stated according to facility policy, the CNAs should do their rounds every two hours to look at the residents and to see if they need any assistance.During an interview on 9/11/25 at 9:50 a.m. with CNA 3, CNA 3 stated she was not the CNA assigned to Resident 1 on 9/2/25 morning shift (6 a.m. to 2 p.m.). CNA 3 stated she went to Resident 1's room on 9/2/25 at around 9:45 a.m. to greet Resident 1. CNA 3 stated, I see his bed all the way up. He was covered with his blanket. It was so tucked in under his head, arms, legs, body. CNA 3 stated when she tapped Resident 1's right leg, his right leg was hard, and Resident 1 did not respond. CNA 3 stated she had to pull the blanket down hard until his neck area and she saw Resident 1 had tape on his mouth. CNA 3 stated she notified staffing coordinator (SC). CNA 3 stated SC and her pulled Resident 1's blanket lower to Resident 1's feet and saw his hands and ankles were tied up. CNA 3 stated SC called the nurses, DON, and Administrator to come to Resident 1's room. CNA 3 stated when she was assigned to Resident 1, usually every morning Resident 1 would be covered with his blanket up to his head but would move his head when asked if he was okay. CNA 3 stated Resident 1 would usually lay on his left side but on 9/2/25 she saw Resident 1 lying on his back with his blanket tucked under his body like a mummy (preserved dead body wrapped in bandages).During an interview on 9/12/25 at 9:52 a.m. with LVN 2, LVN 2 stated he was the nurse assigned to Resident 1 on 9/1/25 night shift (11 p.m. to 7:30 a.m.). LVN 2 stated the last time he saw Resident 1 alive was on 9/2/25 at 1:30 a.m. when Resident 1 pressed his call light and asked for his urinal to be emptied. LVN 2 stated he called CNA 1 to Resident 1's room to provide Resident 1 with assistance. LVN 2 stated he never saw Resident 1 again after 1:30 a.m. on 9/2/25. LVN 2 stated during change of shift at around 7 a.m., the facility's routine was to do rounds (every change of shift) but not necessarily checking on each resident because the nurses know Resident 1 very well. LVN 2 stated he was aware Resident 1 was taking antidepressants and Resident 1 was being monitored for side effects of antidepressants including suicidal ideation. LVN 2 stated Resident 1 was a well-known resident with no issues, and they would not look at this kind of resident during change of shift rounds. LVN 2 stated he relied on the CNAs to tell him if there was something unusual about the residents because the CNAs were expected to do their rounds every two hours. LVN 2 stated he was not sure if CNA 1 did her rounds every two hours on 9/1/25 night shift.During an interview on 9/16/25 at 10:20 a.m. with DSD, DSD stated CNAs were expected to do rounds for all the residents every two hours unless there was an order for hourly monitoring. DSD stated, If the resident is independent, (CNAs) are still supposed to check on the residents visually and make sure the residents are there and make sure they are alive and breathing. DSD stated the CNAs do not document their rounds every two hours.During an interview on 9/16/25 at 10:56 a.m. with CNA 2, CNA 2 stated she was the CNA assigned to Resident 1 on 9/2/25 morning shift (6 a.m. to 2 p.m.). CNA 2 stated she went to Resident 1's room on 9/2/25 at around 6:25 a.m. and saw Resident 1 lying in bed covered with an animal-designed blanket from head to toe. CNA 2 stated at around 9 a.m. she went to Resident 1's room to give a shower to his roommate but she did not look at Resident 1. CNA 2 stated she emptied Resident 1's trash a few minutes after 9 a.m. and saw Resident 1 was still covered with a blanket from head to toe, his bed was a little higher, and the head of the bed was flat. CNA 2 stated Resident 1's bed was not that high and it was normal for him. CNA 2 stated she left Resident 1's room on 9/2/25 at 9:25 a.m. then SC called CNA 2 to Resident 1's room and told her Resident 1 had passed away at around 9 something. CNA 2 stated she was supposed to check on all the residents assigned to her every two hours, even if the resident was alert with a BIMS of 15, to see if they were doing okay and to check if they were breathing.During an interview on 9/17/25 at 3:28 p.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 9/1/25 night shift (10 p.m. to 6 a.m.). CNA 1 stated the last time she talked to Resident 1 was on 9/1/25 at around 10 p.m. when she asked him if he needed some ice. CNA 1 stated she emptied Resident 1's urinal between 1:30 a.m. to 2 a.m. and Resident 1 was asleep in bed. CNA 1 stated when she was doing her rounds at around 2:35 a.m., Resident 1 was still asleep with a thin plain white sheet covering his chest down. CNA 1 stated she looked at Resident 1 briefly at around 3:45 a.m. but did not see his face and she was not sure if he was still breathing because the room was dark. CNA 1 stated she went to Resident 1's room at around 5:45 a.m. but did not see Resident 1 because his curtain was drawn. CNA 1 stated on 9/1/25 night shift, Resident 1 had the thin plain white sheet on him and had no other blankets on his bed. CNA 1 stated she would only go to Resident 1 when he presses his call light to ask for help. CNA 1 stated she only did rounds every two hours for those who are not alert, with behaviors, or unable to use call lights. (Based on staff interviews, CNA 1's description of Resident 1's blanket was different from LVN 1 and CNA 2's description).During a concurrent interview and record review on 12/10/25 at 3 p.m. with DON, Resident 1's CP, dated 8/28/25, the CP indicated, Problem. (Resident 1) is on antidepressant medication (Lexapro). Resident verbalized increased sadness on 8/28/2025. Interventions. NON-PHARMACOLOGICAL INTERVENTION for BEHAVIOR MANAGEMENT prior to give psychotropic meds: 1) 1:1 (one on one resident supervision); 2) Activity; 3) Adjust room temperature; 4) Backrub; 5) Change position; 6) Give fluids; 7) Give food; 8) Redirect; 9) Refer to nurse's notes; 10) Remove resident from environment; 11) Return to room; 12) Toilet; 13) Provide medication(s) as ordered; 14) Other. DON stated the licensed nurses were supposed to provide Resident 1 non-pharmacological interventions for behavior management on 8/28/25 when Resident 1 verbalized increased sadness.During a concurrent interview and record review on 12/10/25 at 3 p.m. with DON, Resident 1's MAR, dated August 2025 was reviewed. The MAR indicated, NON-PHARMACOLOGICAL INTERVENTION for BEHAVIOR MANAGEMENT R/t on psychotropic meds: 1) 1:1 (one on one resident supervision); 2) Activity; 3) Adjust room temperature; 4) Backrub/Massage; 5) Change position; 6) Give fluids; 7) Give food; 8) Redirect; 9) Refer to nurse's notes; 10) Remove resident from environment; 11) Return to room; 12) Toilet; 13) Music, Radio, TV; 14) Other. The MAR indicated, on 8/28/25, the licensed nurses documented 15 for day, evening, and night shift. The MAR indicated, on 8/28/25, there was no non-pharmacological intervention for behavior management provided. DON stated the licensed nurses were supposed to document codes 1-14 corresponding to the non-pharmacological intervention indicated on the physician's order. DON stated the licensed nurses were supposed to provide Resident 1 non-pharmacological interventions for behavior management on 8/28/25 when Resident 1 verbalized increased sadness.During a concurrent interview and record review on 12/10/25 at 3 p.m. with DON, Resident 1's Nurses Notes (NN), dated 8/28/25-9/1/25, the NN indicated, on 8/29/25 day and evening shift, Resident 1 was on 72-hour monitoring for the new physician's order to increase his Lexapro's dose from 15 mg to 20 mg due to increased verbalization of sadness. The NN indicated no documentation of 72-hour monitoring on 8/28/25 day, evening, and night shift, 8/29/25 night shift, and 9/1/25 day, evening, and night shift. DON stated the licensed nurses were supposed to monitor Resident 1 every shift for 72 hours (8/28/25 evening shift until 9/1/25 night shift). DON stated the licensed nurses were supposed to look at Resident 1 to check for any adverse effects from Lexapro including suicidal ideation, and to provide any intervention as needed.During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 5/19/25, the P&P indicated, To ensure residents only receive psychotherapeutic medications when other nonpharmacological interventions are clinically contraindicated and that residents only remain on psychotherapeutic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated. Nursing Responsibility. Monitoring should also include evaluation of the effectiveness of non-pharmacological approaches prior to administering PRN (as needed) medications. Implements and updates the care plan as indicated.

Based on observation, interview and record review, the facility failed to provide a sanitary environment for two of three residents (Resident 1 and Resident 2) when:Resident 1's bathroom had a foul smell. The bathroom tiles in three of four shower rooms used by Resident 2 and other residents were not cleaned.These failures had the potential for unpleasant experience for Resident 1 and Resident 2.Findings:1. During a concurrent observation and interview on 9/3/25 at 10:40 a.m. with Resident 1 in his room, Resident 1 was in his bed facing the bathroom. Resident 1 stated the bathroom had a strong foul and unpleasant smell. The bathroom smelled of urine and bleach like smell.During a concurrent observation and interview on 9/3/25 at 10:55 a.m. with Housekeeping Staff (HS), HS entered Resident 1's bathroom and stated the smell was not pleasant. HS stated another resident used to urinate on the floor in that bathroom and housekeeping was having a difficult time removing the urine odor.2. During an interview on 9/3/25 at 11:10 a.m. with Resident 2 in her room, Resident 2 stated the shower rooms were soiled (not cleaned) and stated had disgusted her.During a concurrent observation and interview on 9/3/25 at 11:15 a.m. with Housekeeping Supervisor (HSUP), HSUP stated there were four resident shower rooms in the facility. The tiles in Shower room [ROOM NUMBER], Shower room [ROOM NUMBER], and Shower room [ROOM NUMBER] had dark stains. HSUP stated the dark stains were buildup from steam, and that staff should wash the tiles and remove them.During a review of the facility's policy and procedure (P&P) titled, Housekeeping - General, dated the August 16, 2023, the P&P indicated, All room of the Facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents.

Based on observation, interview and record review, the facility failed to manage the pain of one of three residents (Resident 4) when Resident 4 reported pain to Certified Nursing Assistant (CNA) A and CNA B but did not inform the Licensed Nurse (LN) C. This failure had the potential for Resident 4 suffering in pain.Findings:During a review of Resident 4's admission Record (AD), undated, the AD indicated Resident 4 was admitted on [DATE] and had diagnoses including Alzheimer's disease (memory loss), muscle weakness, abnormalities of gait and mobility, and pain.During a concurrent observation and interview on 9/3/25 at 10:15 a.m. in Resident 4's room, Resident 4 was lying in bed with Family Member (FM) 4 at bedside. FM 4 stated Resident 4 had dementia (memory loss) but was able make needs known.During an observation on 9/3/25 at 11:40 a.m. in Resident 4's room, CNA A and CNA B were providing care to Resident 4. During care, Resident 4 reported to CNA A and CNA B that he had pain in his arms. CNA A and CNA B left the room, and there was no pain relief interventions were provided to Resident 4.During a concurrent observation and interview on 9/3/25 at 12:20 p.m. (40 minutes later) with LN C in the hallway in front of Resident 4's room, LN C stated she was Resident 4's nurse and that no one had informed her Resident 4 had pain. LN C went to Resident 4's room and asked Resident 4 if he was in pain. Resident 4 reported pain in his arms rated level five (on zero to 10 scale where zero is no pain and 10 is the worst pain).During an interview on 9/3/25 at 1:55 p.m. with the Director of Nursing (DON), DON stated CNAs should immediately inform the resident's LN whenever a resident reports pain. DON stated the LN should then immediately assess the resident for pain and provide appropriate pain interventions.During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated the June 1, 2017, the P&P indicated, Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain.

Based on observation, interview and record review, the facility failed to implement the fall prevention intervention of keeping the bed in the low position for one of three residents (Resident 4) who was high risk for falls. This failure had the potential to place Resident 4 at the risk for falls and injury.Findings:During a review of Resident 4's admission Record (AD), undated, the AD indicated, Resident 4 was admitted on [DATE] and had diagnoses including Alzheimer's disease (memory loss), muscle weakness, abnormalities of gait and mobility and pain.During a review of Resident 4's Assessment Outcomes Record (AOR), dated [DATE], the AOR indicated, Resident 4 had a fall risk assessment score of 50 (scores of 45 or higher indicate high fall risk).During a review of Resident 4's Care Plan Report (CPR), dated [DATE], the CRP indicated, The resident needs a safe environment with. the bed in the low position.During a concurrent observation and interview on [DATE] at 10:15 a.m. in Resident 4's room, with Family Member (FM) 4, Resident 4 was lying in bed on a low bed (a specialty bed that lowers close to the floor with the purpose of mitigating the risk of injury in case of a fall from the bed and is used for residents at risk for falls). During a concurrent interview, FM 4 stated he was concerned about Resident 4 falling from the bed because Resident 4 attempted to get out of bed unassisted. Resident 4's bed was not in the low position, at the height of a regular bed.During a concurrent observation and interview on [DATE] at 10:16 a.m. with Licensed Nurse (LN) C stated Resident 4's bed was not at the low position. LN C then lowered Resident 4's bed at least one foot closer to the floor. LN C stated Resident 4 was at risk for falls and his bed should always be kept in the low position.During an interview on [DATE] at 1:55 p.m. with the Director of Nursing (DON), DON stated Resident 4's bed should be kept at the low position according to his fall prevention care plan.During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated the [DATE], the P&P indicated, Universal Fall Prevention Measures for all Residents.place bed in lowest position.

Based on interview and record review, the facility failed to timely develop a baseline care plan with fall prevention interventions for two of three residents (Resident 1 and Resident 4) who were high risk for falls. This failure had the potential to place Resident 1 and Resident 4 at risk for falls and injury.Findings:During a review of Resident 1s admission Record (AD), undated, the AD indicated, Resident 4 was admitted on [DATE] with diagnoses including muscle weakness and abnormalities of gait and mobility.During a review of Resident 1's Assessment Outcomes Record (AOR), dated [DATE], the AOR indicated, Resident 1's fall risk assessment score of 60 (scores of 45 or higher indicate high fall risk).During a review of Resident 1's Care Plan Report (CPR), undated, the CRP indicated a fall prevention care plan was first created for Resident 1 on [DATE], 26 days after his admission.During a review of Resident 4's AD, undated, the AD indicated, Resident 4 was admitted on [DATE] and had diagnoses including Alzheimer's disease (memory loss), muscle weakness, and abnormalities of gait and mobility.During a review of Resident 4's AOR, dated [DATE], the AOR indicated, Resident 4 had a fall risk assessment score of 50 (scores of 45 or higher indicate high fall risk).During a review of Resident 4's CPR, undated, the CRP indicated, a fall prevention care plan was first created for Resident 4 on [DATE], seven days after admission.During a concurrent interview and record review on [DATE] at 1:55 p.m. with the Director of Nursing (DON), DON stated Resident 1 and Resident 4 were assessed to be at a high risk for falls upon admission but no baseline care plan with fall prevention interventions was developed for them. DON stated a fall prevention care plan was first created for Resident 1 on [DATE], 26 days after admission, and for Resident 4 on [DATE], seven days after admission. DON stated baseline care plans addressing residents' needs should be created within 72 hours of admission.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated the [DATE], the P&P indicated, The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission.During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated the [DATE], the P&P indicated, The Nursing Staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of fall.

Based on interview and record review, the facility failed to provide and accurately document physical therapy (PT - branch of healthcare for the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), occupational therapy (OT -branch of healthcare that helps people adapt to challenges in their daily lives, like getting dressed, eating, or working, by improving their ability to perform those activities) services and speech therapy (branch of healthcare that helps people with difficulties talking, understanding language, or swallowing) services, when the facility therapy staff inaccurately documented the time spent providing therapy to 11 of 11 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11). This failure resulted in Resident 1's right hand contracture (when one or more fingers get stuck in a bent position and can't be straightened) to worsen and had the potential to negatively impact the physical conditions for Resident 2, Resident 3, Resident 4 , Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11. Findings: During a review of Resident 1's ADMISSION RECORD (AR), dated [DATE], the AR indicated, Resident 1 was admitted to the facility on [DATE]. The AR indicated Resident 1 had a diagnosis of Dementia (A brain disorder that affects thinking, movement, behavior, and mood, often causing visual hallucinations and changes in alertness), and neurocognitive disorder with Lewy bodies (a progressive brain disorder characterized by the presence of Lewy bodies[little clumps of a protein that abnormally form inside brain cells] in brain cells, leading to cognitive decline, movement issues, and behavioral changes). During a review of Resident 1's Minimum Data Set (MDS - an assessment tool) under the section BIMS (Brief Interview for mental status) - an assessment of cognition [how well a person thinks, remembers, and learns]) Evaluation, the BIMS indicated, Resident 1 had a score of 99 (due to resident condition not able to assess cognition [how well a person thinks, remembers, and learns] function). The MDS under the section GG (an assessment of the level a care a resident required), dated [DATE], the GG indicated, Resident 1 was completely dependent on staff for all activities of daily living (ADL -the basic things we do every day to take care of ourselves, like eating, dressing, bathing, and using the bathroom). During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, Resident 1 had a potential for contractures (when your skin, muscles, tendons [tough, ropelike cords that connect muscles to bones, enabling movement], or ligaments [tough tissues that act like ropes or bands connecting bones to other bones providing stability and allowing for movement] get permanently stiff or shortened, making it hard to move the affected area). During a review of Resident 1's Physician Order (PO), dated [DATE], the PO indicated Resident 1 was to have OT twice a week for six weeks to reduce the risk of increased contractures and skin breakdown. During a review of Resident 1's OT Evaluation & Plan of Treatment (OTEPT), dated [DATE], the OTEPT indicated, Resident 1 was to be seen by OT two times a week for six weeks from [DATE] to [DATE] with an intensity of daily. The OTEPT indicated Resident 1, noted with contractures and would benefit from splinting (the application of a device, typically made of rigid material like plaster or metal, to support and immobilize an injured body part) and RNA (Restorative Nursing Assistant - a program to assist residents in regaining or maintaining their functional abilities) edu[cation] in order to reduce risk for skin breakdown and increased contractures. During a review of Resident 1's OT Service Log Matrix (SLM - document used to indicate total amount of minutes was spent on a resident for therapy on specific dates), dated [DATE] [DATE], and February 2025, the SML indicated the following documentation for Resident 1: 1. On [DATE] - 60 total OT minutes provided 2. On [DATE] - 30 total OT minutes provided 3. No further OT minutes provided were documented for the month of December 4. On [DATE] - 15 total OT minutes provided 5. On [DATE] - 30 total OT minutes provided 6. No further OT minutes provided were documented for Resident 1 until [DATE] 7. On [DATE] - 30 total OT minutes provided 8. On [DATE] - 23 total OT minutes provided 9. On [DATE] - 38 total OT minutes provided 10. No further OT minutes provided were documented for Resident 1 until [DATE] 11. On [DATE] - 25 total OT minutes provided 12. No further OT minutes provided were documented for Resident 1 until [DATE] 13. On [DATE] - 38 total OT minutes provided 14. On [DATE] - 38 total OT minutes provided 15. On [DATE] - 38 total OT minutes provided 16. On [DATE] - 38 total OT minutes provided 17. On [DATE] - 25 total OT minutes provided 18. On [DATE] - 24 total OT minutes provided During a review of Resident 1's Occupational Therapy OT Therapy Progress Report (OTPR), dated [DATE], the OTPR indicated: 1. On [DATE] - Resident 1 need for splint was indicated for her right hand contracture and it would be ordered for her use. 2. On [DATE] - Resident 1's splint was still pending. 3. On [DATE] - Resident 1's had not obtained her splint. 4. On [DATE] - Pt (Resident 1) noted with increased contracture to (right) hand would benefit from hand roll splint (a type of splint that uses a rolled or inflatable device to help position the hand and fingers in a way that promotes healing or reduces contractures) . During a concurrent interview and record review on [DATE] at 1:58 p.m. with State Director (SD), Resident 1's Electronic Medical Chart (EMR), dated ,d+[DATE] to [DATE], was reviewed. SD stated on [DATE] a note indicated Resident 1 should have been discharged from therapy services and placed on RNA. SD could not explain why Resident 1 continued to be in therapy services for 15 more days ([DATE]) after the note indicated she (Resident 1) needed to be discharged nor how Resident 1 had less function of her right hand after therapy services were started. SD verified there were therapy notes which indicated Resident 1 was evaluated to need a splint for her right hand contracture on [DATE] and notes which indicated Resident 1 never received the splint she was evaluated to need. SD stated the expectation she had for the facility therapy group staff was for them to document in detail to the best of their ability. During a review of Resident 2's admission MDS under the section BIMS Evaluation, dated [DATE], the BIMS indicated, Resident 2 had a score of 15 (cognition is intact). During an interview on [DATE] at 11:20 a.m. with Resident 2, Resident 2 stated he was admitted to the facility on [DATE]. Resident 2 stated when he is seen by therapy (PT and OT), they spent a total of five to 10 minutes providing therapy services (PT and OT) then the therapy would stop. During a review of Resident 2's PO, dated [DATE], the PO indicated, Resident 2 was to have PT five times a week for four weeks. During a review of Resident 2's PT Evaluation and Plan of Treatment (PTEPT), dated [DATE], the PTEPT indicated Resident 2 was to be seen by PT five times a week daily. During a review of Resident 2 ' s PT Service Log Matrix (SLM), dated [DATE], the SML indicated the following documentation for Resident 2: 1. On [DATE] - 60 total PT minutes provided 2. On [DATE] - 30 total PT minutes provided 3. On [DATE] - 32 total PT minutes provided 4. On [DATE] - 30 total PT minutes provided 5. On [DATE] - 30 total PT minutes provided 6. No further PT minutes provided were documented for Resident 2 until [DATE] ( six days without PT) 6. On [DATE] - 30 total PT minutes provided 7. ON [DATE] - 30 total PT minutes provided During a review of Resident 2's PO, dated [DATE], the PO indicated, Resident 2 was to have OT three times a week for six weeks. During a review of Resident 2's OT Evaluation and Plan for Treatment (OTEPT), dated [DATE], the OTEPT indicated Resident 2 was to receive occupational therapy (OT - therapy focused on daily activities and task) three times a week daily. During a review of Resident 2's (OT) SLM, dated ,d+[DATE], the SLM indicated the following documentation for Resident 2: 1. On [DATE] - 60 total OT minutes provided 2. On [DATE] - 30 total OT minutes provided 3. On [DATE] - 30 total OT minutes provided 4. On [DATE] - 35 total OT minutes provided 5. On [DATE] - 15 total OT minutes provided 6. On [DATE] - 30 total OT minutes provided 7. On [DATE] - 30 total OT minutes provided During an interview on [DATE] at 11:36 a.m. with Family Member (FM) 1, FM 1 stated Resident 3 was provided therapy services by the facility therapy group. FM 1 stated when she observed Resident 3 therapy sessions (could not state which date but stated she was at facility everyday) it lasted about 10 minutes total (was not able to identify exact dates/times and which discipline). During a review of Resident 3 ' s PO, dated [DATE], the PO indicated, Resident 3 was to have OT three times a week for six weeks. During a review of Resident 3 ' s OTEPT, dated [DATE], the OTEPT indicated, Resident 3 was to be seen by OT three times a week for six weeks from [DATE] to [DATE] daily. During a review of Resident 3 ' s OT SLM, dated ,d+[DATE] and ,d+[DATE], the SLM indicated the following documentation for Resident 3: 1. On [DATE] - 60 total OT minutes provided 2. On [DATE] - 30 total OT minutes provided 3. On [DATE] - 30 total OT minutes provided 4. On [DATE] - 35 total OT minutes provided 5. On [DATE] - 40 total OT minutes provided 6. On [DATE] - 30 total OT minutes provided 7. On [DATE] - 30 total OT minutes provided There were no further OT minutes provided on [DATE] until [DATE]. During a review of Resident 3's PO, dated [DATE], the PO indicated, Resident 3 was to have PT five times a week for six weeks. During a review of Resident 3's PTEPT, dated [DATE], the PTEPT indicated, Resident 3 was to be seen by PT five times a week for six weeks from [DATE] to [DATE] daily. During a review of Resident 3's PT SLM, dated ,d+[DATE] and ,d+[DATE], the SML indicated the following documentation for Resident 3: 1. On [DATE] - 60 total PT minutes provided 2. On [DATE] - 30 total PT minutes provided 3. On [DATE] - 25 total PT minutes provided 4. On [DATE] - 30 total PT minutes provided 5. No further PT minutes provided were documented for Resident 3 until [DATE] 6. On [DATE] - 30 total PT minutes provided 7. No further PT minutes provided were documented for Resident 3 until [DATE] 8. On [DATE] - 15 total PT minutes provided 9. No further PT minutes provided were documented for Resident 3 until [DATE] 10. On [DATE] - 30 total PT minutes provided 11. On [DATE] - 30 total PT minutes provided 12. No further PT minutes provided were documented for Resident 3 until [DATE] 13. On [DATE] - 30 total PT minutes provided 14. No further PT minutes provided to Resident 3 documented until [DATE] During a review of Resident 3's PO, dated [DATE], the PO indicated, Resident 3 was to have ST evaluation and treatment (specific dates, times and completion date not indicated). During a review of Resident 3's ST SLP (speech language pathologist - title given to professionals who are trained to evaluate and treat communication and swallowing disorders) Evaluation and Plan of Treatment (STEPT), dated [DATE], the STEPT indicated, Resident 3 was to be seen by ST three times a week for 31 days from [DATE] to [DATE] daily. During a review of Resident 3's ST SLM, dated ,d+[DATE] and ,d+[DATE], the SML indicated the following documentation for Resident 3: 1. On [DATE] - 55 total ST minutes provided 2. On [DATE] - 36 total ST minutes provided 3. On [DATE] - 30 total ST minutes provided 4. No further ST minutes provided were documented for Resident 3 until [DATE] 5. On [DATE] - 36 total ST minutes provided 6. On [DATE] - 34 total ST minutes provided 7. On [DATE] - 30 total ST minutes provided 8. On [DATE] - 37 total ST minutes provided 9. On [DATE] - 42 total ST minutes provided 10. On [DATE] - 33 total ST minutes provided 11. On [DATE] - 30 total ST minutes provided 12. On [DATE] - 30 total ST minutes provided 13. No further ST minutes provided to Resident 3 documented until [DATE]. During a review of Resident 4's admission MDS under the section BIMS Evaluation, dated [DATE], the BIMS indicated, Resident 4 had a score of 14 (cognition intact). During an interview on [DATE] at 12:22 p.m. with Resident 4, Resident 4 stated he thought he was supposed to get therapy five times a week and had been getting therapy once or twice a week. Resident 4 stated therapy sessions total lasted approximately five to 10 minutes if working with arms and approximately half an hour if working on legs. During a review of Resident 4's PO, dated [DATE], the PO indicated, Resident 4 was to have PT five times a week for four weeks. During a review of Resident 4's PTEPT, dated [DATE], the PTEPT indicated, Resident 4 was to be seen by PT five times a week daily. During a review of Resident 4's PT SLM, dated ,d+[DATE], ,d+[DATE], and ,d+[DATE], the SML indicated the following documentation for Resident 4: 1. On [DATE] - 30 total PT minutes provided 2. On [DATE] - 35 total PT minutes provided 3. On [DATE] - 40 total PT minutes provided 4. On [DATE] - 26 total PT minutes provided 5. On [DATE] - 30 total PT minutes provided 6. On [DATE] - 30 total PT minutes provided 7. No further PT minutes provided were documented for Resident 4 until [DATE] 8. On [DATE] - 30 total PT minutes provided 9. On [DATE] - 22 total PT minutes provided 10. On [DATE] - 35 total PT minutes provided 11. On [DATE] - 35 total PT minutes provided 12. On [DATE] - 20 total PT minutes provided 13. On [DATE] - 27 total PT minutes provided 14. On [DATE] - 35 total PT minutes provided 15. On [DATE] - 35 total PT minutes provided 16. On [DATE] - 39 total PT minutes provided 17. On [DATE] - 32 total PT minutes provided 18. On [DATE] - 30 total PT minutes provided 19. On [DATE] - 35 total PT minutes provided 20. On [DATE] - 30 total PT minutes provided 21. On [DATE] - 31 total PT minutes provided 22. On [DATE] - 32 total PT minutes provided 23. No further PT minutes provided were documented for Resident 4 until [DATE] 24. On [DATE] - 26 total PT minutes provided 25. On [DATE] - 35 total PT minutes provided 26. On [DATE] - 30 total PT minutes provided 27. On [DATE] - 30 total PT minutes provided 28. No further PT minutes provided were documented for Resident 4 until [DATE] 29. On [DATE] - 30 total PT minutes provided 30. No further PT minutes provided were documented for Resident 4 until [DATE] 31. On [DATE] - 30 total PT minutes provided 32. On [DATE] - 30 total PT minutes provided During a review of Resident 4's PO, dated [DATE], the PO indicated, Resident 4 was to have OT five times a week for 27 days. During a review of Resident 4's OTEPT, dated [DATE], the OTEPT indicated, Resident 4 was to be seen by OT five times a week daily. During a review of Resident 4's OT SLM, dated ,d+[DATE], ,d+[DATE], and ,d+[DATE], the SML indicated the following documentation for Resident 4: 1. On [DATE] - 60 total OT minutes were provided 2. On [DATE] - 30 total OT minutes were provided 3. On [DATE] - 30 total OT minutes provided 4. On [DATE] - 35 total OT minutes provided 5. No further OT minutes provided were documented for Resident 4 until [DATE] 6. On [DATE] - 30 total OT minutes provided 7. On [DATE] - 30 total OT minutes provided 8. On [DATE] - 30 total OT minutes provided 9. On [DATE] - 23 total OT minutes provided 10. On [DATE] - 38 total OT minutes provided 11. On [DATE] - 38 total OT minutes provided 12. On [DATE] - 15 total OT minutes provided 13. On [DATE] - 38 total OT minutes provided 14. On [DATE] - 38 total OT minutes provided 15. On [DATE] - 30 total OT minutes provided 16. On [DATE] - 38 total OT minutes provided 17. On [DATE] - 30 total OT minutes provided 18. On [DATE] - 30 total OT minutes provided 19. On [DATE] - 30 total OT minutes provided 20. On [DATE] - 35 total OT minutes provided 21. On [DATE] - 30 total OT minutes provided 22. On [DATE] - 30 total OT minutes provided 23. On [DATE] - 38 total OT minutes provided 24. On [DATE] - 35 total OT minutes provided 25. On [DATE] - 30 total OT minutes provided 26. On [DATE] - 30 total OT minutes provided 27. On [DATE] - 30 total OT minutes provided 28. On [DATE] - 45 total OT minutes provided 29. On [DATE] - 38 total OT minutes provided 30. On [DATE] - 38 total OT minutes provided 31. On [DATE] - 30 total OT minutes provided 32. On [DATE] - 30 total OT minutes provided 33. On [DATE] - 30 total OT minutes provided 34. On [DATE] - 30 total OT minutes provided 35. On [DATE] - 30 total OT minutes provided 36. On [DATE] - 30 total OT minutes provided During a review of Resident 5's admission MDS under the section BIMS Evaluation, dated [DATE], the BIMS indicated, Resident 5 had a score of 15. During a review of Resident 5's PO, dated [DATE], the PO indicated, Resident 5 was to have PT five times a week for four weeks. The PO indicated Resident 5 was to have OT five times a week for six weeks. During an interview on [DATE] at 12:34 p.m. with Resident 5, Resident 5 stated, he received therapy yesterday ([DATE]) for his upper and lower body. Resident 5 stated therapy lasted 30 minutes total for upper and lower body. During a review of Resident 5's PT and OT SLM, dated ,d+[DATE], the SML indicated the following: 1. On [DATE] - 30 total PT minutes were provided to Resident 5 documented, and 45 total OT minutes were provided to Resident 5 documented for a total time of 75 minutes of total therapy. During a review of Resident 6's quarterly MDS under the section BIMS Evaluation, dated [DATE], the BIMS indicated, Resident 6 had a score of 13 (cognition intact). During a review of Resident 6's PO, dated ,d+[DATE], the PO indicated, Resident 6 was to have OT three times a week for six weeks. During an interview on [DATE] at 12:49 p.m. with Resident 6, Resident 6 stated, she was admitted in October of 2024. According to what they (specific person not mentioned) tell me, I am still on it (therapy services). Resident 6 stated the last time she received therapy was yesterday ([DATE]) and it lasted 15 minutes. Resident 6 stated since [DATE] the therapy sessions are about 10 to 15 minutes total. During a review of Resident 6's OT SLM, dated ,d+[DATE], the SML indicated the following: 1. On [DATE] - 55 total OT minutes were provided to Resident 6 was documented. During an interview on [DATE] at 1:03 p.m. with facility therapy group Regional Clinical Director (RCD), RCD stated, the facility therapy group had trouble finding therapists to provide therapy service. RCD stated, We are meeting Medicare expectations (did not indicate what this meant nor how this was accomplished) to cover this building (facility). During an interview on [DATE] at 1:22 p.m. with Certified Occupational Therapist Assistant (COTA) 1, COTA 1 stated, regarding therapy documentation, the documentation should accurately reflect the actual number of minutes the therapist (PT, ST, OT) provided. During an interview on [DATE] at 4:35 p.m. with Rehabilitation Technician (RT) 1, RT 1 stated facility therapy group was charging insurance for care provided to residents that is not accurate. RT 1 stated for example a therapist will work with a resident (no specific resident mentioned) for five minutes but document one hour of therapy provided, which was not true. RT 1 stated the therapy group relies heavily on telehealth therapy (using technology like video calls or online portals to get medical care without having to physically present with the patient/resident) but the therapist were observed doing other tasks (not relevant to resident treatment) rather than focusing on the treatment provided to the resident (no specific resident mentioned). RT 1 stated if the facility therapy group had six residents, they would charge for six hours of direct resident treatment but only actually do a total of 45 minutes for all six residents. RT 1 stated, Director of Rehabilitation (DOR) and Occupational Therapist (OT) 1 asked him to falsify time spent with residents (no specific resident mentioned). During an interview on [DATE] at 3:06 p.m. with Administrator, Administrator stated he could not recall who, could not recall when, but Administrator observed a therapist providing a therapy telehealth session with a resident (could not recall who) and the therapist was noted driving his/her car and was not focused on the resident. Administrator stated he had spoken to the facility therapy group (could not recall who) about this incident. During an interview on [DATE] at 10:32 a.m. with Physical Therapy Assistant (PTA), PTA stated she had reported Physical Therapist (PT) 1 to the State Director (SD - person in charge of the rehabilitation directors in California) and to DOR for falsifying time spent providing therapy services with residents (specific residents not given). PTA stated, He (PT 1) was not spending the amount of time he billed for as a telehealth physical therapist. PTA stated for example, if the physician ordered therapy services to be rendered five times a week and the facility therapy group could not meet the physician order, then the facility therapy group would document to show they were treated five times a week although they were not performing the treatment. PTA stated OT 1 would fraudulently document time spent with residents. PTA stated with residents (not specific) that required evaluations, facility therapy group would not have the therapist physically in the facility nor via telehealth but would document at 10 or 11 p.m. that services were provided but the residents were asleep in bed. During an interview on [DATE] at 2:44 p.m. with COTA 2, COTA 2 stated, the facility therapy group would conduct a lot of telehealth services because they did not have enough therapy staff. During an interview on [DATE] at 3:20 p.m. with RT 2, RT 2 stated the facility therapy group would have residents (not specific) that would not meet criteria to stay on therapy services, but the facility therapy group would keep the residents on and continue charging for services. RT 2 stated an example of residents not meeting criteria would be a resident (not specific) who would refuse to participate in therapy for a month, but the facility therapy group would keep them on for 100 days and charge for 100 days of therapy services. RT 2 stated PT 1 would see 12 to 15 residents in 30 minutes and document more time was spent. RT 2 stated PT 1 would wait for OT 2 to complete resident evaluations and then copy her notes. RT 2 stated she reported PT 1's actions to DOR and nothing was done. During an interview on [DATE] at 11:05 p.m. with OT 2, OT 2 stated she would have residents in the facility (not specific) who would plateau (a state of little or no change) and no longer require therapy but DOR, SD, and RCD would not allow the residents to discontinue the therapy services. OT 2 stated she called her licensing board about this situation and the licensing board (name of person not given) told her the residents could not remain on therapy services. OT 2 stated for example, Resident 7 and Resident 8, would refuse to participate in therapy services/not progress yet PT 1 would document the residents were receiving therapy services despite the refusals; therefore, therapy services would continue. OT 2 stated she spoke to RCD about this, and RCD did nothing. OT 2 stated she was out of the country in [DATE] and when she returned there was a lot of documentation (of therapy services) not completed due to not enough staff. OT 2 stated residents (not specific) who should have received therapy services five times a week, did not receive their therapy as ordered. OT 2 stated Facility Therapist (FT) documented he conducted an evaluation on Resident 8, but FT did not conduct an evaluation on Resident 8. OT 2 stated this was reported to DOR who stated FT was just being overzealous (someone who is excessively eager) with his documentation. OT 2 stated FT would have over 30 therapy notes due and document on them all without ever physically seeing the resident. OT 2 stated FT documented working with Resident 1 for a contracture to right hand and when OT 2 followed up, she noticed the contracture to Resident 1 ' s hand had worsened. OT 2 stated FT was not seeing Resident 1 despite documentation, and this resulted in Resident 1 ' s harm. OT 2 stated Resident 9 would also refuse all therapy services, yet PT 1 documented an evaluation was done despite Resident 9 refusing to participate. OT 2 stated, COTA 2 documented Resident 10 participated in therapy, but it did not happen. OT 2 stated Resident 10, reported to her, he had never met COTA 2 or participated in therapy with COTA 2. During a review of Resident 7's CPR, dated [DATE], the CPR indicated, Resident 7 was, noncompliant (behavior that does not conform to or follow the rules, regulations, or advice of others) with therapy treatments. During a review of Resident 7's PO, dated [DATE], the PO indicated, Resident 7 was to have PT five times a week for four weeks. The PO on [DATE] indicated Resident 7 was to have PT five times a week for four weeks. During a review of Resident 7's PT SLM, dated ,d+[DATE], the SML indicated the following: 1. Resident 7 refused PT therapy on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 2. Resident 7, when provided care by PT 1 was documented as participating in therapy on [DATE] for 23 minutes, [DATE] for 25 minutes, [DATE] for 30 minutes, [DATE] for 25 minutes, [DATE] for 34 minutes, [DATE] for 17 minutes, [DATE] for 25 minutes, and [DATE] for 25 minutes. During a review of Resident 9 ' s CPR, dated [DATE], the CPR indicated, Resident 9 had a mood problem related to history of refusing care and yelling/cursing at care staff. The CPR dated [DATE] indicated, Resident 9 was resistive to care, continues to refuse care when staff (not identified) switched to provide care. The CPR dated [DATE] indicated, Resident 9 refused to participate in the restorative nursing assistant (RNA) program and requested to have it discontinued. The CPR dated [DATE] indicated, Resident 9 was noncompliant with blood draws, bathing, meals, medications, activities of daily living, and vital signs. During a review of Resident 9's PO, dated [DATE], the PO indicated, Resident 9 was to have PT five times a week for four weeks. The PO dated [DATE] indicated Resident 9 was to have OT five times a week for four weeks. During a review of Resident 9's PT and OT SLM, dated ,d+[DATE] the SML indicated the following documentation for Resident 9: 1. On [DATE] - 75 total PT minutes provided 2. On [DATE] - Resident 9 refused PT 3. On [DATE] - Resident 9 refused PT 4. On [DATE] - 24 total PT minutes provided 5. On [DATE] - 26 total PT minutes provided 6. On [DATE] - Resident 9 was unavailable to do PT 7. On [DATE] - 30 total PT minutes provided 8. On [DATE] - Resident 9 refused PT 9. On [DATE] - 45 total PT minutes provided 9. On [DATE] - Resident 9 refused PT 10. On [DATE] - Resident 9 did not have PT due to a physician hold 11. On [DATE] - Resident 9 refused PT 12. On [DATE] - Resident 9 refused OT 13. On [DATE] - 60 total OT minutes provided 14. On [DATE] - 38 total OT minutes provided 15. On [DATE] - Resident 9 refused OT 16. On [DATE] - 15 total OT minutes provided 17. On [DATE] - 15 total OT minutes provided During a review of Resident 10's PO, dated [DATE], the PO indicated, Resident 10 was to have OT five times a week for four weeks. During a review of Resident 10's OT SLM, dated ,d+[DATE], the SML indicated, Resident 10 was provided care by COTA 2 on [DATE] for 53 minutes. During a review of Resident 10's admission MDS under the section BIMS, dated [DATE], the BIMS indicated, Resident 10 had a score of 15. During an interview on [DATE] at 11:10 a.m. with Resident 10, Resident 10 stated, he had never received therapy from COTA 2. During an interview on [DATE] at 12:12 p.m. with COTA 2, COTA 2, stated he did not recall Resident 10. During an interview on [DATE] at 12:38 p.m. with Doctorate Physical Therapy (DPT), DPT stated, she had worked for the facility therapy group on [DATE] and noticed documentation had not been done in weeks. DPT stated on [DATE] she was assigned residents (not specific), and therapy certification documentation had not been done so she did not see them. DPT stated her concern with fraudulent documentation was more due to the frequencies (number of times a resident is to be seen). DPT stated for example if she made an evaluation and recommendation for a resident to be seen five times a week I (DPT) don ' t understand how they (facility therapy group) are doing that (seeing resident five times a week) with no staff. DPT stated, So my concern is how are we meeting the needs of the residents with not enough staff. During an interview on [DATE] at 2:34 p.m. with DOR, DOR stated, he had never been informed of any concerns with falsified documentation, falsified minutes spent with a resident or encouraged falsification of any type. DOR stated as a rule if a resident had refused to participate in therapy three consecutive times, they would be taken off service. DOR stated his expectation for therapy staff is they, Should be documenting honestly and I (DOR) did not encourage any type of fraud. DOR stated if a resident is set up for 60 minutes of therapy and could only do 45 minutes, then the total minutes should be 45 reflecting what the resident was able to accomplish. During an interview on [DATE] at 3:43 p.m. with SD, SD stated, it is difficult to staff the facility with therapy. SD stated the use of telehealth helps to meet the therapy staffing needs. SD stated the facility therapy group does not have any set criteria to determine when a resident should be taken of therapy services. SD stated her expectation for therapy staff is for them to document as accurately as possible. SD stated to her recollection she could not recall any issues brought forth about falsified documentation or falsified minutes spent with residents. During a review of the facility therapy group email (FTE), dated [DATE], the FTE indicated, PTA had informed DOR, SD, and RCD, (Resident 11) is a long-term resident and has been for at least 2 years. (Unknown facility therapy group member) did this (evaluation). I (PTA) advised previously of what (Residents) where (sic) reporting, that they had not been seen. (OT 2) has also expressed that when she does progress notes, following (Unknown facility therapy group member) (evaluation), that the goals do not pertain to that (resident). He (unknown facility therapy group member) was often referencing a female when (resident) was in fact male or vice versa. This email is not being composed with the intent to accuse however; this has been ongoing thing when he (unknown facility therapy group member) evaluates a (resident). The history and/or goals including PLOF (prior level of function) are not reflective of the (resident). The FTE dated [DATE], indicated OT 2 emailed

Based on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 1) received quality care when the facility failed to: 1. Implement their policy and procedure on a change of condition (an important change in a resident ' s baseline condition which includes physical, mental, emotional or functional changes that require a change in treatment to address) for one of 11 sampled residents (Resident 1). 2. Ensure the MDS assessment (Minimum Data Set - an assessment tool) was accurate for one of 11 sampled residents (Resident 1) when contractures (when your skin, muscles, tendons [tough, ropelike cords that connect muscles to bones, enabling movement], or ligaments [tough tissues that act like ropes or bands connecting bones to other bones providing stability and allowing for movement] get permanently stiff or shortened, making it hard to move the affected area) were not inputted into the assessment. 3. Ensure Restorative Nursing Assistant (RNA - a person that provides therapy to residents) orders reflected to one of 11 sampled residents (Resident 1) ability to complete/participate in. 4. Obtain necessary medical equipment for one of 11 sampled Residents (Resident 1). 5. Document accurately the time spent with one of 11 sampled residents (Resident 1) during therapy. These failures resulted in the worsening of Resident 1 ' s right hand contracture. Findings: During a review of Resident 1 ' s ADMISSION RECORD (AR), dated 4/14/25, the AR indicated, Resident 1 was admitted to the facility on [DATE]. The AR indicated Resident 1 had a diagnosis of Dementia (A brain disorder that affects thinking, movement, behavior, and mood, often causing visual hallucinations and changes in alertness), and neurocognitive disorder with Lewy bodies (a progressive brain disorder characterized by the presence of Lewy bodies[little clumps of a protein that abnormally form inside brain cells] in brain cells, leading to cognitive decline, movement issues, and behavioral changes). During a review of Resident 1 ' s MDS Assessment, under the section Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident ' s cognition is. A score of 99 is the resident was unable to complete the interview and therefore unable to determine the resident ' s cognition), dated 1/1/25, the BIMS score indicated, Resident 1 ' s BIMS score was 99. The MDS assessment dated [DATE], under section GG (assesses functional abilities and goals), Resident 1 was documented as completely dependent on staff for all activities of daily living (ADL refers to the basic, everyday tasks needed focusing on personal care and hygiene such as eating, dressing, bathing, and using the bathroom). 1.During a review of Resident 1 ' s OT (Occupational Therapy - a health profession that helps people of all ages with activities of daily living and improves their ability to engage in meaningful activities) Evaluation and Plan for Treatment (OTEPT), dated 12/22/24, the OTEPT indicated, Resident 1 had contractures of her muscles to multiple sites (no documentation to indicate what muscles) with an onset date of 12/22/24. During a concurrent interview and record review on 4/14/25 at 12:20 p.m. with Director of Nursing (DON) 2, Resident 1 ' s Electronic Medical Record (EMR) was reviewed. DON 2 stated Resident 1 was admitted to the facility on [DATE] with no contractures. DON 2 stated therapy documented Resident 1 had contractures on 12/22/24. DON 2 stated a change of condition should have been implemented but was not. DON 2 stated the medical doctor, and family should have been notified about the change in Resident 1 ' s condition but were not. During a review of the facility ' s policy and procedure (P&P) titled, Change of Condition Notification, dated 6/1/17, the P&P indicated, To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to . An injury/accident . A significant change in the resident ' s physical, cognitive, behavioral or functional status . A significant change in treatment . The Licensed Nurse will notify the resident ' s Attending Physician when there is an . A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications . The Licensed Nurse will assess the resident ' s change of condition and document the observations and symptoms. The Attending Physician will be notified timely with a resident ' s change in condition. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident ' s vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. 2.During a review of Resident 1 ' s Condition on Admission (CAD), dated 11/10/22, the CAD indicated Resident 1 was admitted with no contractures. During a review of Resident 1 ' s OTEPT, dated 12/22/24, the OTEPT indicated Resident 1 had contractures of her muscles to multiple sites with an onset date of 12/22/24. During a concurrent interview and record review on 4/9/25 at 1:30 p.m. with Minimum Data Set Nurse (MDSN), Resident 1 ' s MDS assessments for 10/1/24, 1/2/25 and 4/2/25, were reviewed. MDSN stated, Resident 1 was assessed to be dependent on all aspects of care, Resident 1 was unable to communicate, was not alert and oriented, and was at increased risk for contractures to her upper extremities (arms), but there was no documentation Resident 1 had contractures on 10/1/24, 1/2/25 and 4/2/25. During a review of Resident 1 ' s Care Plan (CP), dated 1/9/24, the CP indicated Resident 1 was at potential risk for complications related to a diagnosis of osteoarthritis (a progressive disorder of the joints [a point where two or more bones connect], caused by a gradual loss of cartilage [A tough, flexible tissue that lines joints]). The CP indicated Resident 1 would be free of complications from her osteoarthritis which included developing contractures. The CP dated 12/22/24 indicated Resident 1 was referred to therapy for contractures to her right and left hands. The CP indicated Resident 1 would have a resting hand splint (a device that positions a resident in a way that provides a stretch to improve range of motion and prevents further tightening of muscles) to her right wrist and a palmar guard splint (a device used to prevent your fingers from digging in to the palm of your hand, to prevent skin damage and prevent further deformity) to her left hand. During a concurrent observation and interview on 4/9/25 at 3:12 p.m. with MDSN, in Resident 1 ' s room, MDSN assessed Resident 1. MDSN stated Resident 1 could not move her upper extremities very well and she had a noted contracture to her right hand (did not mention her left hand). MDSN stated the MDS assessment completed on 1/2/25 and 4/2/25 was incorrect and should have mentioned Resident 1 ' s contracture to right hand (section GG of the MDS). MDSN stated the MDS (1/2/25 and 4/2/25) for Resident 1 indicated no impairment regarding her upper extremities. MDSN stated a new CP should have been created for Resident 1 that identified her contractures and the plan of care for staff (not just therapy) to follow. During a review of the facility ' s policy and procedure (P&P) titled, RAI (Resident Assessment Instrument - an assessment and care planning process used to ensure residents receive the highest quality of care and quality of life) Process, dated 10/1/19, the P&P indicated, To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident ' s preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. The Facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident ' s functional capacity and health status . The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. The quarterly MDS does not require the completion of Care Area Assessments (CAAs). However, the resident ' s care plan must be reviewed and revised by the interdisciplinary team after each assessment. 3.During a review of Resident 1 ' s Physician Orders (PO), dated 2/27/25, the PO indicated, a PO for RNA (Restorative Nursing Assistant - a nursing aide with additional training in restorative care, focusing on helping residents regain and maintain their physical abilities) to provide active range of motion (AROM - the movement of a joint that is achieved through the voluntary and unassisted contraction of surrounding muscles) and passive range of motion (PROM - the movement of a joint through its range of motion by an external force, such as a therapist or a machine, without any muscle effort from the individual) three times a week. During an interview on 4/9/25 at 2 p.m. with RNA 1, RNA 1 stated, she has been providing RNA treatment to Resident 1 since 2/2025. RNA 1 stated she provided PROM to Resident 1 but not AROM because Resident 1 was dependent in all areas of care and the resident could not actively participate in AROM. RNA 1 stated Resident 1 had been on the RNA program since 2/2025 and had not been able to participate in AROM. RNA 1 stated she meets with leadership (not specific who) every Monday to discuss the RNA program but had not brought up the need to clarify Resident 1 ' s AROM physician ' s order (during the one-day remainder of February, the 31 days in March, and nine days in April). During a concurrent observation and interview on 4/9/25 at 3:12 p.m. with MDSN in Resident 1 ' s room, MDSN assessed Resident 1. MDSN stated Resident 1 could not move her upper extremities on her own for AROM and she could not move her upper extremities past her shoulders when being provided with PROM. During a review of the facility ' s policy and procedure (P&P) titled, Specialized Rehabilitative Services, dated 6/1/17, the P&P indicated, The Facility shall meet the assessed needs of any resident admitted to assist them in obtaining or maintaining their highest practicable level of functional well-being. Skilled therapies will be provided to any resident based on physician order, validation of assessed needs . 4. During a review of Resident 1 ' s OTEPT dated 12/22/24, the OTEPT indicated, Resident 1, noted with contractures and would benefit from splinting . in order to reduce risk for skin breakdown and increased contractures. During a review of Resident 1 ' s CP dated 12/22/24, the CP indicated Resident 1 was referred to therapy for contractures to her right and left hands. The CP indicated Resident 1 would have a resting hand splint to her right wrist. During a review of Resident 1 ' s Occupational Therapy OT Therapy Progress Report (OTPR), dated 2/5/25, the OTPR indicated: 1a. On 12/22/24 - Resident 1 need for splint was indicated for her right-hand contracture and it would be ordered for her use. 2b. On 1/24/25 - Resident 1 ' s splint was still pending. 3c. On 1/31/25 - Resident 1 ' s had not obtained her splint. 4d. On 2/5/25 - (Resident 1) noted with increased contracture to (right) hand would benefit from hand roll splint (a type of splint that uses a rolled or inflatable device to help position the hand and fingers in a way that promotes healing or reduces contractures) . During an interview on 4/9/25 at 2:51 p.m. with Central Supply Manager (CSM), CSM stated, he had never received a request for Resident 1 ' s right hand splint. The CSM stated all requests for equipment are made verbally and there is no documentation conducted by either him or central supply staff for a splint for Resident 1. CSM stated a splint for Resident 1 was never obtained. During a concurrent interview and record review on 4/11/24 at 1:58 p.m. with State Director (SD - person in charge of the rehabilitation directors in California), Resident 1 ' s Electronic Medical Chart (EMR), dated 12/2024 to 2/2025 was reviewed. SD verified Resident 1 had less function to her right hand after therapy services were started. SD verified there were therapy notes which indicated Resident 1 was evaluated and needed a splint for her right-hand contracture on 12/22/24. SD reviewed the therapy notes and indicated Resident 1 never received the splint. SD stated the expectation she had for the facility therapy group was for them to document in detail and to inform the facility if a resident needed medical equipment. 5.During a review of Resident 1 ' s Physician Order (PO), dated 12/22/24, the PO indicated, Resident 1 was to have OT twice a week for six weeks to reduce the risk of increased contractures and skin breakdown. During a review of Resident 1 ' s OTEPT, dated 12/22/24, the OTEPT indicated Resident 1 was to be seen by OT two times a week for six weeks from 12/22/24 to 2/1/25 with an intensity of daily. During an interview on 4/2/25 at 10:32 a.m. with Physical Therapy Assistant (PTA), PTA stated she had reported to SD and Director of Rehabilitation (DOR) that Physical Therapist (PT) 1 falsified the amount of time he (PT 1) spent with residents (specific residents not given) for therapy. PTA stated, He (PT 1) was not spending the amount of time he billed for as a telehealth physical therapist. PTA stated due to low staff, residents were not evaluated during their 24-to-48-hour window, therapy treatments were not done, and residents that should have discontinued therapy services were not taken off. PTA stated for example if a resident was to be seen five times a week, the facility therapy group was not able to meet that number of times but would charge/document as if they did. PTA stated OT 1 would fraudulently document time spent with residents. PTA stated with residents (not specific) that needed evaluations, facility therapy group would not have therapist physically be in the facility nor via telehealth but input documentation at 10 or 11 p.m. when residents would be asleep/in bed. During an interview on 4/2/25 at 2:44 p.m. with Certified Occupational Therapy Assistant (COTA) 2, COTA 2 stated, the facility therapy group did not have enough staff. During an interview on 4/2/25 at 3:20 p.m. with Rehabilitation Technician (RT) 2, RT 2 stated, she observed PT 1 see 12 to 15 residents in 30 minutes and document more time was spent. RT 2 stated PT 1 would wait for OT 2 to complete resident evaluations and then copy her notes. RT 2 stated she had reported PT 1 ' s actions to DOR and nothing was done. During an interview on 4/4/25 at 11:05 p.m. with OT 2, OT 2 stated she was out of the country in January 2025 and when she returned there was a lot of documentation not completed due to not having enough therapy staff. OT 2 stated she observed Facility Therapist (FT) have over 30 therapy notes due and document on them all without ever seeing the resident. OT 2 stated FT had documented working with Resident 1 despite not seeing her and when she followed up, she (OT 2) had noticed the contracture had worsened. OT 2 stated FT not seeing Resident 1 despite documentation had resulted in her harm because the identified treatment needed was not given. During a review of Resident 1 ' s OTPR, dated 2/5/25, the OTPR indicated, on 2/5/25 - Pt (Resident 1) noted with increased contracture to (right) hand would benefit from hand roll splint (a type of splint that uses a rolled or inflatable device to help position the hand and fingers in a way that promotes healing or reduces contractures) . During a review of Resident 1 ' s OT Discharge Summary (OTDC), dated 2/20/25, the OTDC indicated, Resident 1 had been on therapy service since 12/22/25 and required a hand roll to her right hand due to increased contracture. During a concurrent interview and record review on 4/11/24 at 1:58 p.m. with SD, Resident 1 ' s Electronic Medical Chart (EMR), dated 12/2024 to 2/2025 was reviewed. SD stated on 2/5/25 a therapy note indicated Resident 1 should have been discharged from therapy services and placed on RNA. SD could not explain why Resident 1 continued to be in therapy services for 15 more days (2/20/25) after the note indicated she (Resident 1) needed to be discharged nor how Resident 1 had less function of her right hand after therapy services were started. During an interview on 4/22/25 at 2:34 p.m. with DOR, DOR stated, he had never been informed of any concerns with falsified documentation, falsified minutes spent with a resident or encouraged falsification of any type. DOR stated his expectation for therapy staff is they, Should be documenting honestly and I (DOR) did not encourage any type of fraud. DOR stated if a resident is set up for 60 minutes of therapy and could only do 45 minutes, then the total minutes should be 45 reflecting what the resident was able to accomplish. During an interview on 4/22/25 at 3:43 p.m. with SD, SD stated, it is difficult to staff the facility with therapy. SD stated her expectation for therapy staff is for them to document as accurately as possible. SD stated to her recollection she could not recall any issues brought forth about falsified documentation or falsified minutes spent with residents. During a review of RT 1 ' s email statement (ES), dated 4/7/25, the ES indicated, RT 1 had been directed by DOR to bill for 11 hours of work despite having completed all job duties by 12:30 p.m. (workday started at 7:30 a.m.). RT 1 ' s ES indicated on 3/17/25 RT 1 had questioned SD how to accurately document her timecard as there were many inconsistencies. RT 1 ' s ES indicated RT 1 was on a call with SD and Rehabilitation Clinical Director (RCD) and had asked why she had been asked by DOR to log in time for a complete shift when in reality she had only worked three to four hours. RT 1 ' s ES indicated RCD told RT 1 she was being inconsiderate considering the time the facility therapy group spent training her and that her question was offensive. RT 1 ' s ES indicated RT 1 had asked SD and RCD about only spending two to three minutes with each resident, but documenting time spent was 25 minutes, 30 minutes, and even up to 60 minutes. RT 1 ' s ES indicated SD told RT 1 not to worry about the accuracy of the times as it was not her concern for the position she was in. RT 1 ' s ES indicated on 3/17/25 RT 1 had assisted SD, Doctorate Physical Therapist (DPT), and OT 1 with resident (not specified) therapy. RT 1 ' s ES indicated SD, DPT, and OT 1 had only spent three to four minutes with each resident (not specific). RT 1 ' s ES indicated on 3/18/25 RT 1 had contacted SD and DOR about not wanting to participate in fraud and the response was that her concern was, noted. RT 1 ' s ES indicated on 3/26/25 RT 1 had spoken to COTA 1 about her timecard and COTA 1 responded, Just do whatever. It doesn't matter. We make up things with our time card (sic). RT 1 ' s ES indicated RT 1 had spoken with Therapy [NAME] President (TVP) (date not given) about her timecard and she had been told to not worry about it since she was not the one doing the billing. RT 1 ' s ES indicated TVP told RT 1 that in worst case scenario the state comes to audit the therapy hours, it would be very difficult to prove. RT 1 ' s ES indicated TVP stated, If anything, maybe what is happening is that the therapists are evaluating (residents) and providing telehealth sessions to (residents) who do not qualify to receive therapy. RT 1 ' s ES indicated RT 1 had reported to TVP about OT 1 not participating in the resident telehealth sessions but documented as if had. During a review of the facility therapy group email (FTE), dated 10/2/24, the FTE indicated, PTA had emailed DOR, SD, and RCD, . I (PTA) advised previously of what (nonspecific residents) where (sic) reporting, that they had not been seen. (OT 2) has also expressed that when she does progress notes, following (Unknown facility therapy group member) (evaluation), that the goals do not pertain to that (resident not identified). He (unknown facility therapy group member) was often referencing a female when (resident not identified) was in fact male or vice versa. This email is not being composed with the intent to accuse however; this has been an ongoing thing when he (unknown facility therapy group member) evaluates a (nonspecific resident). The history and/or goals including PLOF (prior level of function) are not reflective of the ( nonspecific resident). The FTE dated 2/4/25 indicated OT 2 emailed DOR and RCD regarding past-due documentation and missed therapy treatments due to staffing issues. The FTE dated 2/5/25, indicated OT 2 sent an email to [NAME] President of Compliance (VPC). The 2/5/25 FTE indicated, I (OT 2) have previously reached out to (DOR, RCD, SD, and VPC) regarding several concerns, including lack of OT supervision for my ( nonspecific residents), missed frequencies (how often therapy is given), and potential compliance issues. Unfortunately, I (OT 2) have not received clear responses, and this situation is negatively impacting my (nonspecific residents) and placing my license at risk. Due to staffing constraints, my (COTA) (not specifically identified) has reported missed visits [due to staffing constraints], and I (OT 2) have been asked to complete non-billable notes. Some (nonspecific residents) have not seen an OT for their 10th visits or are not receiving adequate OT supervision. Additionally, I was advised to co-treat (treating with another discipline) with the Physical Therapy (PT), but not all of my (nonspecific residents) are suitable for this model. As a result, I am unsure how to proceed with the delayed documentation for (nonspecific residents) I have not seen for cases where the available notes lack sufficient detail .Also, I have noticed that another OT (not identified) [who does not work in the building] was asked to complete recertification and progress notes without seeing the (nonspecific resident) and documenting levels without assessments and there is no billing which has been completed, which is unethical. I (OT 2) am not comfortable with what is going on. I (OT 2) am afraid of retaliation by bringing this to your attention, but this issue is not ethical, and this is a disservice to our (residents). During a review of the facility ' s P&P titled, Documentation, dated 3/11/24, the P&P indicated, Medical record documentation primarily is a means of communication. Documentation facilitates coordination and continuity of care, guides effective treatment to optimize outcomes, justifies billing of services provided, and serves as a legal document. Documentation integrity involves the accuracy of the facts in the medical record. This policy establishes standard guidelines for documentation completion in support of accuracy and meets requirements set forth by federal regulations. If a state or local law is more stringent, the most stringent regulations must be followed. Documentation must be timely, accurate, objective, thorough, and complete, and must present the appropriate facts .

Based on observation, interview, and record review, the facility failed to implement the care plan (comprehensive documents outlining the care and services to be provided by the facility to residents) intervention of providing supervision during toilet transfers for one of three sampled residents (Resident 1), who had generalized muscle weakness, a history of falls, was at risk for falls, and had Alzheimer's Disease (memory loss), when Resident 1 got up unsupervised to use the toilet and fell in her room. This failure resulted in Resident 1 sustaining a fall with fracture (broken bone), requiring admission, and surgical intervention at the acute care hospital. Findings: During a review of Resident 1's Admission Record (AR), dated 1/23/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Schizoaffective Disorder (false perception of reality with mood symptoms), Cognitive Communication Deficits (inability to communicate), Spondylosis (degeneration of the spine), Osteoarthritis (degeneration of joints causing pain and stiffness), Generalized Muscle Weakness, Difficulty Walking, Need for Assistance with Personal Care, and History of Falling. During a review of Resident 1's Minimum Data Set (MDS) (a comprehensive assessment tool), dated 8/6/24, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a mental/intellectual test) score of 5 (scores of 0-7 indicate severe cognitive (how the person thinks, learn and understand] impairment). The MDS indicated Resident 1 needed assistance and supervision with personal hygiene, toileting, getting up and transferring from bed, chair and toilet, and used a wheelchair as a mobility (moving) device. During a review of Resident 1's Fall Prevention Care Plan (FPCP), initiated 5/4/23 and last revised 2/17/24, the FPCP indicated the following fall prevention interventions: resident's call light within reach and encourage the resident to use it for assistance (initiated 5/14/23); educate resident about safety reminders (initiated 5/4/23); encourage resident to participate in activities (initiated 5/4/23); anticipate and meet the resident's needs (initiated 8/16/23); ensure resident is wearing appropriate footwear (initiated 8/16/23); follow facility fall protocol (initiated 8/16/23); physical therapy as needed (initiated 8/16/23); safe environment (initiated 8/16/23); bed and wheelchair in lock position (initiated 11/16/23); keep bed in lowest position when care not being provided (initiated 11/16/23); and pressure pad alarm in bed and wheelchair to alert staff when resident attempting to get up unassisted (initiated 2/17/24). During a review of Resident 1's Activities of Daily Living Care Plan (ADLCP), dated 3/16/24, the ADLCP indicated, TRANSFER: [Resident 1] requires supervision with 1 person staff between surfaces and as necessary. During a review of Resident 1's Fall Risk Evaluation (FRE), dated 8/6/24, the FRE indicated Resident 1 was at risk for falls. The FRE indicated Resident 1 had a history of falls, was confused, and had predisposing health conditions that increased the risk of falls. Three of the four sections of the FRE were blank: Section AS_2 Gait Balance (where the facility has to indicate if the resident has balance problems while standing or walking); Section AS_3 Medications (where the facility has to indicate if the resident is taking medications that increase the risk of falls such as medications to treat hypertension (high blood pressure), psychotropics or medications that affect the mood or cognition), and Section AS_4 Clinical Suggestions (where the facility has to indicate interventions to prevent falls for the resident). The FRE contained fields for staff to indicate fall preventions interventions to be implemented for Resident 1, such as Assist Resident with ambulation and transfers . and Utilize toileting program . The fields for these interventions were unselected and blank. During a review of Resident 1's Situation Background Assessments and Recommendations (SBAR) note, dated 1/21/25 at 9:20 a.m., the SBAR indicated: Situation: unwitnessed fall. Background: Alzheimer's disease, difficulty in walking; Assessment: [Licensed Nurse 1] was passing medications to the next room when the pressure alarm on the bed began beeping. [Licensed Nurse 1] went in the room, [Licensed Nurse 1] found the [Resident 1] lying on the floor. [Resident 1] complained of pain in her left hip . [Resident 1] verbally stated she was heading to the bathroom. [Resident 1's Physician] was contacted and receive order to transfer [Resident 1] to the hospital for further evaluation and treatment. Ambulance arrived and transported [Resident 1] to hospital. During a review of the hospital's History and Physical (H&P) dated 1/21/25, the H&P indicated: Chief Complaint: report of fall .complains of left hip pain. Assessment/Plan: acute [sudden, recent] left femoral neck [thigh bone] fracture s/p [status post/after] fall. During a review of the hospital's Operative and Procedure Reports (OPR), dated 1/23/25, the OPR indicated: Operative Diagnosis: Left Traumatic Intertrochanteric Femur [hip] Fracture. Procedure: Left Hip Intertrochanteric fracture fixation [hip surgery] with a cephanomedullary nail [surgical device to treat fracture]. During an interview with Licensed Nurse 1 (LN 1) on 1/23/25, at 11:41 a.m., LN 1 stated on 1/21/25 at around 9 a.m., she was in the hallway passing medications to residents when she heard Resident 1's bed alarm. LN 1 stated she went into Resident 1's room and found Resident 1 lying on the floor, next to her bed. LN 1 stated Resident 1 reported to her she fell while trying to go the bathroom and indicated left hip pain. LN 1 stated Resident 1 was taken to the hospital for evaluation and treatment. LN 1 stated the fall was unwitnessed. During a concurrent interview and record review on 2/28/25 at 1:20 p.m. with the Director of Nursing (DON) Resident 1's ADL (Activities of Daily Living) Flowsheets (where Certified Nursing Assistants document care), dated January 2025 was reviewed. The ADL Flowsheets indicated no documentation Resident 1 was provided toileting supervision or assistance on 1/21/25 (date of fall incident). The DON stated Resident 1 was not on a toileting program (scheduled toileting-fixed schedule). The DON stated at the time of the fall Resident 1 had a bed alarm to alert staff when she gets out of the bed. The DON stated staff relied on the bed alarm to know when Resident 1 was getting out of bed. The DON stated at the time of the fall Resident 1 received the same supervision as all other residents, meaning that Certified Nursing Assistants (CNAs) checked on Resident 1 every two hours. The DON stated CNAs did not document Resident 1's monitoring. During a concurrent observation and interview on 2/28/25, at 3:15 p.m., with Resident 2, who shared the same room with Resident 1, in her room, Resident 2's bed was next to Resident 1's bed and was directly in front of the bathroom and had an unobstructed view of the bathroom. Resident 2 stated she witnessed Resident 1's fall on 1/21/25. Resident 2 stated Resident 1 got out of bed and went to the bathroom unassisted by staff. After Resident 1 left the bathroom, and on her way back to her bed, Resident 1 lost her balance and fell to the floor. Resident 2 stated she pressed her call light to alert staff of Resident 1's fall. Resident 2 stated she heard no alarms or any noise when Resident 1 got out of bed. Resident 2 stated staff only came to the room to check on Resident 1 after she (Resident 2) pressed the call light. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 1 had a BIMS score of 14 (scores of 13-15 means intact cognition). During a review of facility policy and procedure (P&P) titled, Care Planning dated 3/28/17, the P&P indicated, Consistent with the facility's policy of providing appropriate care and services to residents admitted to the facility. Procedures: .6. Resident Care Plan must address the needs, strengths, and preferences of the resident as identified in the comprehensive assessment. 7. Services that are furnished for resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being are to be included in the plan of care. During a review of facility policy and procedure (P&P) titled Activities of Daily Living , dated 10/14/15, the P&P indicated: Each resident will be assisted to achieve and maintain the highest level of self-care. All residents will be given the appropriate treatment and services to maintain or improve their abilities. Residents who are unable to carry out activities of daily living will receive the necessary services to maintain good hygiene. Staff will ensure resident has the adequate support when providing care. This includes the residents' ability to the following: transfers. During a review of facility policy and procedure (P&P) titled Fall Prevention Policy , dated 10/14/15, the P&P indicated: It is this facility's policy to prevent falls to the extent possible and within the control of the facility. Plans of care shall include interventions on the following: provision of monitoring and supervision to resident to prevent fall incident. Residents identified to be at greater risk for fall or further falls should be monitored closely to prevent further occurrence of fall incident.