Every finding on record at Imperial Care Center

Based on interview and record review, the facility failed to maintain accurate and complete medical records for one of three sampled residents (Resident 1) by failing to document Resident 1's weekly orthostatic blood pressure (a check of the blood pressure and heart rate while lying down, sitting, and or standing to see how the body handles changes in position) on 7/7/2026, 7/14/2026, 7/21/2026, 7/28/2026, 8/4/2026, 8/11/2026, and 8/18/2026.These failures had the potential to cause confusion in care and the medical records containing inaccurate and incomplete documentation.During a review of Resident 1's admission Record/Face Sheet (FS-a one page chart summary containing a resident's vital demographic, contact, insurance, and medical data), the FS indicated the facility admitted Resident 1 on 9/20/2023, with diagnoses that included unspecified (unconfirmed) vascular dementia (a progressive state of decline in mental abilities), generalized muscle weakness, and unspecified (unconfirmed) psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 1's Order Summary Report, dated 4/16/2026, the Order Summary Report indicated to monitor for potential side effects (secondary reaction to a medicine or treatment that happens along with the main intended result) of antipsychotic medication (.postural hypotension [a sudden drop in blood pressure that happens when you stand up from a sitting or lying position] .).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/18/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report, dated 4/24/2026, the Order Summary Report indicated to monitor for orthostatic hypotension on the day shift. Call the Physician if there is a 20-millimeter mercury (mmHg- standard unit used to measure pressure) drop in systolic blood pressure (The top number in a blood pressure reading that measures the force of blood pushing against your artery walls when your heart beats) or a drop in 10 mmHg in diastolic blood pressure (The bottom number in a blood pressure reading that measures the pressure in your arteries when your heart rests between beats) between two readings every Tuesday in lying position and sitting position.During a review of Resident 1's Order Summary Report, dated 5/28/2026, the Order Summary Report indicated Risperdal (antipsychotic medication used to rebalance brain chemicals to improve mood, thinking, and behavior) oral tablet, give one milligram (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day for psychosis.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for showering, personal hygiene and ambulation. The MDS indicated Resident 1 was on antipsychotic (medicine used to calm the brain and treat severe mental health conditions), and antianxiety (medications that reduce or prevent overwhelming feelings of fear, panic, and extreme nervousness).During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 7/2026, the MAR indicated on 7/7/2026, 7/14/2026, 7/21/2026 and 7/28/2026, there were no documented blood pressure for sitting and lying positions.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 8/2026, the MAR indicated on 8/4/2026, 8/11/2026, and 8/18/2026, there were no documented blood pressure on sitting and lying positions.During a concurrent interview and record review on 8/19/2026, at 10:49 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's Order Summary Report, dated 4/24/2026, and MAR, dated 7/2026, and 8/2026, were reviewed. The Order Summary Report indicated to monitor for orthostatic hypotension on the day shift, every Tuesday in lying and sitting position. The MAR, dated 7/2026, and 8/2026, indicated the nurses' initial of blood pressure monitoring. LVN 1 stated the nurses documents the actual blood pressure result in the MAR. LVN 1 stated Resident 1's MAR, on 7/2026, and 8/2026, did not indicate the actual blood pressure results. LVN 1 stated the importance of documenting the actual blood pressure of Resident 1 on lying and sitting position was to check for the side effect of antipsychotic medication. LVN 1 stated if Resident 1's blood pressure was not monitored; Resident 1 could develop side effects, and a change of condition will not be identified.During an interview on 8/19/2026, at 11:46 a.m., with Registered Nurse 1 (RN 1), RN 1 stated the nurses did not follow the physician order to monitor Resident 1 for orthostatic hypotension. RN 1 stated the nurses should inform us (RNs) if there was no space for the blood pressure results in the MAR. RN 1 stated without documented blood pressure monitoring, Resident 1 could have orthostatic hypotension that could possibly lead to Resident 1's having a fall and an accident.During an interview on 8/19/2026, at 12:22 p.m., with the Director of Nursing (DON), the DON stated the nurses should have documented the blood pressure reading on lying and sitting position to know if the resident was experiencing a side effect from the antipsychotic medications. The DON stated the importance of monitoring and documenting blood pressure is to monitor the effect of the medication that could potentially cause Resident 1 to have a fall.During a review of facility's policy and procedure (P&P), titled, Charting and Documentation, dated 7/2017, and last reviewed on 7/2026, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial (how the internal mind [thoughts, feelings, and emotions] connects with the external world [people, relationships, and society]) condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.During a review of facility's P&P, titled, Psychotropic (any medication that changes how the brain works, altering mood, thoughts, behavior, or perception) Medication Use, dated 2/2025, and last reviewed on 7/2026, the P&P indicated, Monitoring and Adverse Consequences (harmful, bad, or unwanted results) .2. Residents receiving psychotropic medication are monitored and the response to treatment is documented.3. Monitoring may include laboratory results, vital signs (measurements of the body's most basic functions), progress notes, behavior flow sheets, medication administration records, and the drug regimen review from the consultant pharmacist.4. In addition, residents are monitored for adverse consequences associated with psychotropic medications, including: .b. Cardiovascular effects - irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis (heavy, abnormal sweating that happens for no obvious reason), chest/arm pain, increased blood pressure, orthostatic hypotension).

Based on interview and record review, the facility failed to rightfully inform one of three sample residents (Resident1) when Resident 1 was readmitted to the facility with a new diagnosis of dysphagia (difficulty swallowing) and had a change in medication administration by failing to:1. Ensure Family Member 1 (FM 1) was notified on 4/16/2026, of the new order for crushed medications due to dysphagia upon readmission.2. Ensure the Physician and FM 1 were notified on 5/19/2026, of the readmission.3. Ensure Conservator 1 (CVT 1- a court-appointed helper who legally manages the finances, property, or personal care of an adult who can no longer look after themselves) and/or CVT 2 were notified on 6/24/2026, when Resident 1 was readmitted to the facility.These failures violated the rights of the CVTs and/or FMs to be informed.Findings:During a review of Resident 1's admission Record/Face Sheet (FS-a one page chart summary containing a resident's vital demographic, contact, insurance, and medical data), the FS indicated the facility admitted Resident 1 on 9/20/2023, with diagnoses that included unspecified (unconfirmed) vascular dementia (a progressive state of decline in mental abilities), generalized muscle weakness, and dysphagia. The FS indicated Resident 1 had two CVTs (CVT 1 and CVT 2).During a review of Resident 1's Order Summary Report, dated 4/16/2026, the Order Summary Report indicated may crush medications and mix with applesauce.During a review of Resident 1's Speech Therapy Evaluation and Plan of Treatment, dated 4/17/2026, the Speech Therapy Evaluation and Plan of Treatment indicated Resident 1 was referred to Speech Therapy for dysphagia services due to decline in oral function. The Speech Therapy Evaluation and Plan of Treatment indicated Resident 1 had impaired oral motor structure and function (had physical differences, weakness, or damage in the parts of the mouth used for speaking and eating) and clinical signs and symptoms of dysphagia.During a review of Resident 1's Order Summary Report, dated 4/17/026, the Order Summary Report indicated may crush medications and mix with applesauce or food.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/18/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's IDT Madwords, dated 4/20/2026, and 5/19/2026, the IDT Madwords indicated Resident 1 had no CVT.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for showering, personal hygiene and ambulation. The MDS indicated Resident 1 was on mechanically altered (means eating food that has been chopped, ground, mashed, or blended so it is very soft and requires very little chewing) and therapeutic diet (a special meal plan prescribed by a doctor or planned by a dietitian to help treat, manage, or prevent a medical condition).During a concurrent interview and record review on 8/19/2026, at 10:49 a.m. with Licensed Vocational Nurse 1 (LVN 1), Resident 1's FS was reviewed. The FS indicated Resident 1 was initially admitted on [DATE], and while at the facility was diagnosed with oral phase dysphagia (having trouble chewing, moving, or controlling food and liquids inside your mouth before the swallow starts) on 4/17/2026. LVN 1 stated Resident 1 was in General Acute Care Hospital (GACH) from 4/5/2026, to 4/16/2026, and was readmitted on [DATE], with an order to crush medication and mixed with applesauce. LVN 1 stated if Resident 1 was readmitted with a change in the form of the medication administration, a change in condition should have been started and notify the Physician and the CVT and or FMs. LVN 1 stated there were no documented Change in Condition (CIC) on 4/16/2026. LVN 1 stated he (LVN 1) had administered Resident 1's medications crushed and mixed with applesauce.During a concurrent interview and record review on 8/19/2026, at 11:46 a.m., with Registered Nurse 1 (RN 1), Resident 1's Clinical Admissions dated 4/16/2026, 5/14/2026 and 6/24/2026, and Progress Notes dated 5/14/2026 and 6/24/2026, were reviewed. Resident 1's Clinical admission indicated the following:1. 4/16/2026- Resident Representative (RR) notified.2. 5/14/2026- Resident Physician and Responsible Party notification was left blank.3. 6/24/2026- Resident 1's Family Member was notified.RN 1 stated when residents are readmitted with new orders, CVTs and or FMs need to be informed and new orders are explained. RN 1 stated the notification will be documented in the Clinical Admissions. RN 1 stated on 4/16/2026, RR was notified and RR's name was not on Resident 1's FS. RN 1 stated she was not sure who RR was since it was not on the FS. RN 1 stated on 5/14/2026, RN 2 did not document the name of the physician and the name of Resident 1's FM who was notified of Resident 1's readmission to the facility on Resident 1's Clinical Admission. RN 1 stated Resident 1's Progress Notes, dated 5/14/2026 also did not indicate notification of the physician and Resident 1's FM. RN 1 stated Clinical Admission, dated 6/24/2026 indicated FM 1 was notified of the readmission but Resident 1 had two CVTs (CVT 1 and CVT 2). RN 1 stated since Resident 1 had CVTs, CVT 1 should be notified first and if unable to contact, nurse should have attempted to notify CVT 2. RN 1 stated there were no documented attempts to notify CVT 1 and CVT 2 before notifying FM 1 on 6/24/2026. RN 1 stated it was CVT 1, CVT 2 and or FM 1 rights to be informed.During an interview on 8/19/2026 at 12:22 p.m., with the Director of Nursing (DON), the DON stated upon admission and readmission, the Interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) should review the orders, and the overall care of Resident 1 and relayed to CVTs and or FMs. DON stated the CVTs should be notified first then followed by FMs. The DON stated the importance of notifying the CVTs and or FMs was to make them aware that Resident 1 was admitted or readmitted to the facility and to discuss Resident 1's plan of care. The DON stated the CVTs should have been informed of the new change in medication administration.During a review of facility's policy and procedure, titled, Change in a Residents Condition, dated 3/2023, and last reviewed on 7/2026, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights). The nurse will notify the resident's attending physician or physician on call when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition;e. need to alter the resident's medical treatment significantly;

Based on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of five sampled residents (Residents 1 and 5) by failing to develop a care plan to address Residents 1 and 5's refusal of medication.This failure had the potential for Resident's 1 and 5's delays in the delivery of necessary care and services.Findings:a. During a review of Resident 1's admission Record/Face Sheet (FS-a one page chart summary containing a resident's vital demographic, contact, insurance, and medical data), the FS indicated the facility admitted Resident 1 on 9/20/2023, with diagnoses that included unspecified (unconfirmed) vascular dementia (a progressive state of decline in mental abilities), generalized muscle weakness, and dysphagia (difficulty swallowing).During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/18/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report (Physician's Order), dated 5/28/2026, the Physician Order indicated famotidine (medication used to treat and prevent heartburn) oral tablet 20 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for gastroesophageal reflux disease (GERD- stomach acid flows back up into the esophagus and causes heartburn).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for showering, personal hygiene and ambulation.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 7/2026, the MAR indicated Resident 1 refused famotidine on 7/5/2026, at 6:30 a.m.During a concurrent interview and record review on 8/19/2026, at 10:49 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's MAR, dated 7/2026, and Care Plans were reviewed. The MAR indicated Resident 1 refused famotidine on 7/5/2026, at 6:30 a.m. LVN 1 stated the nurses make three attempts to administer medication and if Resident 1 still refused, the nurses document the refusal in the MAR. LVN 1 stated a care plan should have been developed for Resident 1's refusal of medication. LVN 1 stated there was no care plan developed to address Resident 1's refusal of medication.b. During a review of Resident 5's FS, the FS indicated the facility admitted Resident 5 on 4/24/2026, with diagnoses that included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (heart damage caused by long-term unmanaged high blood pressure), and unspecified glaucoma (an eye disease that damages the nerve connecting your eye to your brain).During a review of Resident 5's Order Summary Report, dated 4/24/2026, the Order Summary Report indicated the following orders:1. Docusate sodium (medication used to relieve occasional constipation and prevent straining during bowel movements) oral capsule mg, give 100 mg by mouth daily for constipation (having fewer than three bowel movements a week, or passing hard, dry, and lumpy stools that are difficult or painful to pass).2. Finasteride (medication used to treat benign prostatic hyperplasia [BPH, an enlarged prostate]) oral tablet, five mg, give five mg by mouth daily for BPH.3. Januvia (medication used to lower blood sugar levels) oral tablet 50 mg, give 50 mg by mouth daily for DM.4. Metformin hydrochloride (medication used to control blood sugar levels) oral tablet, 500 mg, give 500 mg by mouth two times a day for DM with breakfast and dinner. 5. Metoprolol tartrate (medication used to lower blood pressure, slow heart rate, and reduce the workload on the heart) oral tablet 25 mg, give 25 mg by mouth two times a day for hypertension (HTN- high blood pressure) and hold (temporarily stop) for systolic blood pressure (the top number in a blood pressure reading and measures the force of blood pushing against your artery walls when your heart beats) less than 110 millimeter mercury (mmHg- a standard unit used to measure pressure) or if heart rate less is than 60 beats per minute.6. Brimonidine tartrate (medication primarily used to lower high pressure inside the eye) ophthalmic solution (liquid eye drops) 0.2 percent (%-by the hundred), instill one drop to both eyes two times a day for glaucoma.7. Timolol maleate (medication used to lower eye pressure) ophthalmic solution 0.5%, instill one drop to both eyes two times a day for glaucoma.During a review of Resident 5's H&P, dated 4/27/2026, the H&P indicated Resident 5 was able to make decisions for activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 5's Order Summary Report, dated 6/14/2026 indicated Eliquis (blood thinner [anticoagulant] used to prevent and treat dangerous blood clots) oral tablet 2.5 mg, give 2.5 mg by mouth two times a day for atrial fibrillation (an irregular and often very fast heartbeat).During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 5 was dependent on staff for toileting, showering and personal hygiene. During a review of Resident 5's MAR, dated 8/2026, the MAR indicated on 8/6/2026, at 9 a.m., Resident 5 refused docusate, finasteride, Januvia, Eliquis, metformin, metoprolol, brimonidine, and timolol.During a concurrent interview and record review on 8/19/2026, at 11:16 a.m., with LVN 2, Resident 5's MAR, dated 8/2026, and Care Plans were reviewed. The MAR indicated Resident 5 refused docusate, finasteride, Januvia, Eliquis, metformin, metoprolol, brimonidine, and timolol on 8/6/2026, at 9 a.m. LVN 2 stated on 8/6/2026, Resident 5 refused his (Resident 5) 9 a.m. medications. LVN 2 stated care plan should have been developed for Resident 5's refusal of medications. LVN 2 stated there were no care plans developed for Resident 5's refusal of medications. LVN 2 stated care plans are the nurses guide on how to solve Resident 5's health problems.During an interview on 8/19/2026, At 11:46 a.m., with Registered Nurse 1 (RN 1), RN 1 stated care plans should have been developed when Resident 1 and Resident 5 refused their medications. RN 1 stated without care plans, Resident 1 would be at risk for GERD. RN 1 stated without care plans, Resident 2 would be at risk for what the medication prescribed for.During an interview on 8/19/2026, at 12:12 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated when residents refuse their medications, the care plan should have been developed. The MDSN stated the care plan is a list of resident specific care that tells the nurse what and how to do if the resident refused medication. The MDSN stated without a care plan no one would know that Resident 1 and 5 had refused their medications. During an interview on 8/19/2026, at 12:22 p.m., with the Director of Nursing (DON), the DON stated for any medication refusal, the care plan should have been developed. The DON stated the importance of developing a care plan for medication refusal was to plan specific care to Resident 1 and Resident 5. The DON stated that without a care plan, Resident 1 and 5 would not be monitored for the potential risk of not receiving the medication.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plans, dated 3/2023, and last reviewed on 7/2026, the P&P indicated, 7. The comprehensive, person-centered care plan:a. Includes measurable objectives and timeframes;b. Describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial (how your mind, feelings, and emotions [psycho] interact with the people, relationships, and society around you [social]) well-being, including: (i) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on interview and record review, the facility failed to notify the Ombudsman and the resident's family member regarding the resident's discharge and appeal rights for one of two sampled residents (Resident 1). This failure violated Resident 1's right to appropriate discharge planning and due process by limiting access to advocacy services and the opportunity to appeal the discharge decision.Findings: During a review of Resident 1's admission Record, the admission Record indicated resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Extended Spectrum Beta Lactamase (ESBL- a type of bacteria that has built a strong shield) Resistant, dementia (a progressive state of decline in mental abilities), and sepsis (a life-threatening blood infection). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/19/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADL's- routine tasks/activities such as bathing, dressing and personal hygiene a person performs daily to care for themselves). During a concurrent interview and record review on 7/28/2026 at 8:49 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Notice of Proposed Transfer and discharge date d 9/19/2026 were reviewed. LVN 1 stated that the Notice was incomplete because it was missing Resident 1's representative signature and facility's representative signature as well as the required fax confirmation needed to be attached to the notice form in Resident 1's medical chart. LVN 1 stated that it was important to notify the Ombudsman about any resident transfer and ensure that the family member is informed of their right to appeal the discharge decision. During a telephone interview on 7/29/2026 at 1:58 p.m. with Family Member (FM) 1, FM 1 stated that the facility did not inform him of Resident 1's discharge. FM 1 stated that the facility only notified him of Resident 1's transfer to General Acute Care Hospital (GACH) 1 for carbapenem-resistant enterobacterales (CRE-- a group of dangerous, drug-resistant bacteria) treatment, and the facility's inability to care for Resident 1. FM 1 believed Resident 1 would return to the facility after treatment, but the facility failed to communicate that Resident 1 was being discharged . FM 1 further stated that the facility informed him the Department of Public Health prohibited Resident 1's return due to isolation requirements. FM 1 stated that the facility did not provide FM 1 with the opportunity to consent or object to the discharge decision, and FM 1 did not receive notification of their appeal rights. FM 1 stated that Resident 1 remained at GACH 1 without available placement. During an interview on 7/29/2026 at 4:26 p.m. with Business Office Manager (BOM), the BOM stated that the facility discharged Resident 1 from bed hold on 7/20/2026 due to an infection that the facility was unable to accommodate. The BOM stated that the facility did not provide Resident 1 or their representative with notice of the discharge or any information about the appeal process. The BOM further stated that she was not aware of any written notice requirement that the facility must provide to Resident 1's representative. During a concurrent interview and record review on 7/30/2026 at 10:09 a.m. with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated that nursing staff must notify the Ombudsman by completing the Notice of Proposed Transfer and Discharge form and faxing it to the Ombudsman department. The DON stated nursing staff are responsible for ensuring the form is fully completed, with signatures from both the facility and Resident 1's representative, and that the fax confirmation is attached to Resident 1's chart along with the notice. The DON stated that Resident 1's Notice of Proposed Transfer and Discharge form dated 7/19/2026 was missing the required signatures and the fax confirmation, making it unclear whether the Ombudsman received notification. The DON stated that the facility staff failed to inform Resident 1 of their appeal rights and did not properly educate Resident 1 or their representative about the appeal process. The DON further stated that the BOM is responsibility for notifying Resident 1's representative in writing, but this notification did not occur.During a review of the facility's P&P titled, Bed-Holds and Returns, dated 03/2022, the P&P indicated, Residents and or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge.5. The resident and representative are notified in writing of the following information:a. The specific reason for the transfer or discharge;b. The effective date of the transfer or discharge;c. The location to which the resident is being transferred or discharged ;d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email and telephone number of the entity which receives appeal hearing request; (2) information about how to obtain, complete and submit an appeal request; and (3) how to get assistance completing the appeal process;e. The facility bed hold policy;f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman.

Based on interview and record review, the facility failed to allow one of two sampled resident (Resident 1) to return to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 7/21/2026 according to the facility's policy and procedure (P&P) titled, Bed-holds and Returns. This failure had the potential to result in Resident 1 remaining in GACH 1 since 7/19/2026 and had the potential to cause psychosocial harm. Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Extended Spectrum Beta Lactamase (ESBL- a type of bacteria that has built a strong shield) Resistant, dementia (a progressive state of decline in mental abilities), and sepsis (a life-threatening blood infection). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/19/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and personal hygiene a person performs daily to care for themselves).During a review of Resident 1's Physician Order Report, dated 7/19/206, the Physician Order Report indicated to Transfer resident to (GACH 1).During a review of Resident 1's Progress Notes, dated 7/19/2026 timed at 4:20 p.m., the Progress Notes indicated staff Received a call from (GACH 1); resident urine is carbapenem-resistant enterobacterales (CRE- a group of dangerous, drug-resistant bacteria). Isolation precautions started. Resident will be transferred back to (GACH 1) for further treatment.During a review of Resident 1's Notification of Bed Hold, dated 7/19/2026, the Notification of Bed Hold indicated A bed hold will maintain not to exceed seven (7) days for the period of: 7/19/2026 through 7/26/2026.During a review of the facility's License, with effective date of 2/10/2025, the license indicated that the facility has a bed capacity of 130 residents for skilled nursing.During a review of the facility's daily census, the daily census indicated the following: i. On 7/18/2026, facility had a census of 130ii. On 7/19/2026, facility had a census of 129iii. On 7/20/2026, facility had a census of 130iv. On 7/21/2026, facility had a census of 130v. On 7/22/2026, facility had a census of 130vi. On 7/23/2026, facility had a census of 129vii. On 7/24/2026, facility had a census of 129During a phone interview on 7/28/2026 at 3:50 p.m. with the GACH's Case Manager (CM), the CM stated that Resident 1 was ready to be discharged back to facility on 7/21/2026. The CM stated she sent the referral to the facility and contacted the facility, in which she was told that they could not accept Resident 1 back because Resident 1 was ambulatory and had CRE, Resident 1 could walk into other residents' rooms and spread the infection. The CM stated that the facility does not accept residents with CRE. During an interview on 7/29/2026 at 10:26 a.m. with Admissions Coordinator (AD), the AD stated that she spoke with GACH's CM on 7/21/2026 and told her that the facility would not readmit Resident 1 because the facility does not accept residents with CRE, did not have available room, and believed Resident 1 required permanent isolation. The AD stated that the Director of Nursing (DON) and the Administrator (Admin) determined that the facility could not accommodate Resident 1 because of the resident isolation needs. The AD stated that the facility did not follow its bed hold policy because staff removed Resident 1 from bed hold on 7/20/2026. The AD further stated that the facility's actions damaged its relationship with the GACH case managers and made it more difficult to secure placement for Resident 1.During an interview on 7/29/2026 at 11:05 a.m. with the Infection Prevention (IP) Nurse, the IP Nurse stated that the facility does not admit residents with CRE because they would require a private room and are not able to accommodate them. The IP nurse stated that Resident 1 would require to be on contact isolation (residents with known or suspected infections that represent an increased risk for contact transmission) and the facility would not be able to accommodate Resident 1. The IP Nurse stated that CRE was a Multidrug-Resistant Organism (MDRO- germ (usually bacteria) that does not respond to many common antibiotics). The IP Nurse further stated that Resident 1 was placed on a bed hold from 7/19/2026 through 7/26/2026 but does not guarantee that the resident can come back to the facility.During an interview on 7/29/2026 at 12:45 p.m. with the Administrator (Admin), the Admin stated that Resident 1 was transferred to GACH 1 because Resident 1 tested positive for CRE. The Admin stated that the facility would not be able to take care of Resident 1 because the facility cannot manage it because Resident 1 is ambulatory and the facility would not be able to keep him in a room. The Admin stated that the facility spoke with Resident 1's Family Member (FM) 1 and explained the situation and of Resident 1 did not have CRE the facility would readmit. Admin stated that the facility removed Resident 1 from bed hold on 7/20/2026 because the facility knew that they were not going to readmit Resident 1. During an interview on 7/29/2026 at 4:26 p.m. with Business Office Manager (BOM), the BOM stated that the facility discharged Resident 1 from bed hold on 7/20/2026 because Resident 1 had an infection and the facility could not accommodate Resident 1's needs. The BOM stated that the facility did not follow its bed hold policy. The BOM stated, I discharged (Resident 1) on 7/20/2026 after I was told to stop billing the insurance because we could not accommodate Resident 1. The BOM further stated that facility should have maintained Resident 1's bed hold from 7/19/2026 through 7/26/2026 and readmitted Resident 1 on 7/21/2026.During a concurrent interview and record review on 7/30/2026 at 10:09 a.m. with Director of Nursing (DON), reviewed the Facility Assessment Tool, updated on 6/8/2026. The DON stated that the facility assessment provides an overview of the facility's patient population, facility's capacity and care required by the resident population. The Facility Assessment Tool indicated that the facility could care for residents with infections, including MDRO. The DON stated that the facility should not have canceled the bed hold on 7/20/2026 or discharged Resident 1. The DON stated that Resident 1 lives in the facility, and he should be readmitted when ready to be discharge from the GACH. The DON stated that there was no documentation in Resident 1's medical record indicating that Resident 1's representative received and understood the bed hold policy. The DON further stated that the facility failed to follow its bed hold policy, discharged Resident 1 without completing the required discharge process, and prevented Resident 1 from returning to the facility. During a review of the facility's P&P titled, Bed-Holds and Returns, dated 03/2022, the P&P indicated, All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: well in advance of any transfer; and at the time of transfer (or, if the transfer was an emergency, within 24 hours). The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there's not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to previous distinct part when a bed becomes available.

Based on observation, interview, and record review, the facility failed to ensure three of six sampled residents' (Resident 4, Resident 5, and Resident 6) meal trays were served at the same time. These deficient practices resulted in Resident 4 and Resident 6's agitation. This deficient practice furthermore had the potential to negatively affect Resident 4's, Resident 5's, and Resident 6's dignity and self-esteem. Findings: a. During a review of Resident 4's undated admission Record, the admission Record indicated the facility admitted Resident 4 on 7/3/2026 with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), restlessness and agitation, and unspecified dementia (a decline in brain function including memory, language, reasoning, and behavior severe enough to interfere with daily life but the specific type had not been identified). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 7/6/2026, the MDS indicated Resident 4's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 4 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. During a review of Resident 4's Order Summary Report (OSR), for the active orders as of 7/20/2026, the OSR indicated a physician order for Resident 4's diet with an order date of 7/6/2026. The OSR indicated Resident 1 was on a regular diet with soft and bite-sized texture. During a concurrent observation and interview on 7/20/2026 at 12:13 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated Resident 4 was not served lunch while the other residents, sitting at the same table, were already eating. Resident 4 was visibly agitated and yelled asking for food. Resident 4 went out of the dining room looking for the meal tray. The IPN stated failure to provide meals at the same time to the residents sitting at the same table could negatively affect the residents' dignity. During an observation on 7/20/2026 at 12:24 p.m., Resident 4 was observed being wheeled back inside the dining room. Resident 4 was served the lunch meal 11 minutes after the other residents had started eating their meal, sitting at the same table. b. During a review of Resident 5's undated admission Record, the admission Record indicated the facility admitted Resident 5 on 6/12/2024 with diagnoses including unspecified dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that involve excessive fear, worry, or nervousness that interfere with daily life). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 5 required set up or clean-up assistance (helper assists only prior to or following the activity) with eating. During a review of Resident 5's OSR, for the active orders as of 7/20/2026, the OSR indicated a physician order for Resident 5's diet with an order date of 3/19/2026. The OSR indicated Resident 5 was on a regular texture diet and with no added salt. During a concurrent observation and interview on 7/20/2026 at 12:13 p.m. with the IPN, the IPN stated Resident 5 was not served the lunch meal tray while the other residents, sitting at the same table, were already eating. Resident 5 was observed with head down staring at the table. The resident in front of Resident 5 was observed asking the facility staff where Resident 5's food was. The IPN stated failure to provide meals at the same time to the residents sitting at the same table could negatively affect the residents' dignity. During an observation on 7/20/2026 at 12:22 p.m., Resident 5 received the lunch meal tray, nine minutes after the other residents had started eating their meal, sitting at the same table. c. During a review of Resident 6's undated admission Record, the admission Record indicated the facility admitted Resident 6 on 7/3/2026 with diagnoses including metabolic encephalopathy, unspecified dementia, and type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 6 required moderate assistance with eating. During a review of Resident 6's OSR, for the active orders as of 7/21/2026, the OSR indicated a physician order for Resident 6's diet with an order date of 7/14/2026. The OSR indicated Resident 6 was on a puree texture diet with no added salt. During a concurrent observation and interview on 7/20/2026 at 12:13 p.m. with the IPN, the IPN stated Resident 6 was not served the lunch meal tray while the other residents, sitting at the same table, were already eating. The IPN stated Resident 6 was visibly agitated, yelling, and pointing at the table. Resident was observed looking at other residents' food, sitting in the table. The IPN stated failure to provide the meals at the same time to the residents sitting at he same table could negatively affect the residents' dignity. During an observation on 7/20/2026 at 12:23 p.m., Resident 6 received the lunch meal tray, nine minutes after the other residents had started eating their meal, sitting at the same table. During an interview on 7/21/2026 at 11:05 a.m. with the Director of Nursing (DON), the DON stated the licensed nurses should ensure the residents' meal trays are provided to the residents at the same table at the same time. The DON stated the residents could feel left out, started grabbing other resident food, and could cause increased anxiety. The DON stated the residents with existing diagnosis of depression could potentially exacerbate. The DON acknowledged and stated the facility failed to ensure the residents seated at the same table were served at the same time to maintain residents' dignity. During a review of the facility's policy and procedure (PnP) titled, Resident Rights, last reviewed on 7/2026, the PnP indicated employees shall treat all residents with kindness, respect, and dignity. The PnP indicated these rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity. During a review of the facility's PnP titled, Dignity, last reviewed on 7/2026, the PnP indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The PnP indicated Residents are treated with dignity and respect at all times. The PnP indicated when assisting with care, residents are supported in exercising their rights.residents are .provided with a dignified dining experience.

Based on interview and record review, the facility failed to follow its policies and procedures regarding individualized care planning by failing to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) addressing one of three sampled residents` (Resident 1) prednisone (a powerful steroid used to decrease swelling, inflammation, and allergies) use. This deficient practice increases the risks for Resident 1 to not understand the purpose of the medication's use, the possibility of treatment failure, and the lack of interventions for staff to monitor Resident 1 for any harmful adverse side effects related to taking the medication. FindingsDuring a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 2/26/2025, with diagnoses including muscle weakness (loss of strength), dysphagia (having difficulty swallowing), hypertensive heart disease with heart failure (a damaged heart due to long-term high blood pressure resulting in inefficient pumping), and chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow, making it difficult to breath). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/5/2025, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was with moderate impairment. The MDS also indicated Resident 1 needed partial/moderate assistance (helper does less than half the effort) for toileting needs, showering or bathing, and assistance when applying footwear. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:- 2/12/2026 8:02 p.m., a telephone order for Prednisone (a powerful steroid used to decrease swelling, inflammation, and allergies) oral tablet 20 milligrams (mg-a unit of measurement), give one tablet by mouth one time a day for cough for five days. During an interview with Assistant Director of Nursing (ADON) on 2/6/2026 at 3:16 p.m., the ADON stated, The purpose of creating a care plan is to create goals for the resident (Resident 1) and address the needs. The ADON stated licensed staff did not develop a care plan for Resident 1`s prednisone use. The ADON stated staff should have created a care plan because there are side effects that could potentially be caused by the use of medications. The ADON stated care plan has goals and interventions such as monitoring of vital signs, any potential side effects, or to see if the resident was exhibiting any side effects. The ADON stated if the resident exhibits any side effects, staff are required to notify the doctor if the medication would need to be continued or discontinued. The ADON stated the failure here was not developing a care plan to address Resident 1`s Prednisone usage. During a review of the facility provided policy & procedure (P & P) titled Care Plans, Comprehensive Person-Centered with last revision date of 3/2022, the P & P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also stated; 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change.;

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical well-being, when Registered Nurse (RN 2) and RN 3 failed to complete the admission assessment timely when Resident 1 was re-admitted to the facility on [DATE]. This deficient practice had the potential to result in Resident 1 receiving inadequate care. Findings: During a review of Resident 1's admission Record, dated 01/02/2026, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, judgment, and behavior), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy levels, and behavior), and schizoaffective disorder (a mental illness that mixes symptoms of schizophrenia, such as hallucinations, delusions, and disorganized thinking, with symptoms of intense mood swings). During a review of Resident 1's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 07/10/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 1 needed moderate assistance for personal hygiene, shower/bathe, and lower body dressing (a helper does less than half the effort of the activity). The MDS indicated Resident 1 needed supervision or touching assistance for toileting, oral hygiene, and upper body dressing (a helper provides verbal cues or touching assistance throughout the activity or intermittently). During a review of Resident 1's Change of Condition (COC - when a resident experiences any physical, mental, or psychosocial change from his/her baseline status), dated 12/09/2025, the COC indicated that on 12/09/2025 at 4 a.m., Resident 1 was found at the end of the hall banging his walker against the facility doors attempting to break and exit [the] facility. Staff attempted [to] redirect, however unsuccessful due to [Resident 1] lashing out at staff and becoming verbally and physically aggressive. [Resident 1] proceeded down the hall ignoring de-escalation attempts by staff and proceeded to [NAME] the walker against the walls and paintings on the wall. The COC further indicated that 911 [was] called for transport to the hospital for evaluation and for being a danger to [Resident 1's self] and others. During a phone interview on 12/23/2025 at 10:45 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated when he began his shift on 12/08/2025 at approximately 11 p.m., he found Resident 1 asleep and sitting in a chair in front of the nursing station. CNA 1 stated he assisted Resident 1 back to his room to lay on his bed. CNA 1 stated that at approximately 3 a.m., another resident started to yell and scream and that was enough to [wake up Resident 1. CNA 1 stated when CNA 1 returned from his break, another CNA (which CNA 1 could not recall) had changed Resident 1's adult diaper. CNA 1 stated he saw Resident 1 walking around with his walker at about 4 a.m. CNA 1 stated he then heard Resident 1 mad and crashing the back door with his walker. CNA 1 stated he saw numerous staff members approach Resident 1, but CNA 1 was unable to assist because he was preoccupied with another resident. CNA 1 stated he remembers RN 2 calling 911 because Resident 1 took his walker and tried to hit people. CNA 1 stated staff members tried to offer [Resident 1] cookies or juice but it didn't work. CNA 1 stated he saw Resident 1 spit on one of the CNAs. CNA 1 stated Resident 1 only calmed down when he saw the police, and Resident 1 was then transferred to an acute hospital. CNA 1 stated he recalls Resident 1 was re-admitted to the facility on [DATE] around 2 p.m. to 3 p.m. During an interview on 12/23/2025 at 11:47 a.m. with RN 1, RN 1 stated an admission assessment is completed when a resident is admitted or re-admitted to the facility. RN 1 stated that a registered nurse can endorse (give the task to the next shift to complete) other assessments like fall risk, dehydration, skin if [the RN does not] have time to finish those, but the priority is the admission assessment and obtaining doctor's orders when a resident returns to the facility from an acute hospital. RN 1 stated the importance of timely completing the admission assessment is to get a baseline of your patient from head to toe so you know where they start when they arrive. During a concurrent interview and record review on 12/23/2025 at 12:03 p.m. with RN 1, Resident 1's electronic medical record was reviewed. RN 1 stated Resident 1's clinical admission assessment was completed on 12/23/2025 at approximately 3 a.m. by the night shift nurse. RN 1 stated there was no licensed nursing note regarding Resident 1's re-admission on [DATE] in the afternoon. RN 1 stated the clinical admission assessment should have been documented on 12/22/2025 when resident was admitted in the afternoon. During a phone interview on 12/23/2025 at 12:37 p.m. with RN 2, RN 2 stated Resident 1 came back from the hospital yesterday on 12/22/2025 around 2 p.m. or 2:30 p.m. RN 2 stated she was the assigned nurse when Resident 1 was re-admitted to the facility, and RN 2 was also assigned to another resident who was being admitted around the same time. RN 2 stated that when Resident 1 arrived, RN 2 did [her] assessment with the patient. When asked what kind of assessment RN 2 performed, RN 2 stated: I just checked if [Resident 1] is ok and how he feels and if he has pain. When asked if RN 2 completed an admission assessment, RN 2 stated, I endorsed it to the treatment nurse and next shift because at this time I had 2 residents come in. RN 2 stated, If a patient comes at 2:30 p.m., then the next shift needs to continue and do all the assessments. RN 2 stated she did not document any admission assessment for Resident 1 when he arrived on 12/22/2025. During a phone interview on 12/23/2025 at 1:35 p.m. with RN 3, RN 3 stated she recalls Resident 1 being re-admitted on [DATE], and RN 3 received report from RN 2. RN 3 stated RN 2 was working on another admission and RN 2 mentioned [Resident 1] was also admitted and [RN 2] hadn't done much for that one yet. RN 3 stated that usually whoever the RN is when a patient arrives is the one who needs to complete the admission assessment. RN 3 stated, if the [resident] comes before 2:45 p.m., the admission needs to be done by the prior shift. RN 3 stated that RN 3 had seen in the facility's computer system that Resident 1 had arrived at 2:01 p.m. RN 3 stated: Since [Resident 1] came at 2:01 p.m., the prior nurse should have done the admission assessment. RN 3 stated she asked if RN 2 had completed the admission assessment, and RN 2 replied that the treatment nurse said she's going to do it. RN 3 stated that she called Resident 1's primary doctor and psychiatrist to notify them of Resident 1's arrival and to obtain doctor's orders. RN 3 stated she had a new admission on her shift and was unable to complete Resident 1's admission assessment. RN 3 stated at the end of her shift, RN 3 realized [Resident 1's] admission assessment wasn't done by the treatment nurse. RN 3 stated she endorsed Resident 1's admission assessment to the night nurse whose shift was from 11 p.m. to 7 a.m. During an interview on 12/23/2025 at 2:36 p.m. with the Director of Nursing (DON), the DON stated a registered nurse needs to perform a head-to-toe assessment (checking the overall well-being of a resident starting from his/her head down to the toes) when a resident is admitted or re-admitted to the facility. The DON stated it is important to complete an admission assessment when a resident is re-admitted because the nursing staff needs to know if there are any new changes and compare it to the patient's baseline status. When asked which shift is responsible for completing the admission assessment if a resident arrives at the facility at 2:01 p.m., the DON stated the morning shift [from 7 a.m. to 3 p.m.] can start but it can be continued by the afternoon shift [from 3 p.m. to 11 a.m.]. The DON stated the admitting nurse (the assigned nurse who is present when a resident arrives at the facility) needs to assess the patient's condition when they arrive is most important, and at the very least document the clinical admission assessment. DON stated the admitting nurse can then endorse the other assessments to the following shift. During a review of the facility's policy and procedure (P&P) titled, admission Assessment and Follow Up: Role of the Nurse, dated 9/2012, the P&P indicated the following: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. The P&P indicated the nurse needs to conduct a physical assessment, which .should be recorded in the resident's medical record. including the date and time the assessment was performed.[and] all relevant assessment data obtained during the procedure.

Based on interview and record review, the facility failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurately documented to reflect the fall risk of one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services. Findings:Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/7/2024 and was readmitted on [DATE] with diagnoses including encephalopathy (any condition that damages or impairs the brain, leading to changes in brain function or structure), dementia (a progressive state of decline in mental abilities), and anxiety (a common mental health condition characterized by excessive worry, fear, and unease).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/25/2025, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with toileting, and requires partial to moderate assistance (the helper does less than half the effort) with oral hygiene, showering, upper and lower body dressing, and putting on and taking off footwear and requires supervision or touching assistance (helper provides verbal cues and or touching or contact guard assistance) with eating, walking 10 feet and walking 50 feet.During a review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident's condition) Assessment Form, dated 7/3/2025 at 3:50 a.m., the COC Assessment Form indicated Resident 1 had a fall. At 3:50 p.m. Certified Nursing Assistant (CNA) 1 notified Registered Nurse (RN) 1, Resident 1 is sitting on the floor between the resident's bed and bathroom door.During a review of Resident 1's Fall Risk Evaluation, dated 7/22/2025 at 1:17 a.m., the Fall Risk Evaluation indicated Resident 1 had a fall risk score of 16 (total score is 10 or greater, the resident should be considered at high risk for potential fall).During a review of Resident 1's Fall Risk Evaluation, dated 7/22/2025 at 1:35 a.m., the Fall Risk Evaluation indicated Resident 1 had a fall risk score of 18.During a review of Resident 1's COC, dated 8/3/2025 at 8:18 a.m., the COC indicated Resident 1 had a status post unwitnessed fall, complaint of right groin and leg pain, middle forehead redness, left anterior knee redness. The COC indicated at 7:20 a.m. CNA 1 reported to the charge nurse Resident 1 was on the floor.During a review of Resident 1's Fall Risk Evaluation, dated 8/3/2025 at 8:18 a.m., the evaluation indicated Resident 1's had a fall risk score of 16.During a review of Resident 1's Fall Risk Evaluation, dated 8/7/2025 at 1:44 p.m., the evaluation indicated Resident 1's had a fall risk score of 17.During a review of Resident 1's Fall Risk Evaluation, dated 8/9/2025 at 8:56 p.m., the evaluation indicated Resident 1's had a fall risk score of 15.During a concurrent interview and record review on 8/14/2025 at 9:24 a.m. with the Administrator (Adm), Resident 1's Fall Risk Evaluation dated 7/22/2025 was reviewed. The Adm stated was not sure why Resident 1 had multiple Fall Risk Evaluations for 7/22/2025 and will get the Minimum Data Set Coordinator (MDS) to answer the questions.During a concurrent interview and record review on 8/14/2025 at 9:27 a.m. with the MDS, Resident 1's Fall Risk Evaluation dated 7/22/2025 was reviewed. The MDS stated Resident 1 was discharged then returned to the facility on 7/21/2025. The MDS stated Resident 1 had multiple fall risk evaluations on 7/22/2025 because the nursing staff did not communicate with each other. The MDS stated was unsure which fall risk evaluations were accurate.During a concurrent interview and record review on 8/14/2025 at 3 p.m. with the Director of Nursing (DON), Resident 1's Fall Risk Evaluation dated 7/22/2025 was reviewed. The DON stated Resident 1 prior to fall on 8/3/2025 was not a high risk for falls but all residents in this facility are fall risk due to poor cognitive awareness and safety issues. The DON stated Resident 1 was able to ambulate without devices and had a prior fall in Resident 1's room without injury on 7/3/2025. The DON stated Resident 1 was discharged prior due to behavioral issues and returned to the facility on 7/21/2025. The DON stated the facility has a new system for the Fall Risk Evaluation, the DON stated was aware that two entries were done on 7/22/2025 one was from the nurse from 7 a.m. to 3 p.m. shift and the other was from the nurse from the 3 p.m. to 11 p.m. shift. The DON stated was not sure which fall risk evaluation was accurate. The DON stated the one Registered Nurse (RN) 2 did indicated Resident 1 had a fall risk score of 16 and RN 3's fall risk evaluation indicated Resident 1's fall risk score was 18. The DON stated RN 2 and RN 3's fall risk evaluation was inaccurate because RN 2 and RN 3 indicated Resident 1 had no falls in the past three (3) months and that is inaccurate because Resident 1 had a fall on 7/3/2025. The DON stated RN 2 inaccurately documented Resident 1's COC because Resident 1 did have a COC for behaviors and that is why Resident 1 was readmitted on [DATE]. The DON stated RN 2 inaccurately documented Resident 1's medications, the record indicates Resident 1 takes one to two of the listed medications, but it should indicate Resident 1 takes three to four of the listed medications. The DON reviewed the fall risk evaluation for Resident 1 for 8/7/2025 and the DON stated the fall risk evaluation was inaccurate because it indicated Resident 1 had none of the listed predisposing diseases. The DON stated assessment must be accurate because if assessments are not accurate there is a potential to not have the appropriate intervention for the residents.During a review of the facility's Policies and Procedures (P&P) titled, Charting and Documentation, last reviewed on 7/2025, the P&P indicated, documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.During a review of the facility's P&P titled, Falls and Fall Risk, Managing, last reviewed on 7/2025, the P&P indicated, based on previous evaluations and current data, the staff will identify related to the resident's specific risk and cause to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review, the facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) within two hours to the State Survey Agency (SSA) on 7/17/2025, when the Director of Staff Development (DSD) received a text message from Certified Nurse Assistant (CNA) 4 that she (CNA 4) witnessed abuse while training with CNA 3. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: During an interview with the DSD on 7/24/2025 at 11:00 a.m., the DSD stated she (DSD) received a text message on 7/17/25 at 6:14 a.m. from CNA 4, a CNA trainee, that she (CNA 4) will not be coming back because CNA 3, the CNA that CNA 4 was training with, was very abusive towards the residents. The DSD stated CNA 4 reported that residents were left soaking in urine for hours and CNA 3 was very rough and mean to a lot of the residents. The DSD stated she immediately texted CNA 4 to obtain more information, however CNA 4 was unresponsive. The DSD stated she called the Administrator (ADMIN) and reported CNA 4's allegations against CNA 3. The DSD stated CNA 4 left the facility and was not able to obtain more information. The DSD stated the allegation was not reported and CNA 3 was never suspended for a proper investigation. The DSD stated that any allegation of abuse needs to be reported within two hours. During an interview with the ADMIN on 7/24/2025 at 11:30 a.m., the ADMIN stated the DSD called her on 7/17/2025, the ADMIN does not recall exact time, to notify her (ADMIN) that CNA 4 had texted the DSD that she will not be coming back to work because she had witnessed abuse from CNA 3 towards her (CNA 3) assigned residents. The ADMIN stated she instructed the DSD to obtain a statement from CNA 4, however CNA 4 left the facility and did not provide a written statement providing more information regarding her allegation of abuse. The ADMIN stated, she (ADMIN) did not report the allegations to the SSA because she did not receive a full statement. The ADMIN stated any allegation of abuse needs to be reported within two hours. During an interview with the Director of Nurses (DON) on 7/24/2025 at 3:00 p.m., the DON stated all allegations of abuse are reported to the ADMIN. The DON stated when there is an allegation of abuse, the facility must initiate an investigation and report the allegation within two hours. The DON stated CNA 4 might have misinterpreted the care CNA 3 was providing to her residents, so the facility decided not to report the allegation of abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, the P&P indicated all reports of resident abuse. are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse. is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated Immediately is defined as within two hours of an allegation involving abuse.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to one of three sampled residents (Resident 2) when there was no documented evidence in Resident 2's medical record showing Licensed Vocational Nurse (LVN 3) had assessed Resident 2's reported pain on 6/29/2025. This failure had the potential to result in Resident 2's reported pain to be left unmanaged which can prevent Resident 2 from reaching her highest practicable wellbeing.Findings: During a review of Resident 2's admission Record, dated 7/7/2025, the admission Record indicated Resident 2's diagnoses included polyneuropathy (a condition where nerves running along the arms, hands, legs, and feet are damaged causing pain, weakness, numbness, and tingling), and osteoarthritis (a joint condition where the cartilage between bones wears down, causing pain, stiffness, and decreased movement) of both knees. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/13/2025, the MDS indicated Resident 2 is usually understood but occasionally has difficulty communicating some words. The MDS indicated Resident 2 is usually able to comprehend most conversation. During a review of Resident 2's care plan, dated 7/2/2025, the care plan indicated Resident 2 has potential for [a]lteration in Comfort/Pain related to [a]dvanced aging and osteoarthritis. The care plan indicated interventions include assess[ing] characteristics of pain and administer[ing] medication as ordered. During a concurrent observation and interview on 7/8/2025 at 2:57 p.m. with Resident 2 in the activities room, Resident 2 was sitting in a recliner wheelchair. Resident 2 stated that sometimes she has pain in her knees which she rates 5 out of 10 on a pain scale (a tool used to describe the intensity of pain, typically ranging from 0 which represents no pain, and up to 10 which represents the highest pain possible). Resident 2 stated her knee pain can reach as high as 10 out of 10. Resident 2 touched both of her knees and stated sometimes both knees have pain at the same time. Resident 2 stated: I call [the nurses] only if I really, really need them, and when I can't stand the pain no more. Resident 2 stated she remembers having pain at the end of last month on her knees all the way down to [her] toes. Resident 2 stated she had asked for pain medication but does not recall if any nurse gave her medication. During a review of Resident 2's Medication Administration Record (MAR), dated 7/8/2025, the MAR indicated Resident 2's doctor ordered 2 tablets of Tylenol 325 milligrams every 6 hours for mild pain rated 1-3 out of 10, and 2 tablets of Tylenol 500 milligrams every 6 hours for moderate pain rated 4-6 out of 10. During an interview on 7/8/2025 at 3:53 p.m. with LVN 2, LVN 2 stated: I remember [Resident 2] reported pain directly to me approximately the end of June. LVN 2 stated she was walking in the hallway near Resident 2's room when LVN 2 heard Resident 2 yell Help!. LVN 2 entered Resident 2's room and asked what was wrong. LVN 2 stated Resident 2 reported pain in both knees and requested pain medication. LVN 2 stated: I told [Resident 2] that I would tell the charge nurse who was assigned to Resident 2. LVN 2 stated she reported Resident 2's pain to LVN 3 and asked if any pain medication had been given to which LVN 3 stated no. LVN 2 stated: I reported to [LVN 3] and said go check her out and see if there is anything you can give her for pain. LVN 2 stated she did not observe LVN 3 enter Resident 2's room to assess for pain or administer any pain medication. During a concurrent interview and record review on 7/8/2025 at 4:00 p.m. with LVN 2, Resident 2's MAR, dated 6/1/2025 to 6/30/2025, was reviewed. LVN 2 stated the pain assessment section in Resident 2's MAR indicated that LVN 3 was assigned to Resident 2 only once during the last week of June, which was on 6/29/2025. LVN 2 stated the MAR indicated LVN 3 documented a pain level of zero for Resident 2 on 6/29/2025, however it is unknown when that pain level was assessed since the MAR does not list the exact time. LVN 2 stated Resident 2's MAR indicated no pain medication was administered to Resident 2 during the entire last week of June 2025, consisting of 6/22/2025 through 6/31/2025. LVN 2 stated pain management is important because if we don't control it, it gets worse. LVN 2 stated pain can't be taken lightly because it can cause other issues and harm. During a phone interview on 7/9/2025 at 9:57 a.m. with LVN 3, LVN 3 stated he worked on 6/29/2025 and was assigned to Resident 2. LVN 3 stated LVN 2 informed him that Resident 2 had reported pain and requested medication. LVN 3 stated: I do remember that incident. LVN 3 stated he was currently passing medications to a different resident at the time of LVN 2's reporting. LVN 3 stated approximately 10 minutes later, LVN 3 entered Resident 2's room to assess for pain but found Resident 2 asleep. LVN 3 stated he visually checked Resident 2 later during LVN 3's shift but Resident 2 remained asleep. When asked where in Resident 2's records indicate LVN 3 assessed Resident 2's reported pain, LVN 3 stated: For this instance, I didn't document. I should have. LVN 3 stated per professional standards of nursing practice, if it's not documented, then it's not done. During an interview on 7/9/2025 at 12:02 p.m. with Director of Nursing (DON), DON stated if a resident reports pain and requests medication, a licensed nurse must assess the pain level, pain location, and whether pain medication is available to be given. DON stated, pain is what the patient says it to be. DON stated that if a nurse goes into a resident's room to assess for pain but finds the resident sleeping, the nurse should let the resident sleep but continue to do their routine rounds of pain assessment. DON stated that if a nurse documents the assessment of a resident's pain, that is enough to support that the nurse already assessed for pain management. DON stated if there is no documentation in the resident's record of a pain assessment, then there is no proof that it was completed. DON stated that per professional standards of practice, if it's not written, then it's not done. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated 7/2024, the P&P indicated the facility's pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The P&P indicated [a]cute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The P&P indicated that [u][NAME] completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure the medical record of one of three sampled residents (Resident 2) was complete, accurately documented, and contained a record of Resident 2's pain assessments when Licensed Vocational Nurse (LVN 3) stated Resident 2's pain was assessed on 6/29/2025 after Resident 2 reported pain to both knees. This failure resulted in an incomplete medical record as there was no documented evidence that Resident 2's reported pain was addressed.Findings: During a review of Resident 2's admission Record, dated 7/7/2025, the admission Record indicated Resident 2's diagnoses included polyneuropathy (a condition where nerves running along the arms, hands, legs, and feet are damaged causing pain, weakness, numbness, and tingling), and osteoarthritis (a joint condition where the cartilage between bones wears down, causing pain, stiffness, and decreased movement) of both knees. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/13/2025, the MDS indicated Resident 2 is usually understood but occasionally has difficulty communicating some words. The MDS indicated Resident 2 is usually able to comprehend most conversation. During a review of Resident 2's care plan, dated 7/2/2025, the care plan indicated Resident 2 has potential for [a]lteration in Comfort/Pain related to [a]dvanced aging and osteoarthritis. The care plan indicated interventions include assess[ing] characteristics of pain and administer[ing] medication as ordered. During a concurrent observation and interview on 7/8/2025 at 2:57 p.m. with Resident 2 in the activities room, Resident 2 was sitting in a recliner wheelchair. Resident 2 stated that sometimes she has pain in her knees which she rates 5 out of 10 on a pain scale (a tool used to describe the intensity of pain, typically ranging from 0 which represents no pain, and up to 10 which represents the highest pain possible). Resident 2 stated her knee pain can reach as high as 10 out of 10. Resident 2 touched both of her knees and stated sometimes both knees have pain at the same time. Resident 2 stated: I call [the nurses] only if I really, really need them, and when I can't stand the pain no more. Resident 2 stated she remembers having pain at the end of last month on her knees all the way down to [her] toes. Resident 2 stated she had asked for pain medication but does not recall if any nurse gave her medication. During a review of Resident 2's Medication Administration Record (MAR), dated 7/8/2025, the MAR indicated Resident 2's doctor ordered 2 tablets of Tylenol 325 milligrams every 6 hours for mild pain rated 1-3 out of 10, and 2 tablets of Tylenol 500 milligrams every 6 hours for moderate pain rated 4-6 out of 10. During an interview on 7/8/2025 at 3:53 p.m. with LVN 2, LVN 2 stated: I remember [Resident 2] reported pain directly to me approximately the end of June. LVN 2 stated she was walking in the hallway near Resident 2's room when LVN 2 heard Resident 2 yell Help!. LVN 2 entered Resident 2's room and asked what was wrong. LVN 2 stated Resident 2 reported pain in both knees and requested pain medication. LVN 2 stated: I told [Resident 2] that I would tell the charge nurse who was assigned to Resident 2. LVN 2 stated she reported Resident 2's pain to LVN 3 and asked if any pain medication had been given to which LVN 3 stated no. LVN 2 stated: I reported to [LVN 3] and said go check her out and see if there is anything you can give her for pain. LVN 2 stated she did not observe LVN 3 enter Resident 2's room to assess for pain or administer any pain medication. During a concurrent interview and record review on 7/8/2025 at 4:00 p.m. with LVN 2, Resident 2's MAR, dated 6/1/2025-6/30/2025, was reviewed. LVN 2 stated the pain assessment section in Resident 2's MAR indicated that LVN 3 was assigned to Resident 2 only once during the last week of June, which was on 6/29/2025. LVN 2 stated the MAR indicated LVN 3 documented a pain level of zero for Resident 2 on 6/29/2025, however it is unknown when that pain level was assessed since the MAR does not list the exact time. LVN 2 stated Resident 2's MAR indicated no pain medication was administered to Resident 2 during the entire last week of June 2025, consisting of 6/22/2025 through 6/31/2025. LVN 2 stated pain management is important because if we don't control it, it gets worse. LVN 2 stated pain can't be taken lightly because it can cause other issues and harm. During a phone interview on 7/9/2025 at 9:57 a.m. with LVN 3, LVN 3 stated he worked on 6/29/2025 and was assigned to Resident 2. LVN 3 stated LVN 2 informed him that Resident 2 had reported pain and requested medication. LVN 3 stated: I do remember that incident. LVN 3 stated he was currently passing medications to a different resident at the time of LVN 2's reporting. LVN 3 stated approximately 10 minutes later, LVN 3 entered Resident 2's room to assess for pain but found Resident 2 asleep. LVN 3 stated he visually checked Resident 2 later during LVN 3's shift but Resident 2 remained asleep. When asked where in Resident 2's records indicate LVN 3 assessed Resident 2's reported pain, LVN 3 stated: For this instance, I didn't document. I should have. LVN 3 stated per professional standards of nursing practice, if it's not documented, then it's not done. During an interview on 7/9/2025 at 12:02 p.m. with Director of Nursing (DON), DON stated if a resident reports pain and requests medication, a licensed nurse must assess the pain level, pain location, and whether pain medication is available to be given. DON stated, pain is what the patient says it to be. DON stated that if a nurse goes into a resident's room to assess for pain but finds the resident sleeping, the nurse should let the resident sleep but continue to do their routine rounds of pain assessment. DON stated that if a nurse documents the assessment of a resident's pain, that is enough to support that the nurse already assessed for pain management. DON stated if there is no documentation in the resident's record of a pain assessment, then there is no proof that it was completed. DON stated that per professional standards of practice, if it's not written, then it's not done. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated 7/2024, the P&P indicated the facility's pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The P&P indicated [a]cute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The P&P indicated that [u][NAME] completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2024, the P&P indicated .any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The P&P indicated objective observations and [c]hanges in the resident's condition are types of information to be documented in the resident medical record.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control in one of four sampled residents (Resident 1) when Licensed Vocational Nurse (LVN 1) prepared to administer Gabapentin (a medication that prevents/controls seizures and can also relieve nerve pain) without first washing hands or using alcohol hand sanitizer per the facility's protocol. This failure had the potential to result in spreading infection to Resident 1 during the administration of Gabapentin. Findings: During a review of Resident 1's admission Record, dated 7/9/2025, the admission Record indicated Resident 1's diagnoses include dementia (a decrease in thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life), neuralgia (pain caused by irritation or damage to a nerve), and neuritis (inflammation of a nerve causing pain, numbness, tingling, or weakness). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 1's ability is limited in making concrete requests. The MDS indicated Resident 1 comprehends most conversation. The MDS also indicated Resident 1 has functional limitations to the lower extremities, which consists of the hips, knees, ankles and feet. During an observation on 7/3/2025 at 12:53 p.m. in Resident 1's room, LVN 1 entered Resident 1's room and advised Resident 1 that Gabapentin will be given. LVN went to the medication cart in front of Resident 1's room and began preparing the medication by unscrewing two Gabapentin capsules in order to mix the powdered medication with applesauce. LVN 1 was not observed to have washed hands or used alcohol hand sanitizer prior to preparing and handling the Gabapentin capsules. During a review of Resident 1's Medication Administration Record (MAR), dated 7/3/2025, the MAR indicated Resident 1's doctor ordered Gabapentin Capsule 100 milligrams and to give 2 capsules by mouth three times a day for neuropathy. During an interview on 7/3/2025 at 4:03 p.m. with LVN 1, LVN 1 stated handwashing or alcohol hand sanitizing did not occur prior to LVN 1 holding and taking apart the Gabapentin capsules so that the powdered medication can be mixed with applesauce. LVN 1 stated handwashing had occurred downstairs when [LVN 1] went there to get medicine cups prior to preparing medications for Resident 1. When asked if LVN 1 took the elevator to come back up to Resident 1's room, LVN 1 stated: No, I used the stairs. LVN 1 stated he had to touch the doorknobs leading to and away from the staircase in order to arrive at Resident 1's room. LVN 1 stated it is possible to spread infection from touching the doorknobs and then proceeding straight to handling Resident 1's medications. During an interview on 7/9/2025 at 12:02 p.m. with Director of Nursing (DON), DON stated before licensed nurses prepare and handle medications with their bare hands, they must wash their hands. DON stated if nurses do not handwash or sanitize prior to medication preparation and administration, the negative outcome would be the possibility of spreading infection. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 7/2024, the P&P indicated [t]his facility considers hand hygiene the primary means to prevent the spread of infection. The P&P indicated [a]ll personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The P&P indicated alcohol-based hand rub containing at least 62% alcohol; or, alternative, soap.and water is to be used before preparing or handling medications.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from a significant medication error when Licensed Vocational Nurse (LVN 1) was about to administer Gabapentin (a medication that prevents/controls seizures and can also relieve nerve pain) without first checking Resident 1's respiration rate (the amount of breaths a person takes per minute) per the doctor's order. This failure had the potential to result in an adverse effect (undesired effect of a drug or other type of medical treatment) from taking Gabapentin, which can significantly decrease respirations (the process of breathing air in and out of the lungs). Findings: During a review of Resident 1's admission Record, dated 7/9/2025, the admission Record indicated Resident 1's diagnoses include dementia (a decrease in thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life), neuralgia (pain caused by irritation or damage to a nerve), and neuritis (inflammation of a nerve causing pain, numbness, tingling, or weakness). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 1's ability is limited in making concrete requests. The MDS indicated Resident 1 comprehends most conversation. The MDS also indicated Resident 1 has functional limitations to the lower extremities, which consists of the hips, knees, ankles and feet. During an observation on 7/3/2025 at 12:53 p.m. in Resident 1's room, Resident 1 was sitting in a recliner wheelchair. LVN 1 entered Resident 1's room and advised Resident 1 that Gabapentin will be given. LVN went to the medication cart in front of Resident 1's room and began preparing the medication by unscrewing the Gabapentin capsules in order to mix the powdered medication with applesauce. LVN 1 returned to Resident 1 and was observed to be holding a spoonful of applesauce mixed with the medication. LVN 1 was about to feed the spoonful of applesauce to Resident 1, when LVN 1 was asked by surveyor to stop and step out of Resident 1's room. During a concurrent interview and record review on 7/3/2025 at 12:58 p.m. with LVN 1, Resident 1's Medication Administration Record (MAR), dated 7/3/2025 was reviewed. LVN 1 was asked if Resident 1's doctor had ordered any parameters (instructions ordered by a doctor regarding when to give or hold medication) to be checked before administering Gabapentin. LVN 1 stated the MAR indicated to hold if respiration rate is less than 12 and to notify MD. LVN 1 stated Resident 1's respiration rate was not checked in surveyor's presence because Resident 1's respirations were checked 15 minutes ago, but LVN 1 didn't put it in the computer and save. LVN 1 stated Resident 1's respiration rate should have been checked at the moment medication is about to be administered because it is safer and more accurate per standard nursing practice. LVN 1 stated the respiration rate must be accurately assessed to ensure it is safe to give the Gabapentin to Resident 1 per the doctor's orders. During an interview on 7/9/2025 at 12:02 p.m. with Director of Nursing (DON), DON stated parameters are part of a doctor's order. DON stated if a licensed nurse administers a medication, such as Gabapentin, without checking the parameters, it is considered a significant medication error because you have to follow the doctor's order. DON stated the consequence of failing to check parameters prior to administering Gabapentin is the possibility that the medication can cause respiratory distress and harm to the resident. During a review of the facility's policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, dated 7/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs.which is not in accordance with physician's order. The P&P also indicated an adverse consequence is an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's.physical condition. The P&P indicated that staff and practitioner shall strive to minimize adverse consequences resulting from medication errors.

Based on observation, record review, and interview, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity and care in a manner that promotes maintenance or enhancement of their quality of life by failing to ensure Certified Nursing Assistant (CNA) 1 assisted Resident 2 with their meal was not standing over Resident 2. This deficient practice had the potential to negatively affect Resident 2 psychosocially (involving mental, emotional, social, and spiritual aspects of a person's life). Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 6/29/2017 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety disorder (a group of mental health conditions where feelings of worry, fear, apprehension, and nervousness are excessive, persistent, and interfere with daily life), and other lack of coordination. During a review of Resident 2 ' s Minimum Data Set (MDS – a resident assessment tool) dated 4/7/2025, the MDS indicated Resident 2 had the ability to sometimes understand and sometimes be understood. The MDS indicated Resident 2 was dependent (helper does all of the effort) with showering, required substantial assistance (helper does more than half the effort) with oral hygiene, toileting, putting on and taking off footwear and personal hygiene, required partial assistance (helper does less than half the effort) with upper and lower body dressing and required supervision assistance (helper provides verbal cues and or touching and or contact guard assistance) with eating. During a concurrent observation and interview on 6/25/2025 at 8:15 a.m. of Resident 2 with CNA 1, CNA 1 was observed standing with over Resident 2, no chair noted in the room. CNA 1 stated a chair was provided to assist a resident with meals but is not using one. CNA 1 stated does not sit while assisting Resident 2 with meal because Resident 2 will try to get up. CNA 1 stated should be sitting at eye level with Resident 2 when assisting with their meal. During an interview on 6/25/2025 at 3:15 p.m. with the Director of Nursing (DON), the DON stated staff assisting residents with their meal need to sit down and be at eye level. The DON stated if staff are not at eye level and the staff are standing over the resident while assisting with meals mean it is not respecting the resident ' s right to dignity. During a review of the facility ' s Policy and Procedures (P&P) titled, Assistance with Meals, last reviewed on 1/2025, the P&P indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for examples: a. Not standing over residents while assisting them with meals;

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three of three sampled residents (Residents 70, 81, and 102) reviewed for physical restraints by failing to ensure: 1. Resident 70's restraint bed placed against the wall had a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident and/or representative, and a physical restraint assessment for its safe use. 2. Residents 81 and 102's restraint pad/tab alarm (a device that alerts staff when a resident who is at risk for falls is attempting to get up from their bed or chair) had a physician's order, informed consent, and had a physical restraint assessment prior to its use. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (an occurrence involving a patient who is caught, trapped, or entangled in a hospital bed system), and death of residents. Findings: 1. During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 10/31/2023, and readmitted the resident on 6/13/2025, with diagnoses including abnormalities of gait (a manner of walking or moving on foot) and mobility, muscle weakness, and history of falling. During a review of Resident 70's History and Physical (H&P), dated 6/17/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 70's Minimum data Set (MDS - a resident assessment tool), dated 5/13/2025, the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired cognition (a person has trouble with mental processes like thinking, learning, remembering, and making decisions). The MDS indicated the resident required partial to set up assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had a fall with injury. During a review of Resident 70's Order Summary Report, dated 6/20/2025, the Order Summary Report did not indicate an order for restraint bed placed against the wall. During a review of Resident 70's Fall Risk Assessment, dated 6/14/2025, the Fall Risk Assessment indicated the resident was high risk for falls. During a review of Resident 70's Care Plan (CP) Report titled, Falling Star Program at risk for falls, initiated on 6/14/2025, the CP indicated an intervention to respect resident wishes for independence and dignity and restraint assessment. During a concurrent observation and interview on 6/16/2025 at 11:05 a.m. with Treatment Nurse (TN) 1 inside Resident 70's room, observed Resident 70's bed was placed against the wall at the right side of the bed. TN 1 stated placing the bed against the wall is a restraint because it limits the residents bed exit and entry to one side of the bed. TN 1 stated before applying a restraint on a resident they should obtain a physician's order, informed consent from the resident or representative, restraint assessment, and a care plan on its use. TN 1 stated obtaining all the necessary order, consents, assessments, and care plan before applying the restraint ensures its safe use. During a concurrent interview and record review on 6/18/2025 at 9:43 a.m. with the Assistant Director of Nursing (ADON), Resident 70's Order Summary Report, Informed Consents, Restraint Assessment, and Care Plans were reviewed. The ADON stated there was no physician's order, no informed consent obtained from the resident or representative, no restraint assessment, and no care plan developed and implemented on the use of bed placed against the wall on the resident. The ADON stated prior to applying restraints on resident they need to obtain a physician's order, informed consent from the resident or representative to honor their right to agree or disagree with the proposed treatment, a restraint assessment to prevent bed entrapment, and a care plan to standardize the care provided to the resident. During an interview on 6/20/2025 at 11:57 a.m. with the Director of Nursing (DON), the DON stated the staff should have obtained a physician's order, obtained an informed consent from the resident or representative after explaining the risk and benefits of applying the restraint, performed a restraint assessment to prevent bed entrapment, and developed a care plan on its use to ensure Resident 70's safety. 2. During a review of Resident 81's admission Record, the admission Record indicated the facility admitted the resident on 2/18/2025, with diagnoses including traumatic subdural hemorrhage (is essentially bleeding on the surface of the brain, under the skull's tough outer layer (dura mater), caused by a head injury), lack of coordination, and muscle weakness. During a review of Resident 81's H&P, dated 2/19/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 81's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired cognition. The MDS indicated the resident was dependent to needing substantial assistance on mobility and ADLs. During a review of Resident 81's Order Summary Report, dated 6/20/2025, the Order Summary Report did not indicate an order for pad/tab alarm. During a review of Resident 81's Fall Risk Assessment, dated 5/27/2025, the Fall Risk Assessment indicated the resident was high risk for falls. During a review of Resident 81's Care Plan (CP) Report titled Resident is at risk for falls/injury, last revised on 2/18/2025, the CP indicated to visibly observed resident frequently. During a concurrent observation and interview on 6/16/2025 at 10:06 a.m. with Restorative Nursing Assistant (RNA) 2 inside Resident 81's room, Resident 81 had a tab/pad alarm on the bed. RNA 2 stated the pad/tab alarm was placed on Resident 81's bed to alert the staff when the resident is getting out of bed. RNA 2 stated the resident was high risk for falls that is why they applied the pad/tab alarm on the resident. During a concurrent interview and record review on 6/18/2025 at 10:06 a.m. with Registered Nurse (RN) 1, Resident 81's Order Summary Report, Informed Consents, Restraint Assessment, and Care Plans were reviewed. RN 1 stated there was no order for pad/tab alarms on the resident, no informed consent obtained, no restraint assessment, and no care plan prior to application of the restraint. RN 1 stated the pad/tab alarm is a restraint and requires an order, assessment, consent, and a care plan to ensure its safe use. During an interview on 6/20/2025 at 11:57 a.m. with the DON, the DON stated pad/tab alarms are restraints. The DON stated the staff should have obtained a physician's order, informed consent from the resident or representative, performed a restraint assessment, and developed a care plan on its use prior to application on Resident 81. The DON stated the pad/tab alarms limits the movement of the resident by sounding alarms every time they get out of bed. The excessive use of pad/tab alarms can result to deconditioning on residents. 3. During a review of Resident 102's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2024, with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), age-related osteoporosis (is a condition where your bones become weak and fragile as you get older), and stress fracture (a tiny crack in a bone caused by repetitive stress, often from overuse in activities like running or jumping) of the pelvis. During a review of Resident 102's H&P, dated 1/28/2025, the H&P indicated the resident was alert and oriented to person only, and had minimal vocalization. During a review of Resident 102's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (means a person has significant problems with their thinking, remembering, and learning abilities, to the point that it severely affects their daily life and ability to live independently). The MDS indicated the resident was dependent to requiring substantial assistance on mobility and ADLs. During a review of Resident 102's Order Summary Report, dated 6/20/2025, the Order Summary Report did not indicate an order for pad/tab alarm. During a review of Resident 102's Fall Risk Assessment, dated 4/15/2025, the Fall Risk Assessment indicated the resident was high risk for falls. During a review of Resident 102's Care Plan (CP) Report titled Resident is on low bed with floor mat (a cushioned pad placed on the floor next to a bed to help prevent or lessen injuries from falls) to decrease potential injury, last revised on 5/5/2025, the CP indicated an intervention to attempt to use less restrictive devices on an ongoing basis. During a concurrent observation and interview on 6/16/2025 at 10:06 a.m. with RNA 2 inside Resident 102's room, Resident 102 had a pad/tab alarm applied on the bed. RNA 2 stated the resident had the pad/tab alarm on to alert the staff when the resident is trying to get out of the bed to prevent a fall. During a concurrent interview and record review on 6/20/2025 at 9:17 a.m. with Licensed Vocational Nurse (LVN) 7, Resident 102's Order Summary Report, Informed Consents, Restraint Assessment, and Care Plans were reviewed. LVN 2 stated there was no physician's order, no informed consent from the resident or representative, no restraint assessment, and no care plan was developed on the use of pad/tab alarm on the resident. LVN 2 stated it was important to have all the components mentioned to ensure the application of the restraint is safe and to honor the resident's right to informed consent. During an interview on 6/20/2025 at 11:57 a.m. with the DON, the DON stated pad/tab alarms are restraints. The DON stated the staff should have obtained a physician's order, informed consent from the resident or representative, performed a restraint assessment, and developed a care plan on its use prior to application on Resident 102. The DON stated the pad/tab alarms limits the movement of the resident by sounding alarms every time they get out of bed. The excessive use of pad/tab alarms can result in deconditioning of residents. During a review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 7/2024, the P&P indicated physical restraints are defined as any manual method of physical or mechanical, device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restrict normal access to one's body. Prior to placing a resident in restraints, there shall be an assessment and a review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint, Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use, seven days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. During a review of the facility's recent P&P titled Care Plans, Comprehensive Person-Centered, last reviewed on 7/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven days.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for three of eleven sampled residents (Residents 116, 81 and 70) by: a. Failing to implement Resident 116 ' s care plan on the use of wheelchair pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on 6/17/2025 and 6/18/2025 as per physician order. b. Failing to ensure a care plan was developed for Resident 116 ' s behavior of removing the bed pad alarm. c. Failing to ensure a care plan was developed for Resident 116 ' s use of Ativan (medication used to treat anxiety [common human emotion characterized by feelings of worry, nervousness, or unease, often about an event with an uncertain outcome] and related conditions) and Haldol (medication used to treat nervous, emotional, and mental conditions). d. Failing to develop and implement a comprehensive care plan on Resident 81 ' s use of restraint pad/tab alarm (a device that alerts caregivers or staff when someone, often elderly or with mobility issues, attempts to get out of a bed or chair) reviewed for physical restraints (are methods, devices, or actions used to restrict a person's movement). e. Failing to develop and implement a comprehensive care plan on Resident 70 ' s use of antibiotic (Cephalexin HCl) reviewed for unnecessary medications. These failures had the potential for delays in the delivery of necessary care and services, could potentially result to accidents like fall and injury, and residents develop adverse effects (an undesired effect of a drug or other type of treatment, such as surgery). Findings: a. During a record review of Resident 116 ' s admission Record, the admission Record indicated the facility admitted Resident 116 on 10/15/2024, with diagnoses that included unspecified (unconfirmed) cerebrovascular disease (a group of conditions that affect blood flow to the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and vascular dementia (reduced blood flow to the brain, which damages brain tissue and impairs cognitive functions). During a review of Resident 116 ' s History and Physical Examination (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) Visit, dated 10/15/2024, the H&P indicated Resident 116 was alert and needed visual cues (non-verbal signals that provide information, guide actions, or enhance understanding through visual elements). During a review of Resident 116 Minimum Data Set (MDS-a resident assessment tool), dated 5/16/2025, the MDS indicated Resident 116 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 116 needed maximum assistance from staff for toileting and personal hygiene. The MDS indicated Resident 116 was frequently incontinent (unable to control) bowel and bladder functions. The MDS indicated Resident 116 used bed and chair alarm. During a review of Resident 116 ' s Physician Order, dated 5/15/2025, the Physician Order indicated use of wheelchair with pad alarm when out of bed to alert staff Resident 116 was getting up unassisted to prevent fall every shift. During a review of Resident 116 Change of Condition (COC-a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status) Interact Assessment Form, dated 6/1/2025, the COC indicated on 6/1/2025, at 8:28 p.m., Certified Nursing Assistant 1 (CNA 1) witnessed Resident 116 stood up from the wheelchair in the hallway unassisted and fell on the floor. During an observation on 6/17/2025, at 9:14 a.m., in the lower dining room, Resident 116 seated on a wheelchair with no pad alarm noted. During a concurrent observation, and interview on 6/18/2025, at 6:42 a.m., outside Resident 116 room with Licensed Vocational Nurse 1 (LVN 1), observed Resident 116 seated on a wheelchair at the hallway outside of Resident 116 ' s room with no wheelchair pad alarm. LVN 1 checked Resident 116 wheelchair and stated Resident 116 had no wheelchair pad alarm. During a concurrent interview, and record review on 6/18/2025, with LVN 4, Resident 116 Care Plan dated 10/25/2024 was reviewed. LVN 4 stated care plan on the use of the wheelchair pad alarm was developed on 10/25/2024 and was still active. During an interview on 6/18/2025, at 10:39 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 116 had an order for wheelchair pad alarm to alert staff for Resident 116 ' s safety. The ADON stated if Resident 116 had no wheelchair pad alarm, Resident 116 can get up and possibly fall. The ADON stated fall could lead to possible injury. During an interview on 6/18/2025, at 1:30 p.m., with the Director of Nursing (DON), the DON stated Resident 116 had a physician order and a care plan on the use of wheelchair pad alarm to alert staff when Resident 116 attempts to get up by himself (Resident 116) to lower Resident 116 risk of fall. During a concurrent interview, and record review on 6/20/2025, at 12:34 p.m., with the DON, facility ' s policy and procedure (P&P), tilted, Alarm Monitor undated and last reviewed on 7/2024, the P&P indicated, This facility may use alarm monitor as one of the less restrictive measures to alert staff member and provide immediate assist as needed. The type of alarm to be used: tab alarm, pad alarm, alarm in wheelchair and alarm in bed. The staff will apply the alarm to the resident, following the manufacture's instruction, to ensure its functionalists. The DON stated the wheelchair pad alarm was used to alert staff that Resident 116 was attempting to get up without assistance. The DON stated Resident 116 can get up, fall and sustain injury if no wheelchair pad alarm was used. b. During a review of Resident 116 ' s Care Plan, dated 10/17/2024, on resident at risk for recurrent fall/injury, the Care Plan indicated an intervention to use wheelchair with pad alarm when out of bed to alert staff of resident getting up unassisted. During a review of Resident 116 ' s COC dated 6/12/2025, the COC indicated on 6/13/2025, at 12:15 a.m., Resident 116 fell. The COC indicated Registered Nurse 3 (RN 3) heard a sound and found Resident 116 removed his (Resident 116) bed pad alarm. During an interview on 6/20/2025, at 8:17 a.m., with LVN 5, LVN 5 stated on 6/13/2025, at 12:15 a.m., LVN 5 heard a sound and found Resident 116 on the floor. LVN 5 stated there was no bed alarm sound heard before the fall. During an interview on 6/20/2025, at 8:48 a.m., with RN 3, RN 3 stated on 6/13/2025, at 12:15 a.m., Resident 116 bed pad alarm wire was disconnected from the bed alarm machine. RN 3 stated she (RN 3) thought Resident 116 disconnected his (Resident 116) bed alarm. RN 3 stated she (RN 3) did not develop a care plan of Resident 116 ' s removal of bed alarm. During an interview on 6/20/2025, at 9:59 a.m., with RN 1, RN 1 stated there was no care plan developed on Resident 116 behavior of removing his (Resident 116) bed alarm. RN 1 stated there should be a care plan on Resident 116 attempt to remove and disconnect his (Resident 116) bed alarm. RN 1 stated the importance of developing a care plan was to list the interventions on what to do when Resident 116 removes his (Resident 116) bed alarm to prevent a fall. RN 1 stated Resident 116 could possibly fall because the intervention was not there to prevent fall. During a concurrent interview, and record review on 6/20/2025, at 12:34 p.m., with the DON, facility P&P titled, Comprehensive Person-Centered Care Plans, dated 3/2022, and last reviewed on 7/2024, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. The DON stated staff should have developed a care plan on Resident 116 removal of bed alarm. c. During a review of Resident 116 ' s Physician Order, dated 5/4/2025, the Physician Order indicated Ativan oral tablet 0.5 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give 0.5 mg by mouth every four hours as needed for anxiety manifested by restlessness causing shortness of breath. During a review of Resident 116 ' s Physician Order, dated 5/6/2025, the Physician Order indicated Haldol lactate oral concentrate 2 mg/milliliter (ml- unit of volume, one milliliter is equal to one thousandth of a liter), given 0.5 ml by mouth every four hours as needed for anxiety or nausea (the feeling of sickness in the stomach and the urge to vomit). During a concurrent interview, and record review on 6/18/2025, at 10: 16 a.m., with the ADON, Physician Order dated 5/4/2025 to 5/6/2025 and Care Plans were reviewed. The ADON stated there was no care plan developed on the use of Ativan and Haldol. During an interview on 6/20/2025, at 9:37 a.m. with RN 1, RN 1 stated a care plan should have been developed on the use of Ativan and Haldol because the facility needs to prove that there was a problem that needed the use of the Ativan and Haldol. During an interview on 6/20/2025, at 12:34 p.m., with the DON, the DON stated there should be a care plan developed on the use of Ativan and Haldol so the facility can plan on how to approach a resident if medication was administered, plan on how to handle the resident and provide care. During a review of facility ' s P&P titled, Comprehensive Person-Centered Care Plans, dated 3/2022, and last reviewed on 7/2024, the P&P indicated, .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (I) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. d. During a review of Resident 81 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/18/2025, with diagnoses including Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), muscle weakness, and history of falling. During a review of Resident 81 ' s H&P, dated 2/19/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 81 ' s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self understood and understand others and had impaired cognition (a person has trouble with mental processes like thinking, learning, remembering, and making decisions). The MDS indicated Resident 81 was dependent to needing substantial assistance on mobility and activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 81 ' s Fall Risk Assessment, dated 5/27/2025, the Fall Risk Assessment indicated the resident was high risk for falls. During a review of Resident 81 ' s Order Summary Report, dated 6/20/2025, the Order Summary Report did not indicate any order for pad/tab alarm. During a review of Resident 81 ' s Care Plan Report titled Resident is at risk for falls/injury, last revised on 2/18/2025, the Care Plan indicated an intervention to visibly observe resident frequently. During a concurrent observation, and interview on 6/16/2025, at 10:09 a.m., with Restorative Nursing Assistant (RNA) 2, inside Resident 81 ' s room, observed Resident 81 had a pad/tab alarm in bed and the pad sensor alarm wires were broken and not connected to the alarm unit. RNA 2 stated that the pad/tab alarm was placed on the resident ' s bed because the resident was a high risk for fall. RNA 2 stated the pad/tab alarm alerts the staff if the resident is getting out of bed without assistance. During a concurrent interview, and record review on 6/18/2025, at 10:06 a.m., with RN 1, reviewed Resident 81 ' s Care Plans. RN 1 stated there was no comprehensive care plan developed and implemented on the use of restraint pad/tab alarm on the resident. RN 1 stated it was important to have a comprehensive care plan on the use of tab/pad alarm to ensure appropriateness of its use and to standardize the care provided to the resident. RN 1 stated the care plan serves as a communication tool to all healthcare providers to provide appropriate care. During an interview on 6/20/2025, at 11:57 a.m., with the DON, the DON stated it was important to develop and implement a comprehensive care plan on the use of restraint pad/tab alarm on Resident 81 to ensure its safe use. The DON stated the care plan serves as a guide to all clinicians on what appropriate interventions are to be provided to the resident to standardize the care to achieve their desired goals. During a review of the facility's recent P&P titled Care Plans, Comprehensive Person-Centered, last reviewed on 7/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven days. During a review of the facility's recent P&P titled Use of Restraints, last reviewed on 7/2024, the P&P indicated physical restraints are defined as any manual methos of physical or mechanical, device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restrict normal access to one's body. Prior to placing a resident in restraints, there shall be an assessment and a review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent form the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint, Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. e. During a review of Resident 70 ' s admission Record, the admission Record indicated the facility admitted the resident on 10/31/2023, and readmitted the resident on 6/13/2025, with diagnoses including chronic osteomyelitis (a long-term infection of the bone that can cause pain, swelling, and other problems) of left ankle and foot, type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer, and methicillin resistant staphylococcus aureus (MRSA, a bacteria that does not respond to antibiotics) infection. During a review of Resident 70 ' s H&P, dated 6/17/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 70 ' s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self understood and understand others and had impaired cognition. The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 70 ' s Order Summary Report, dated 6/15/2025, the Order Summary Report indicated an order of Cephalexin tablet 500 mg, give 500 mg by mouth every six hours for bilateral foot infection until 6/27/2025, at 11:59 p.m. Take first dose on 6/15/2025 at 1200 from emergency kit (e-kit, is essentially a small collection of medications and medical supplies kept on hand to address sudden or worsening symptoms that require immediate attention). During a concurrent interview, and record review on 6/18/2025, at 11:31 a.m., with RN 4, reviewed Resident 70 ' s Order Summary Report and Care Plans. RN 4 stated there was an order for antibiotic cephalexin tablet 500 mg however, there was no care plan developed and implemented on the use of the antibiotic (cephalexin). RN 4 stated it was important to develop and implement a care plan on the use of cephalexin to monitor for its effectiveness and their adverse effects to report to the primary physician to mitigate the adverse effects timely. RN 4 stated the care plan serves as a communication tool for all healthcare disciplines to eliminate unnecessary interventions to residents. During an interview on 6/20/2025, at 11:57 a.m., with the DON, the DON stated it was important to develop and implement a comprehensive care plan on the use of antibiotic (cephalexin) on Resident 70 to ensure its safe use. The DON stated the care plan serves as a guide to all clinicians on what appropriate interventions are to be provided to the resident to standardize the care to achieve their desired goals. During a review of the facility's recent P&P titled Care Plans, Comprehensive Person-Centered, last reviewed on 7/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven days.

Based on interview and record review, the facility failed to provide quality of care in accordance with professional standards of practice to meet the resident ' s physical, mental, psychosocial needs (encompass the emotional and social requirements that individuals have to feel safe, supported, and function effectively in their environment) for one of three sampled resident (Resident 116) by: 1. Failing to ensure nurses follow physician order to monitor Resident 116 for orthostatic hypotension (also known as postural hypotension, is a sudden drop in blood pressure that occurs when you stand up after sitting or lying down) every Tuesday. No blood pressure documentation on 6/3/2025 (Tuesday), 6/10/2025 (Tuesday), and 6/17/2025 (Tuesday) on a lying position. 2. Failing to ensure neurocheck (a series of quick assessments performed by nurses to evaluate a patient's neurological status [anything related to the nervous system, which includes the brain, spinal cord, and nerves]) was assessed after Resident 116 fall on 6/13/2025. No neurocheck documentation on 6/13/2025, at 6 a.m., 6/14/2025 at 12 a.m., 6/14/2025, at 8 a.m., 6/15/2025, at 12 a.m., 6/15/2025, at 8 a.m., 6/15/2025, at 4 p.m., and 6/16/2025, at 12 a.m. 3. Failing to rotate (a method to ensure repeated injections are not administered in the same area) insulin (a hormone that lowers the level of sugar in the blood) injection administration sites each time insulin was administered for one of three sampled residents (Resident 96). These failures had the potential to result in a delay of care and services for Resident 116 and for Resident 96 to experience adverse effects, such as lipohypertrophy (when fatty tissue builds up under the skin and delays the effect of the injected medication). Findings: a. During a record review of Resident 116 ' s admission Record, the admission Record indicated the facility admitted Resident 116 on 10/15/2024, with diagnoses that included unspecified (unconfirmed) cerebrovascular disease (a group of conditions that affect blood flow to the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and vascular dementia (reduced blood flow to the brain, which damages brain tissue and impairs cognitive functions). During a review of Resident 116 ' s History and Physical Examination (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) Visit, dated 10/15/2024, the H&P indicated Resident 116 was alert and needed visual cues (non-verbal signals that provide information, guide actions, or enhance understanding through visual elements). During a review of Resident 116 ' s Order Summary Report, dated 10/22/2024, the Order Summary Report indicated the following order: Monitor for orthostatic hypotension on day shift. Call the physician if there is a 20 millimeter mercury (mmhg-a unit of measurement) drop in systolic blood pressure (sbp-the top number in a blood pressure reading, representing the pressure in your arteries when your heart beats) or a drop of 10 mmhg in diastolic blood pressure (dbp-the bottom number in a blood pressure reading, representing the pressure in the arteries when the heart is resting between beats) between two readings, every Tuesday on lying position. Monitor for orthostatic hypotension on day shift. Call the physician if there is a 20 mmhg drop in sbp or a drop of 10 mmhg in dbp between two readings, every Tuesday on sitting position. During a review of Resident 116 Minimum Data Set (MDS-a resident assessment tool), dated 5/16/2025, the MDS indicated Resident 116 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 116 was on antidepressant (medication used to treat depression and other mental health condition) medication. During a concurrent interview, and record review on 6/18/2025, at 10:16 a.m., with the Assistant Director of Nursing (ADON), Resident 116 ' s Physician Order, dated 10/22/2024, Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2025 and Weights and Vitals Summary, dated 6/2025 were reviewed. The MAR indicated no blood pressure documentation on 6/3/2025, 6/10/2025 and 6/17/2025 on a lying position. The ADON stated there were no documented blood pressure of Resident 116 on a lying position on 6/3/2025, 6/10/2025 and 6/17/2025. The ADON stated nurses need to document the blood pressure of Resident 116 on a lying position as ordered by the physician. The ADON stated nurses did not document the blood pressure therefore it was not done. The ADON stated the importance of checking the blood pressure on two separate position (lying and sitting) was to know if Resident 116 had stable blood pressure before medication administration. The ADON stated if Resident 116 was not monitored for orthostatic hypotension, nurses would not be able to know if Resident 116 was experiencing adverse reaction (any unwanted, harmful, or unintended response to a drug) and can result in delay in physician notification and delay in treatment. During an interview on 6/18/2025, at 1:24 p.m., with the Director of Nursing (DON), the DON stated nurses did not follow the physicians order to monitor Resident 116 for orthostatic hypotension. The DON stated the nurses need to identify if Resident 116 had orthostatic hypotension so preventive measures on what was the cause of the orthostatic hypotension could be developed. During a concurrent interview, and record review on 6/20/2025, at 12:34 p.m., with the DON, facility ' s policy and procedure (P&P) titled, Orthostatic Hypotension Policy, undated and last reviewed on 7/2024, the P&P indicated, To ensure that resident who are at risk for orthostatic hypotension receive the proper care. The license nurse will carry out the orders for monitoring orthostatic hypotension if physician orders. The license nurse will check and document the orthostatic hypotension order in the MAR. The orthostatic hypotension monitoring will include the blood pressure in lying position and sitting position (May take blood pressure in standing position if indicated or appropriate). Notify the physician if a drop of 20 mmhg for systolic blood pressure and/or a drop of 10 mmhg of diastolic blood pressure from lying position to sitting position and adjust the treatment plan as indicated. The licensed nurse will develop and create a care plan if orthostatic hypotension is identified. The DON stated resident on psychotropic medications (medications that affect the brain's activity and are used to treat mental illnesses like depression) need to be assess for orthostatic hypotension once a week on a lying and sitting position. The DON stated nurses need to check Resident 116 blood pressure on a lying position, wait five minutes and recheck the blood pressure on the same arm and if there was a 20 mmhg difference then it means Resident 116 was positive for orthostatic hypotension. The DON stated Resident 116 was not monitored that could result to Resident 116 getting dizzy causing him (Resident 116) to fall. The DON stated if orthostatic hypotension was not monitored, nurses could miss a change in condition and could result to a possible delay in intervention. During a review of facility ' s P&P titled, Psychotherapeutic Medications, undated and last reviewed on 7/2024, the P&P indicated, Evaluate the resident's response to psychotropic medication therapy ( .Antidepressant .) to determine that the medications are appropriate, and resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. The licensed nurse will assess resident to ensure . F. Actual behavior manifestation and potential side effects being monitored. During a review of facility ' s P&P, titled, Antipsychotic Medication Use, dated 2001 and last reviewed on 7/2024, the P&P indicated, 18. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician . b. Cardiovascular: orthostatic hypotension, arrhythmias (irregular heartbeats) . b. During a review of Resident 116 ' s [NAME] of Condition (COC-refers to a sudden illness or decline in a resident's health status), dated 6/12/2025, the COC indicated on 6/13/2025, at 12:15 a.m., Resident 116 fell. During a review of Resident 116 ' s 72 Hour Neuro-Check, dated 6/13/2025, the 72 Hour Neuro-Check indicated missing neurocheck assessment on the following dates and times; 6/13/2025 at 6 a.m. 6/14/2025 at 12 a.m. 6/14/2025 at 8 a.m. 6/15/2025 at 12 a.m. 6/15/2025 at 8 a.m. 6/15/2025 at 4 p.m. 6/16/2025 at 12 a.m. During an interview on 6/20/2025, at 8:17 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated she (LVN 5) got distracted on 6/13/2025, at 6 a.m., with another phone call and did not complete the neurocheck. LVN 5 stated the importance of checking Resident 116 ' s neurocheck after fall was to find out if there was a change in level of consciousness (loc-refers to a person's awareness and responsiveness to their surroundings) and change in vital signs (measurements of the body's most basic functions). LVN 5 stated not checking Resident 116 neurocheck after fall, nurses might miss a change in Resident 116 condition and delays physician notification. LVN 5 stated she (LVN 5) did not follow the post (after) fall protocol and could result in a delay in care. During an interview on 6/20/2025, at 9:59 a.m., with Registered Nurse 1 (RN 1), RN 1 stated there were seven times Resident 116 ' s neurocheck was not assessed in a 72-hour period after 6/13/2025 fall. RN 1 stated the importance of neurocheck was to check the condition of the resident after a fall. RN 1 stated nurses could miss Resident 116 ' s change in condition and delays the physician notification. During a concurrent interview, and record review on 6/20/2025, at 12:34 p.m., with the DON, facility ' s P&P, titled, Neurological Assessment, dated 10/2010, and last reviewed on 7/2024, the P&P indicated, 1. Neurological assessments are indicated: a. Upon physician order; b. Following an unwitnessed fall; c. Following a fall or other accident/injury involving head trauma; or d. When indicated by resident's condition. 2. When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be indicative of increasing intracranial pressure (ICP-the pressure inside your skull, exerted by your brain). 3. Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately. The DON stated neurocheck should be done for 72 hours after fall. The DON stated the nurses need to do a neurocognitive (refers to the mental processes involved in thinking, learning, and remembering) assessment to early identify head trauma for unwitnessed fall. The DON stated the policy did not mention that neurocheck should be for 72 hours but it ' s what the facility follows. During a review of facility ' s P&P, titled, Vital Signs undated and last reviewed on 7/2024, the P&P indicated, Vital signs will be taken on change of condition, including neurological checks for 72 hours as needed. c. During a review of Resident 96 ' s admission Record, dated 6/20/2025, the admission Record indicated Resident 96 ' s diagnoses include cerebral vascular accident (when blood flow to the brain is blocked or there is sudden bleeding in the brain), diabetes mellitus (DM-a disease where the body is unable to properly control blood sugar levels), hypertension (high blood pressure), and major depressive disorder (a condition in which a person has persistent feelings of sadness, hopelessness, and a loss of interest in activities once enjoyed). During a review of Resident 96 ' s MDS, dated [DATE], the MDS indicated Resident 96 has difficulty communicating some words or finishing thoughts. The MDS indicated Resident 96 is dependent to needing substantial assistance on mobility and activities of daily living (ADLs – such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 6/20/2025 at 9:55 a.m. with LVN 7, Resident 96 ' s Order Summary Report, dated 6/20/2025, were reviewed. LVN 7 stated the Order Summary Report indicated that regular insulin is to be injected subcutaneously (the area located just beneath the skin) before meals and at bedtime to treat Resident 96 ' s DM, and to rotate injection sites each time an injection is given. LVN 7 stated the Order Summary Report also indicated insulin glargine solution to be injected subcutaneously at bedtime depending on Resident 96 ' s blood sugar level, and to rotate injection sites. During a concurrent interview and record review on 6/20/2025 at 9:59 a.m. with LVN 7, Resident 96 ' s Location of Administration Report, for the month of 4/2025 and 5/2025, were reviewed. LVN 7 stated the facility failed to rotate the injection sites when giving insulin injections to Resident 96 on the following dates: 4/18/2025, 4/19/2025, 4/20/2025, 4/21/2025, 4/22/2025, 5/3/2025, 5/4/2025, 5/5/2025, and 5/31/2025. LVN 7 stated the failures to rotate insulin injection sites were performed by multiple, different nurses. LVN 7 stated injecting repeatedly at the same site of the body can make the skin thicker at the injection site, which prevents insulin from being absorbed properly. During a concurrent interview and record review on 6/20/2025 at 1:04 p.m. with the DON, Resident 96 ' s Location of Administration Report, for the month of 4/2025 and 5/2025 were reviewed. The DON stated the facility failed to rotate the injection sites when giving insulin injections to Resident 96 on the following dates: 4/18/2025, 4/19/2025, 4/20/2025, 4/21/2025, 4/22/2025, 5/3/2025, 5/4/2025, 5/5/2025, and 5/31/2025. The DON stated insulin injections may be given in fatty areas of the body such as the abdomen, upper extremities, and anterior portion of the thighs. The DON stated nurses must rotate the injection sites when giving insulin injections to avoid lipohypertrophy, which is a complication resulting in thicker skin that affects the absorption of insulin by the body. During an interview on 6/20/2025 at 1:10 p.m. with the DON, the DON stated rotating insulin injection sites is part of licensed nursing professional practice. The DON stated that if nurses are failing to rotate insulin injections sites, then it means [the facility is] not administering the prescribed medication per the doctor's orders. The DON stated manufacturing specifications for insulin will specify that the insulin administration must be rotated to avoid adverse effects. The DON stated the facility did not follow the MD Orders, professional practice, and manufacturing specifications. During a review of the facility ' s P&P titled, Insulin Administration, dated 7/2024, the P&P indicated: Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

3. During a record review of Resident 116 ' s admission Record, the admission Record indicated the facility admitted Resident 116 on 10/15/2024, with diagnoses that included unspecified (unconfirmed) cerebrovascular disease (a group of conditions that affect blood flow to the brain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and vascular dementia (reduced blood flow to the brain, which damages brain tissue and impairs cognitive functions). During a review of Resident 116 ' s H&P Visit, dated 10/15/2024, the H&P indicated Resident 116 was alert and needed visual cues (non-verbal signals that provide information, guide actions, or enhance understanding through visual elements). During a review of Resident 116 ' s Care Plan, dated 10/17/2024, on at risk for recurrent fall/injury, the Care Plan indicated an intervention to use wheelchair with pad alarm to alert staff when resident gets up unassisted. During a review of Resident 116 ' s Order Summary Report, dated 10/25/2024, the Order Summary Report indicated a physician order for wheelchair with pad alarm when out of bed to alert staff that resident was getting up unassisted to prevent fall, every shift. During a review of Resident 116 ' s Minimum Data Set (MDS-a resident assessment tool), dated 5/16/2025, the MDS indicated Resident 116 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 116 needed maximum assistance from staff for toileting and personal hygiene. The MDS indicated Resident 116 was frequently incontinent (unable to control) bowel and bladder functions. The MDS indicated Resident 116 used bed and chair alarm. During a review of Resident 116 ' s Change of Condition (COC-a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status) Interact Assessment Form, dated 6/1/2025, the COC indicated on 6/1/2025, at 8:28 p.m., Certified Nursing Assistant 1 (CNA 1) witnessed Resident 116 stood up from the wheelchair in the hallway unassisted and fell on the floor. During a review of Resident 116 ' s COC dated 6/12/2025, the COC indicated on 6/13/2025, at 12:15 a.m., Resident 116 fell. The COC indicated Registered Nurse 3 (RN 3) heard a sound and found Resident 116 removed his (Resident 116) bed pad alarm. During a review of Resident 116 ' s Fall Risk Assessment, dated 6/1/2025 and 6/13/2025, the Fall Risk Assessment indicated Resident 116 was a high risk for fall. During an observation on 6/17/2025, at 9:14 a.m., in the lower dining room, Resident 116 seated on a wheelchair with no pad alarm noted. During a concurrent observation, and interview on 6/18/2025, at 6:42 a.m., outside Resident 116 ' s room with Licensed Vocational Nurse 1 (LVN 1), observed Resident 116 seated on a wheelchair at the hallway outside of Resident 116 room with no wheelchair pad alarm. LVN 1 checked Resident 116 wheelchair and stated Resident 116 had no wheelchair pad alarm. During an interview on 6/18/2025, at 10:39 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 116 had an order for wheelchair pad alarm to alert staff for Resident 116 safety. The ADON stated if Resident 116 had no wheelchair pad alarm, Resident 116 can get up and possibly fall. The ADON stated fall could lead to possible injury. During an interview on 6/18/2025, at 1:30 p.m., with the Director of Nursing (DON), the DON stated Resident 116 had a physician order and a care plan on the use of wheelchair pad alarm to alert staff when Resident 116 attempts to get up by himself (Resident 116) to lower Resident 116 risk of fall. During a concurrent interview, and record review on 6/20/2025, at 12:34 p.m., with the DON, facility ' s policy and procedure (P&P), tilted, Alarm Monitor undated and last reviewed on 7/2024, the P&P indicated, This facility may use alarm monitor as one of the less restrictive measures to alert staff member and provide immediate assist as needed. The type of alarm to be used: tab alarm (uses a pull-tab that, when removed, triggers an alarm), pad alarm, alarm in wheelchair and alarm in bed. The staff will apply the alarm to the resident, following the manufacture's instruction, to ensure its functionalists. The DON stated the wheelchair pad alarm was used to alert staff that Resident 116 was attempting to get up without assistance. The DON stated Resident 116 can get up, fall and sustain injury because wheelchair pad alarm was not used. During a review of facility ' s P&P, titled, Managing Falls and Fall Risk dated 3/2018, and last reviewed on 7/2024, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk: -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls -In conjunction with the attending physician, staff will identify and implement relevant interventions (hip padding or treatment of osteoporosis [weak and brittle bones due to lack of calcium and Vitamin D], as applicable) to try to minimize serious consequences of falling. -Position-change alarms will not be used as the primary or sole intervention to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. 4. During a review of Resident 69 ' s admission Record (AR), the AR indicated the facility originally admitted the resident on 6/24/2021 and most recently admitted the resident on 1/3/2025 with diagnoses that included metabolic encephalopathy a (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 69 ' s MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated Resident 69 required partial / moderate assistance from staff for bathing, lower body dressing, personal hygiene; and the resident required staff supervision for mobility. During a review of Resident 96 ' s Self-Administration of Drugs Assessment form, dated 1/26/2022, the Self-Administration of Drugs Assessment form indicated the resident needs assistance with all medication administration and was not safe for self-administration of medication. During a review of Resident 69 ' s Care Plan (CP) titled, Rash / Pruritus. Skin integrity impairment manifested by skin rash / pruritis. Location: right upper extremity, initiated 4/23/2025, the CP indicated a goal that eczema would resolve. During a concurrent observation and interview on 6/16/2025 at 10:50 a.m., Resident 69 lay in bed. Observed an individual packet of A&D ointment on Resident 69 ' s nightstand. Resident 69 stated facility staff give Resident 69 the A&D ointment for Resident 69 to apply to the face once a day. Resident 69 pressed the call light (a device used to summon staff for assistance). During an observation on 6/16/2025 at 11 a.m., Restorative Nursing Assistant (RNA) 3 entered Resident 69 ' s room and spoke with the resident. Observed an individual packet of A&D ointment on the resident ' s nightstand. RNA 3 then exited Resident 69 ' s room, observed RNA 3 did not remove the packet of A&D ointment. During a concurrent observation and interview on 6/16/2025 at 11:20 a.m., with the Director of Staff Development (DSD), the DSD entered Resident 69 ' s room and stated there was an individual packet of A&D ointment on the resident ' s nightstand. The DSD stated A&D ointment is considered a medication and residents cannot keep A&D ointment packets in the room for self-administration. The DSD stated staff should assess the resident ' s environment every time the staff enters the room and RNA 3 should have identified the ointment and removed it, but RNA 3 did not. During a concurrent interview and record review on 6/16/2025 at 11:25 a.m., with Registered Nurse (RN) 4, RN 4 reviewed Resident 69 ' s physician orders. RN 4 stated Resident 69 had dryness on the legs with a topical treatment. RN 4 stated Resident 69 did not have an order for A&D ointment, but sometimes the facility Certified Nursing Assistants (CNAs) apply the ointment. RN 4 stated A&D ointment should not be left in a resident ' s room because residents could gain access to the ointment. During a concurrent observation and interview on 6/16/2025 at 11:30 a.m., with RNA 3, RNA 3 stated RNA 3 did not see the A&D ointment in the resident ' s room, but the resident should not have it. Observed RNA 3 entered Resident 69 ' s room and removed the A&D ointment. During an interview on 6/20/2025 at 11:03 a.m., with Treatment Nurse (TN) 1, TN 1 stated residents may not self-administer A&D ointment. TN 1 stated A&D ointment should not be left in a resident ' s room because it is a safety risk to any facility resident. TN 1 stated Resident 69 or any resident may inappropriately apply the ointment or even eat it, causing digestive issues. TN 1 stated all staff are responsible to identify safety issues when providing care. TN 1 stated RNA 3 should have identified the A&D ointment in Resident 69 ' s room. During a concurrent interview and record review on 6/20/2025 at 10:50 a.m., the Director of Nursing (DON) reviewed the facility policy and procedures (P&P) regarding medication administration, medication storage, and resident safety. The DON stated A&D ointment is an over-the-counter medication and should not be stored at a resident ' s bedside for resident self -administration. The DON stated the facility P&P was not followed when A&D ointment was left at Resident 69 ' s bedside potentially resulting in a safety concern when residents ingest the ointment. During a review of the facility P&P titled, Self-Administration of Medications, last reviewed 7/2024, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment the IDT assesses each resident ' s cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. Self-administered medications are stored in a safe and secure place which is not accessible by other residents. During a review of the facility P&P titled, Safety and Supervision of Residents, last reviewed 7/2024, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training. employee monitoring, and reporting processes. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. During a review of Manufacture 1 ' s A&D Ointment Safety Data Sheet, dated 1/7/2015, the Safety Data Sheet indicated a warning that indicated for external use only. A small number of individuals may experience reactions such as redness, rash, and/or swelling upon prolonged or repeated skin contact or eye contact. Overexposure may cause skin reaction. Ingestion may cause nausea, vomiting, or diarrhea. Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of five sampled residents (Residents 84, 81, 116, and 69) reviewed for accidents by failing to ensure: 1. Resident 84 ' s fall mattress (a cushioned floor pad designed to help prevent injury should a person fall) did not have any furniture or medical equipment on top of them. 2. Resident 81 ' s pad/tab alarm (a device used to alert caregivers when a resident, particularly one at risk of falling, attempts to get out of bed or a chair without assistance) did not have a broken pad alarm sensor cord. 3. Resident 116 had a wheelchair pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) as per physician order. These deficient practices increased the risk of accidents such as falls with injuries on residents. 4. Resident 69 ' s Vitamin A&D Ointment (a topical medication used to treat and prevent various skin irritations) was not left unattended and readily available in the resident ' s shared room. This deficient practice had the potential to result in other residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to other residents. Findings: 1. During a review of Resident 84 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/28/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), epilepsy (a brain condition that causes recurring seizures), and history of falling. During a review of Resident 84 ' s History and Physical (H&P), dated 3/28/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 84 ' s Minimum Data Set (a resident assessment tool), dated 4/7/2025, the MDS indicated the resident usually had the ability to make self understood and understand others and had severe cognitive impairment (when someone has a significant loss of mental abilities, making it hard for them to think, learn, remember, and make decisions, to the point where they can't live independently). The MDS indicated Resident 84 had upper extremity impairment and uses a walker and a wheelchair to ambulate. The MDS indicated Resident 84 was dependent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 84 ' s Order Summary Report, dated 3/28/2025, the Order Summary Report indicated an order for low bed (a bed that sits closer to the ground than a traditional bed) with floor mats to decrease potential injury, every shift. During a review of Resident 84 ' s Fall Risk Assessment, dated 3/30/2025, the Fall Risk Assessment indicated the resident was high risk for falls. During a review of Resident 84 ' s Care Plan (CP) Report titled, Resident is on low bed with floor mats to decrease potential for injury, last revised on 3/30/2025, the CP indicated a goal to prevent or reduce incident of injury/falls as well as for comfort of getting in and out of bed through the next assessment. The CP indicated an intervention to attempt to use less restrictive devices on an ongoing basis. During a concurrent observation and interview on 6/16/2025, at 11 a.m., with Treatment Nurse (TN) 1, inside Resident 84 ' s room, observed Resident 84 ' s bilateral fall mat with the resident ' s wheel of the bed on top of the left fall mat. TN 1 stated the wheel of the bed was on top of the left fall mat. TN 1 stated the wheel on the fall mat can cause a permanent dent on the fall mat decreasing its cushioning effect to prevent injury. During an interview on 6/20/2025, at 11:57 a.m., with the Director of Nursing (DON), the DON stated there should be no furniture or medical equipment on top of Resident 84 ' s fall mat to prevent falls with injury. The DON also stated placing a heavy object on top of the fall mat can cause a permanent indentation on the fall mat decreasing its ability to lessen the impact of the fall of the resident. During a review of the facility-provided Instructions on the use of Fall Mat 1, dated 3/2023, the Instruction indicated when moving equipment such as lifts and wheelchairs across the mat, always make sure wheel locks are not engaged, as locked wheels may damage the surface. Sharp objects may cause damage to the mat. Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur. During a review of the facility's recent policy and procedure (P&P) titled Safety and Supervision of Residents, last reviewed on 7/2024, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data, and a facility-wide commitment to safety at all levels of the organization. Resident Risks and Environmental Hazards a. Bed safety; g. Electrical safety 2. During a review of Resident 81 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/18/2025, with diagnoses including Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), muscle weakness, and age-related osteoporosis (the development of osteoporosis, a condition characterized by weakened and brittle bones, as a natural consequence of aging). During a review of Resident 81 ' s H&P, dated 2/19/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 81 ' s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self understood and understand others and had impaired cognition (a person has trouble with mental processes like thinking, learning, remembering, and making decisions). The MDS indicated Resident 81 was dependent to needing substantial assistance on mobility and ADLs. During a review of Resident 81 ' s Order Summary Report, dated 6/20/2025, the Order Summary Report did not indicate any order for pad/tab alarms in bed. During a review of Resident 81 ' s Fall Risk Assessment, dated 5/27/2025, the Fall Risk Assessment indicated the resident was high risk for falls. During a review of Resident 81 ' s Care Plan (CP) report titled Resident is at risk for falls/injury related to dementia, difficulty walking ., last revised on 2/18/2025, the CP indicated an intervention to visibly observe resident frequently and to provide a safe and clutter-free environment. During a concurrent observation and interview on 6/16/2025, at 10:06 a.m., with Restorative Nursing Assistant (RNA) 2, inside Resident 81 ' s room, observed Resident 81 ' s pad/tab alarm with broken sensor pad wires. RNA 2 stated the pad wires should be connected to the monitor and the pad wires were broken with frayed wires. RNA 2 stated she will report the incident to the maintenance staff right away. RNA 2 stated it was the responsibility of the Maintenance Department to ensure the pad/tab alarms are working and not broken. RNA 2 stated with the pad alarm wires not connected and broken the resident will get out of bed without assistance without the staff knowledge and could fall and sustain an injury. During an interview on 6/18/2025, at 7:17 a.m., with the Maintenance Assistant (MA), the MA stated they are not responsible for the pad/tab alarm maintenance and checking on the facility. The MA stated Central Supply is responsible for making sure the pad/tab alarms were working in the facility. During an interview on 6/20/2025, at 12:47 p.m., with the Central Supply Supervisor (CSS), the CSS stated they provide the tab/pad alarms and attachments, but they are not responsible for ensuring the pad/tab alarms attached to residents were working. The CSS stated the nursing staff were responsible for testing and ensuring the pad/tab alarms attached to the residents were functioning. During an interview on 6/20/2025, at 11:576 a.m., with the DON, the DON stated all staff working on the unit are responsible in ensuring the pad/tab alarms attached to residents are working. The DON stated the staff should test the pad alarm daily for functionality and to check if there are broken accessories that needed to be replaced. The DON stated the failure of the staff to ensure the pad alarm is working and connected to Resident 81 could lead to accidents such as falls. During a review of the facility-provided User's Manual Mobile Monitor 1 (MM 1), mobile monitor, undated indicated to carefully read the instructional manual prior to use. Failure to comply with instructions, warnings and cautions may result in serious injury to patient. Always test system and battery before each use. During a review of the facility-provided Instructions for Use Sensor Pad, undated, indicated to route cords towards the alarm unit, being careful to keep cord clear of moving assist bars, latching mechanisms and all other moving parts. Connect sensor pad to alarm. Test the system operates correctly. During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 7/2024, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data, and a facility-wide commitment to safety at all levels of the organization. Resident Risks and Environmental Hazards a. Bed safety; g. Electrical safety

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of five sampled residents (Resident 33) reviewed during the Medication Administration task, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 administered medication per facility policy and procedure (P&P) within one hour of the scheduled time. 2. Ensure LVN 3 documented the administration of medication per facility P&P at the time of administration in the resident ' s medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). These deficient practices had the potential to result in adverse reactions (unwanted, uncomfortable, or dangerous effects that a drug may have) from the early administration of medication and miscommunication among caregivers. Cross Reference to F759 and F842. Findings: During a review of Resident 33 ' s admission Record (AR), the AR indicated the facility admitted the resident on 5/1/2015 and most recently admitted the resident on 4/17/2025 with diagnoses that included sepsis (a life-threatening blood infection), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen) with hypoxia (low levels of oxygen in your body tissues), paranoid schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and hypertensive chronic kidney disease (kidney damage caused by hypertension [HTN, high blood pressure]). During a review of Resident 33 ' s Minimum Data Set (MDS – resident assessment tool) dated 4/22/2025, the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated Resident 33 required partial/moderate assistance from staff for dressing, oral hygiene, and toileting; and the resident required substantial / maximal assistance from staff for mobility. During a review of Resident 33 ' s Order Summary Report, the Order Summary Report indicated the following orders: 1. Divalproex sodium (a medication to treat conditions related to mood regulation and the nervous system) sprinkles oral capsule, delayed release, 125 milligrams (mg, a unit of measurement), give 250 mg by mouth three times a day for schizoaffective disorder manifested by uncontrollable extreme mood swings causing anger interfering with daily living activities, dated 4/22/2025. 2. Apixaban (a medication to help prevent blood clots [clumps that occur when blood hardens from a liquid to a solid]), oral tablet 2.5 mg, give 2.5 mg orally two times a day for cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) prophylaxis, dated 4/17/2025. 3. Olanzapine (a medication to treat mood disorders) oral tablet 7.5 mg, give 7.5 mg by mouth two times a day for schizoaffective disorder manifested by yelling at staff without apparent reason, dated 6/6/2025. 4. Metoprolol succinate (a medication to treat high blood pressure), give 75 mg by mouth one time a day for HTN, give with food, dated 5/8/2025. During a review of Resident 33 ' s Care Plan (CP) regarding olanzapine, initiated 11/1/2024 and last revised 6/6/2025, the CP indicated an intervention to administer medication as per physician ' s order. During a review of Resident 33 ' s CP regarding divalproex sodium, initiated 11/1/2024 and last updated on 4/18/2025, the CP indicated an intervention to administer medication as ordered. During an interview on 6/18/2025 at 7:24 a.m., with LVN 3, LVN 3 stated Resident 33 had medications due at 7:30 a.m. During a concurrent medication pass observation and interview on 6/18/2025 at 7:30 a.m., with LVN 3 at the Station 1 Medication Cart, LVN 3 prepared and administered the following medications to Resident 33: 1. Three 25 mg tablets of metoprolol succinate 2. Two capsules of 125mg divalproex sodium 3. One 2.5 mg tablet of apixaban 4. One 7.5 mg tablet of olanzapine LVN 3 then exited Resident 33 ' s room and stated LVN 3 would document the administration of Resident 33 ' s administered medications. LVN 3 again stated that Resident 33 ' s medications were due at 7:30 a.m. During an interview on 6/18/2025 at 10:16 a.m. with the Infection Preventionist (IP), the IP stated the daily, routine a.m. medication pass is 9 a.m. The IP stated 9 a.m. medications may be administered up to one hour before and one hour after 9 a.m. The IP stated 9 a.m. medications should not be given prior to 8 a.m. The IP stated some resident medications are scheduled for an earlier pass time because those medications are administered with food. During an interview on 6/18/2025 at 10:30 a.m., with LVN 3, LVN 3 stated all the medications LVN 3 administered to Resident 33 on 6/18/2025 at 7:30 a.m. were due at 7:30 a.m. because the medications needed to be given with food. During a concurrent interview and record review on 6/18/2025 at 10:43 a.m., with Registered Nurse (RN) 1, RN 1 reviewed Resident 33 ' s physician orders and Progress Notes for 6/2025. RN 1 stated the process for medication administration is to give medications within one hour of the prescribed time. RN 1 stated for medications that are prescribed to be administered twice a day and three times a day, the a.m. dose is routinely scheduled to be administered at 9 a.m. RN 1 reviewed Resident 33 ' s physician orders and progress notes and noted the following for the a.m. medications administered by LVN 3 on 6/18/2025: - Divalproex sodium was scheduled to be administered at 9 a.m. When LVN 3 administered divalproex sodium at 7:30 a.m. it was given at the wrong time because divalproex sodium was not administered within one hour of the scheduled time. There was no documented evidence that LVN 3 administered divalproex sodium to Resident 33 early at 7:30 a.m. - Apixaban was scheduled to be administered at 9 a.m. When LVN 3 administered apixaban at 7:30 a.m. it was given at the wrong time because apixaban was not administered within one hour of the scheduled time. There was no documented evidence that LVN 3 administered apixaban to Resident 33 early at 7:30 a.m. - Olanzapine was scheduled to be administered at 9 a.m. When LVN 3 administered olanzapine at 7:30 a.m. it was given at the wrong time because olanzapine was not administered within one hour of the scheduled time. There was no documented evidence that LVN 3 administered olanzapine to Resident 33 early at 7:30 a.m. - Metoprolol was schedule to be administered at 7:30 a.m. and LVN 3 administered it at the correct time. During an interview on 6/18/2025 at 11:10 a.m. with LVN 3 while in the presence of RN 1, LVN 3 stated in general medications need to be administered at the scheduled time. LVN 3 stated Resident 33 ' s olanzapine, apixaban, and divalproex sodium were due at 9 a.m., and 8 a.m. was the earliest time the medications should be administered. LVN 3 stated LVN 3 did not administer Resident 33 ' s olanzapine, apixaban, and divalproex sodium at the scheduled time. LVN 3 stated Resident 33 ' s olanzapine, apixaban, and divalproex sodium were administered early at 7:30 a.m. because LVN 3 prefers to give Resident 33 all the morning medications at the same time. LVN 3 stated Resident 33 is unpredictable and does not always want to take the medications when they are administered as scheduled at different times. LVN 3 stated LVN 3 did not document the administration of Resident 33 ' s olanzapine, apixaban, and divalproex sodium at 7:30 a.m. when the medications were administered. LVN 3 stated LVN 3 documented later in Resident 33 ' s MAR that olanzapine, apixaban, and divalproex sodium were administered during the scheduled time of 9 a.m. LVN 3 stated it was probably a medication error to administer Resident 33 ' s medications early. During a follow-up interview and record review on 6/18/2025 at 11:27 a.m. with RN 1, RN 1 reviewed the facility P&P regarding medication administration and documentation. RN 1 stated the facility policy is to administer medications within one hour of the scheduled time and LVN 3 did not follow the facility P&Ps when LVN 3 administered Resident 33 ' s medications early at 7:30 a.m. RN 1 stated medications must be documented in the MAR right after administration to a resident and prior to administering medications to the next resident to ensure the documentation is correct. RN 1 stated LVN 3 did not follow the facility process when LVN 3 did not document Resident 33 ' s medications at the time of administration and when LVN 3 did not document that the medications were given early. During an interview on 6/18/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated it is important to administer medications at the correct time to ensure the amount of medication in the resident ' s body has the intended effect. The DON stated 9 a.m. medications should not be administered prior to 8 a.m. because the facility P&P indicates to administer medications within one hour of the scheduled time. The DON stated when LVN 3 administered Resident 33 ' s olanzapine, apixaban, and divalproex sodium at 7:30 a.m., it was considered early administration. The DON stated LVN 3 did not follow the facility P&P when Resident 33 ' s medications were administered early. During a follow-up interview and record review on 6/20/2025 at 3 p.m. with the DON, the DON reviewed Resident 33 ' s Medication Administration Audit Report and the facility policy and procedures regarding medication administration. The DON stated nurses do not decide to adjust the time of medication administration without contacting the physician. The DON stated the facility process is when a nurse is aware that a resident wants their morning medications administered all together at the same time, it is the nurse ' s responsibility to contact the physician. The DON stated if the physician agrees, then the medication administration times will be adjusted to ensure personalized care for the resident. The DON stated when LVN 3 administered Resident 33 ' s medications early there was a potential that medications would be given too close together affecting the efficacy of the medication. The DON stated LVN 3 did not follow the facility P&P and there was a potential that the resident ' s behaviors would not be properly managed by the medications and that the resident ' s preferences would not be respected. The DON stated the facility process is to document the administration of medication in the MAR right after administering medications to ensure accurate documentation of the medication given. The DON reviewed the Medication Administration Audit Report and noted the following for Resident 33 ' s a.m. medication administration on 6/18/2025: - Divalproex sodium was scheduled for 9 a.m., LVN 3 administered at 7:30 a.m., and LVN 3 documented the administration at 10:57 a.m. - Apixaban was scheduled for 9 a.m., LVN 3 administered at 7:30 a.m., and LVN 3 documented the administration at 10:57 a.m. - Olanzapine was scheduled for 9 a.m., LVN 3 administered at 7:30 a.m., and LVN 3 documented the administration at 10:57 a.m. The DON stated LVN 3 did not follow the facility P&P when LVN 3 did not document the administration of Resident 33 ' s medication right after administration. During a review of the facility P&P titled, Administering Medications, last reviewed 7/2024, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a) enhancing optimal therapeutic effect of the medication. b) preventing potential medication or food interactions; and c) honoring resident choices and preferences, consistent with his or her care plan. Medication errors are documented and reported. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document the reason. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered. During a review of the facility P&P titled, Adverse Consequences and Medication Errors, last reviewed 7/2024, the P&P indicated an adverse consequence refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. The staff and practitioner strive to minimize adverse consequences. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders. Examples of medications errors include administering at the wrong time. The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis.

Based on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) to one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and was admitted to a secured facility (specialized healthcare setting that restricts patient movement and access to promote safety with measures such as locked doors and surveillance). On 4/24/2025 at 6:48 p.m., Restorative Nurse Aide (RNA - focuses on helping residents regain or maintain their physical abilities and independence through restorative program and activities) 1 without verifying Resident 1 ' s identity, opened the facility ' s locked gate due to RNA 1 thought Resident 1 was a visitor, and allowed Resident 1 to exit the facility ' s building. This deficient practice resulted in Resident 1 ' s elopement (the act of leaving a facility unsupervised and without prior authorization) on 4/24/2025 at 6:48 p.m., placing Resident 1 at risk for vehicular accidents since the facility is located in a busy street with many cars passing by, negative outcome from not receiving Resident 1 ' s medication, and exposure to extreme temperatures (heat during the day and cold during the night) that could lead to serious injury, serious harm, or death. On 4/26/2025 at 5:49 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator and the Director of Nursing (DON) due to the facility ' s failure to provide supervision to Resident 1 and to prevent the elopement of Resident 1 on 4/24/2025 at 6:48 p.m. On 4/27/2025 at 2:34 p.m., the DON provided an acceptable IJ removal plan (a detailed plan to address the IJ findings) for the facility ' s failure to provide supervision to Resident 1 and to prevent the elopement of Resident 1 on 4/24/2025 at 6:48 p.m. On 4/27/2025 at 6:19 p.m., while onsite at the facility, the SSA verified and confirmed the facility ' s full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding elopement due to lack of supervision was no longer present. The SSA removed the IJ on 4/27/2025 at 6:48 p.m., in the presence of the Administrator and the DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On 4/25/2025, the Administrator gave a disciplinary action (a reprimand or corrective action in response to employee misconduct, rule violation, or poor performance) and suspended RNA 1 pending investigation. 2. On 4/25/2025 at 5 p.m., Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, and 2 local police officers located Resident 1 in Resident 1 ' s apartment, approximately 7.8 miles (unit of measurement) away from the facility. 3. On 4/25/2025 at 5:56 p.m., RN 1, LVN 1, and 2 local police officers accompanied Resident 1 back to the facility. RN 2 completed Resident 1 ' s skin assessment and noted a scab (a dry, rough protective crust that forms over a cut or wound during healing) on Resident 1 ' s left knee. 4. On 4/25/2025 at 8:30 p.m., Resident 1 was transferred to General Acute Care Hospital (GACH) 1 for further evaluation. 5. From 4/25/2025 to 4/26/2025, the DON, the Quality Assurance (QA) Nurse Consultant (a registered nurse specializing in improving resident care quality, ensuring compliance with regulations, and enhancing healthcare practices), and the Director of Staff Development (DSD), conducted a series of in-services (a planned, workplace-based training program designed to enhance staff competency, improve job performance, and keep staff up to date with current best practices and new techniques) to staff regarding Safety and Supervision of Residents, Elopement, Missing Person, and Resident Identification policies, emphasizing the following: a. The purpose and importance of identifying and confirming with the Licensed Nurses (LNs), RNs, the Administrator, or Receptionist, that the person leaving the facility is a visitor and not a resident of the facility before allowing anyone to leave the (facility ' s secured) premises. b. The purpose and importance of supervising residents while in the facility and always being mindful of their (residents) whereabouts to ensure residents ' safety. c. The purpose and importance of identifying residents by checking if they are wearing an Identification (ID) wristband [a bracelet-like band, often worn on the wrist, contain at the minimum two identifiers (name and birthday) used for identification purposes] or having another form of identification such as a photograph. d. The purpose and importance of immediate action and interventions such as initiating a code to initiate search immediately once a resident was found missing. e. The purpose and importance of seeking assistance from the Local Police Department in searching for a missing resident. 6. On 4/26/2025, LN, Medical Records Director, and Designee checked all residents to see if in-house residents were wearing ID wristbands. There were four residents (Residents 3, 6, 12, and 13) who were found not wearing ID wristbands due to refusal. An Interdisciplinary meeting (IDT meeting, involves professionals from different fields or specialties collaborating to address a shared problem or achieve a common goal) was conducted to discuss Residents 3, 6, 12, and 13 ' s noncompliance. The residents ' refusal to wear ID wristbands was addressed in the residents ' care plans. 7. On 4/26/2025, the Social Service Director (SSD) or designee and LNs evaluated all residents to see if the residents feel safe while in the facility using the safety/wellness evaluation tool. No other resident was found to be affected by the deficient finding. 8. On 4/26/2025, the IDT members comprising of the Administrator, the DON, and the DSD reviewed a new policy pertaining to secured unit/facility integrating the guidelines on admission process, environment special consideration, and visitation. a. The RN or Licensed Designee will immediately apply an ID wristband to a resident upon admission to help identify a resident while in the facility. A resident ' s photograph will also be taken, and the resident ' s picture will be uploaded in the resident ' s electronic health record (a digital version of a resident ' s medical history, stored on a computer and designed to be shared across different healthcare settings). b. A green colored ID wristbands will be provided to residents who are ambulatory without assistance for identification purposes and to alert staff about the risk for elopement especially when the residents seek exit doors. c. The Administrator will assign Department Heads or IDT members to conduct room inspections and check residents to see if they are wearing ID wristbands. The Administrator will also assign a Department Manager to be a Manager of the Day (MOD) on the weekends (Saturday to Sunday) to conduct random room inspection, including but not limited to checking Residents if they are wearing ID wristbands. d. The LNs will be conducting visual monitoring every 30 minutes for 72 hours to check newly admitted residents ' whereabouts, activities, and behaviors. e. The facility will assign a staff member to monitor the reception area daily seven days a week to monitor the front lobby as well as monitoring individuals entering and exiting the facility. The assigned receptionist will inform the SSD and/or designee five times a week (Monday to Friday) and the Manager of the Day on the weekends as coverage if the assigned receptionist will go on a break. An alarm has been installed on the main entrance door to also alert staff when there is someone coming in and out of the facility, in the absence of the receptionist in the front lobby. Findings: During a review of Resident 1 ' s History and Physical (H&P) from GACH 2, dated 3/9/2025, the H&P indicated Resident 1 was admitted to GACH 2 due to hypertensive urgency (a situation where blood pressure is significantly elevated, but there is no immediate evidence of organ damage), and had diagnoses of hypertension (high blood pressure), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s GACH 2 Progress Notes, dated 4/2/2025, the Progress Notes indicated Resident 1 had a history of involvement from Adult Protective Services (APS - program to promote the safety, independence, and quality of life for adults who are unable to protect themselves) for self-neglect. The Progress Notes indicated Resident 1 had altered mental status (any significant change in a resident ' s normal mental state, encompassing a range of conditions from mild confusion to complete unconsciousness) with episodes of agitation (a condition in which a resident is unable to relax and be still), delirium (a sudden change in a resident ' s mental state, characterized by confusion and difficulty focusing), and had high concern for falls. The Progress Notes indicated it was not safe for Resident 1 to return home. During a review of Resident 1 ' s H&P from the Center of Behavioral Health (CBH), dated 4/11/2025, the H&P indicated Resident 1 had cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and was gravely disabled (refers to a condition where a resident, because of a mental health disorder, is unable to provide for the basic personal needs for food, clothing, shelter, personal safety, or necessary medical care) with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 1 ' s Admission Assessment, dated 4/24/2025, the Admission Assessment indicated Resident 1 was admitted to the facility on [DATE] at 5 p.m. The Admission Assessment indicated Resident 1 was alert and oriented to time, place, with slow comprehension and required assistance with showers, bed baths, oral hygiene, grooming, and dressing. During a review of Resident 1 ' s Change of Condition (COC - when there is a sudden significant change in a resident ' s health status) Assessment Form, dated 4/24/2025, the COC indicated on 4/24/2025 at 6:50 p.m., Resident 1 walked out of the facility after RNA 1 opened the facility ' s locked gate. The COC indicated LVN 2 noticed an unfamiliar person leaving the facility after RNA 1 used the code to open the locked gate. The COC indicated on 4/24/2025 at 7:55 p.m., the police was notified of Resident 1 ' s elopement. During a concurrent observation, interview, and record review on 4/25/2025 at 11:15 a.m., the facility ' s video surveillance footage of Station 1 and Reception area with the recording date and time of 4/24/2025 at 6:28:40 p.m. (adjusted to reflect the 12-hour clock) was observed and reviewed with the Administrator. The video footage showed RNA 1 opened the facility ' s locked gate, and a person (Resident 1) walked toward the open gate and exited the facility. The Administrator stated Resident 1 was the person in the video surveillance. The Administrator stated the following: a. On 4/24/2025 at 6:46:56 p.m., Resident 1 came out of Resident 1 ' s room and walked towards Station 1. b. On 4/24/2025 at 6:47:34 p.m., Resident 1 was ambulating (walking) near Station 1 while LVN 3 was standing in front of Station 1, in the hallway leading to the locked gate. RN 1 was inside Station 1, while RNA 1 was walking towards the locked gate. Resident 1 passed by LVN 3 who was standing near Station 1 and walked towards the locked gate, behind RNA 1. c. On 4/24/2025 at 6:47:56 p.m., LVN 3 was walking behind Resident 1 towards the locked gate. d. On 4/24/2025 at 6:47:57 p.m., Resident 1 was walking towards the locked gate and talked to RNA 1. e. On 4/24/2025 at 6:48:10 p.m., RNA 1 opened the locked gate and Resident 1 walked outside the locked gate towards the reception area. f. On 4/24/2025 at 6:48:29 p.m., Resident 1 opened the front door (in the reception area) and exited the facility building. The Administrator stated there was no facility staff present in the lobby. During a concurrent interview and record review on 4/25/2025 at 1:17 p.m. with the DON, Resident 1 ' s Discharge Reconciliation Report, from the CBH, dated 4/24/2025 was reviewed. The Discharge Reconciliation Report indicated Resident 1 was gravely disabled. The DON stated Resident 1 was admitted to the facility as gravely disabled. The DON stated the facility was in a high traffic area, with an occasionally homeless population and Resident 1 was at risk of being hit by a car and at risk of physical and sexual abuse from the homeless individuals. The DON stated Resident 1 was at risk of hypothermia (a significant and potentially dangerous drop in body temperature caused by prolonged exposure to cold) at night and hyperthermia (a condition characterized by abnormally high body temperatures) during the day when the temperature would go up. The DON stated Resident 1 could potentially experience any type of injury while outside of the facility including death. The DON stated the facility did not have a policy and procedure addressing supervision and access of the locked gate. The DON stated the facility was a secured facility and all the exit doors were kept locked and required a special key or code to open to prevent residents from wandering outside the building without supervision. The DON stated residents could exit the locked area only with staff supervision. The DON stated RNA 1 should not have opened the locked gate for Resident 1. The DON stated RNA 1 failed to identify Resident 1 as a resident of the facility resulting in Resident 1 ' s elopement. The DON stated the facility had not located Resident 1 (as of this time of the interview) and as a result Resident 1 was at risk to experiencing negative effects from missing her medications, including hypoglycemia (a condition in which the body ' s blood sugar level drop below the normal range) or hyperglycemia (a condition in which the there is too much sugar in the blood). A concurrent review of the Discharge Reconciliation Report with the DON indicated Resident 1 was prescribed the following medications: - Olanzapine (Zyprexa, a medication to treat several mental health conditions including psychosis) 2.5 milligram (mg - unit of measurement for weight/mass) twice daily for severe psychosis. - Divalproex Sodium (Depakote, a medication to improve mood, thoughts, and behavior) 125 mg three times daily for mood changes (sudden changes in how you feel). - Aspirin (a medication used to treat pain, fever, inflammation and blood clots) 81 mg daily for the prevention of myocardial infarction (a medical condition where blood flow to the heart muscle is suddenly blocked). - Furosemide (Lasix, a medication used to treat excessive fluid accumulation) 20 mg every Monday, Wednesday, and Friday for edema (swelling caused by the accumulation of excess fluid in the body). - Nebivolol HCL (Bystolic, a medication used to treat high Blood Pressure) 20 mg daily for hypertension. - Repaglinide (Prandin, a medication used to treat high blood sugar levels) 0.5 mg three times a day with meals for diabetes mellitus. - Insulin Lispro (Humalog - a rapid-acting insulin used to manage high blood sugar levels) 3 units (unit of measurement) before meals for diabetes mellitus. - Nifedipine (Procardia, a medication used to treat high Blood Pressure and chest pain) 90 mg daily for the prevention of anginal pain (chest pain) associated with coronary artery disease (a condition where the arteries that supply blood to the heart become narrowed or blocked). During an interview on 4/25/2025 at 2:40 p.m. with RNA 1, RNA 1 stated on 4/24/2025 at approximately 6:50 p.m. while walking towards the locked gate, Resident 1 asked RNA 1 to open the door stating, I have to leave now. I need to buy stuff. I will be back soon. RNA 1 stated she (RNA 1) did not ask Resident 1 if Resident 1 was a visitor or a resident and did not check to see if Resident 1 was wearing an ID wristband. RNA 1 stated because Resident 1 looked nice and well-dressed RNA 1 concluded Resident 1 was a visitor and opened the locked gate allowing Resident 1 to leave the facility without supervision. RNA 1 stated RNA 1 should have verified Resident 1 ' s identity prior to letting Resident 1 leave the facility. During an interview on 4/25/2025 at 5:02 p.m. with RN 2, RN 2 stated RN 2 was the RN assigned to care for Resident 1 on 4/24/2025. RN 2 stated, on 4/24/2025 at approximately 5 p.m., RN 2 initiated Resident 1 ' s admission assessment. RN 2 stated Resident 1 was transferred from the CBH where Resident 1 was admitted due to being gravely disabled. RN 2 stated Resident 1 was cognitively impaired, required frequent reminders on Resident 1 ' s location and situation. RN 2 stated during the admission, Resident 1 was not provided with an ID wristband since the facility does not utilize ID wristbands. RN 2 stated on 4/24/2025 at approximately 7:10 p.m., she (RN 2) was informed by Certified Nursing Assistant (CNA) 1 that Resident 1 was missing after which staff (unable to identify) initiated a facility search but were not able to locate Resident 1. RN 2 stated RNA 1 should not have opened the locked gate before confirming Resident 1 ' s identity. RN 2 stated Resident 1 had diabetes and was at risk of experiencing hypoglycemia or hyperglycemia without diabetes medication and possibly without food. RN 2 stated Resident 1 could potentially experience negative effects from missing Resident 1 ' s medications and was at risk of being hit by a car. During an interview on 4/26/2025 at 10:14 a.m. with the DON, the DON stated all residents in the facility should be wearing ID wristbands for identification. The DON stated that upon admission social services staff or RNs were required to provide ID wristbands to new residents. The DON stated the facility had a policy addressing the identification of residents during medication administration but did not have a policy regarding provision of ID wristbands and verification of residents' or visitors' identity prior to allowing them (residents and visitors) to leave the facility. During an interview on 4/26/2025 at 12:20 p.m. with CNA 1, CNA 1 stated on 4/24/2025 CNA 1 was the CNA assigned to care for Resident 1. CNA 1 stated Resident 1 was admitted around 5 p.m. on 4/24/2025. CNA 1 stated when Resident 1 was admitted to the facility, CNA 1 introduced self to Resident 1 and with RN 1, they completed Resident 1 ' s inventory list after which CNA 1 left to assist with dinner. CNA 1 stated she last saw Resident 1 (on 4/24/25) between 6:30 p.m. to 7 p.m., walking in the hallway of Station 1. CNA 1 stated at approximately 7:35 p.m. CNA 1 went to check on Resident 1 but was not able to locate Resident 1. CNA 1 stated CNA 1 then notified RN 1 that Resident 1 was missing. CNA 1 stated facility staff (unable to identify) searched for Resident 1 inside and outside of the facility building but were not able to locate Resident 1. During an observation on 4/26/2025 at 3:19 p.m. in front of the facility entrance, the facility was located on a busy street in a commercial area (designated location used for business, retail, and offices) and a large number of cars are moving along the road. During an interview on 4/27/2025 at 1:07 p.m. with RN 1, RN 1 stated on 4/25/2025 at approximately 5 p.m. RN 1 located Resident 1 in Resident 1 ' s apartment. RN 1 stated Resident 1 was accompanied back to the facility after approximately 24 hours, at 6 p.m. on 4/25/2025 with the assistance of 2 local police officers. RN 1 stated Resident 1 ' s elopement incident could have been prevented if the facility had a system in place for the identification of residents and monitoring of the locked gate. RN 1 stated Resident 1 could have potentially experience physical harm, abuse, and negative effects from missing Resident 1 ' s medications such as low or high blood sugar levels, and behavioral issues from missing Resident 1 ' s psychotropic medications (used to treat mental health disorders). During an interview on 4/27/2025 at 5:15 p.m. with the DON, the DON stated the facility did not have a system in place for the monitoring of the locked gate and identification of the residents and visitors. The DON stated Resident 1 ' s elopement incident could have been prevented if the facility had a system in place for the monitoring of the locked gate and identification of the residents and visitors. During a review of the current facility-provided policy and procedure titled, Wandering and Elopement, last reviewed on 7/2024, the policy and procedure indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. During a review of the current facility-provided policy and procedure titled, Safety and Supervision of Residents, last reviewed on 7/2024, the policy and procedure indicated, Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risk for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . and a facility-wide commitment to safety at all levels of the organization Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individuals together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors and then adjust interventions accordingly. 2. Resident supervision is a core component of the system ' s approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and overtime for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment

Based on interview and record review, the facility failed to follow its abuse policies and procedures (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, and Abuse & Mistreatment of Residents, to protect one of three sampled residents (Resident 1) from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) received abuse training. 2. Ensure CNA 1 did not hit (slap and punch) Resident 1. As a result, on 5/1/2024 at 5:30 p.m., Student Nurse 1 (SN 1) walked in Resident 1 ' s room and witnessed CNA 1 slapping and punching Resident 1 in Resident 1 ' s arms and back. Resident 1 was subjected to physical abuse inflicted by CNA 1 while under the care of the facility. Based on the reasonable person concept (refers to a tool to assist the survey team ' s assessment of the severity level of negative, or potentially negative, psychosocial [pertaining to the influence of social factors on an individual ' s mind or behavior, and to the interrelation of behavioral and social factors] outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s severely impaired cognition (ability to think and process information), an individual subjected to physical abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self). On 5/9/2024 at 1:42 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), the Director of Nursing (DON), and Nurse Consultant 1 (NC 1) due to the facility ' s failure to prevent physical abuse for Resident 1 under 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation. On 5/10/2024 at 3:47 p.m., the ADM provided an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified that Resident 1 was no longer subjected to physical abuse and confirmed the facility ' s implementations of the IJ removal plan through observations, interviews, and record reviews, the SSA accepted the IJ removal plan and removed the IJ situation in the presence of the ADM, DON, NC 1, and NC 2 on 5/10/2024, at 5:55 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1. On 5/9/2024, the DON conducted a head-to-toe assessment on Resident 1, with no signs or symptoms of any physical trauma, abuse, emotional distress. 2. On 5/9/2024, the Psychiatrist (a medical doctor who diagnoses and treats mental, emotional, and behavioral disorders) conducted a virtual assessment for Resident 1 to provide emotional and psychosocial support and informed the nurses that Resident 1 was noted at baseline condition (an initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes) with no new orders. 3. On 5/9/2024, the Psychologist (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) assessed Resident 1 and provided Resident 1 with emotional and psychosocial support. 4. On 5/9/2024, the DON conducted a care plan meeting for Resident 1 at Resident 1 ' s bedside. 5. On 5/9/2024, the DON notified Resident 1 ' s Family Member 1 (FM 1) of Resident 1 that CNA 1 was witnessed allegedly hitting Resident 1. 6. On 5/9/2024 CNA 1 was officially terminated from employment. 7. On 5/9/2024, the Psychologist and the DON provided in-service education to all facility staff (150 staff members) regarding the policies/procedures of abuse prevention and emphasized that the facility is prohibited from any willful act, using verbal, mental sexual or physical abuse, corporal punishment, or involuntary seclusion (separation of a resident from other residents against the resident ' s will) of any resident. 8. On 5/9/2024, the Social Services Designees interviewed and observed all residents (117 residents) with no reports of abuse or mistreatment. All residents were observed in their baseline condition with no signs of emotional stress or fear. 9. On 5/9/2024 and 5/10/2024, the DON and the ADM initiated in-services and re-training to all current employees (150 employees) including, but not limited to abuse prevention. 10. The Department Managers to conduct daily designated room rounds to interview residents and observe for any emotional distress, change in behavior, increased agitation, pain, or discomfort. 11. The DON and the ADM or designees to conduct proactive abuse prevention in-services to the facility staff monthly for three months, and then followed up every quarterly and as needed, to ensure ongoing education. 12. The ADM and the DON or designees to conduct monthly quality circle meetings with the nursing staff to ensure ongoing understanding and effective abuse prevention training is provided. 13. On 5/9/2024 and 5/10/204, the Director of Staff Development (DSD) Designee checked all current employee files, which include, but not limited to abuse training. 14. The interdisciplinary team (IDT- a group of healthcare professional from different discipline who participate in the care of the residents) members will conduct IDT care plan meeting for all residents upon admissions and then quarterly and upon any changes. During the IDT meetings, the IDT members will provide complete and accurate information to ensure resident/family notification. Findings: A review of Resident 1 ' s Admission Record, indicated the facility admitted Resident 1 on 6/21/2021 and readmitted the resident on 9/3/2023 with diagnoses including dementia (loss of memory and other mental abilities severe enough to interfere with daily life), mood disorder (a mental health condition that causes severe disruptions in emotions), anxiety disorder (a mental health disorder characterized by feelings of worry), and major depressive disorder (persistent feeling of sadness and loss of interests). A review of Resident 1 ' s History and Physical, dated 9/5/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Abuse Care Plan, dated 9/30/2023, indicated Resident 1 and/or Resident 1 ' s responsible party have been made aware that the facility had stable systems to prevent not only abuse but also those practices and omissions, neglect and misappropriation of property that is left unchecked, that can lead to abuse. The care plan indicated Resident 1 shall not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies, family member or legal counsel. The goal was for Resident 1 to be free from abuse daily until the next assessment (6/17/2024). The approached interventions were for staff to ensure a safe environment and the resident is free from abuse by providing monitoring and providing supervision to Resident 1. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screen tool), dated 3/19/2024, indicated Resident 1 had severe impaired cognition. The MDS indicated Resident 1 required moderate assistance with personal hygiene, lower body dressing, toileting hygiene, and putting on/off footwear. The MDS indicated Resident 1 had symptom presence of feeling down, depressed, or hopeless. A review of Resident 1 ' s Change of Condition (COC, a term used to describe a significant worsening of a patient ' s/resident's physical health) Report, dated 5/1/2024 at 5:40 p.m., indicated (on 5/1/2024) at 3 p.m. Resident 1 was noted ambulating (walking) down station 1 hallway with no apparent distress or discomfort. The COC report indicated that (on 5/1/2024) at 5:30 p.m., a SN 1 reported to SN 1 ' s Clinical Instructor (CI) that SN 1 saw CNA 1 moving CNA 1 ' s arms in the form of punching Resident 1. The COC report indicated SN 1 noted CNA 1 in Resident 1 ' s room with CNA 1 ' s back facing the doorway and appeared to be punching Resident 1. The COC report indicated SN 1 could not see where CNA 1 was punching Resident 1, but SN 1 was able to see CNA 1 ' s back and CNA 1 ' s punching movements towards Resident 1. The COC report indicated Resident 1 was screaming for help, was defending herself (had her arms covering her face. During a telephone interview with SN 1 on 5/7/2024 at 8:36 a.m., SN 1 stated that on 5/1/2024 at around dinner time (unable to recall the exact time) SN 1 went into Resident 1 ' s room to look for CNA 1. SN 1 stated as she walked into Resident 1 ' s room, she witnessed CNA 1 slapping and punching Resident 1 in Resident 1 ' s arms and back. SN 1 stated, Resident 1 was trying to protect her face with her arms up and attempting to hit CNA 1 back. SN 1 stated CNA 1 was slapping Resident 1 ' s arms, then Resident 1 turned around to get away from CNA 1, then CNA 1 proceeded to punch Resident 1 ' s back with a closed fist. SN 1 stated she saw Resident 1 and CNA 1 fall on the floor. SN 1 stated Resident 1 was crying and yelling for help. SN 1 stated, she assisted Resident 1 back to bed. SN 1 stated Resident 1 yelled, Do not let that monster back in here. SN 1 stated she left the room and notified her CI that she witnessed CNA 1 hitting Resident 1. SN 1 stated the CI, the Assistant DON (ADON), Registered Nurse 1 (RN 1) and herself went into an office, and she notified them (the CI, the ADON and RN 1) that she witnessed CNA 1 hitting and punching Resident 1. During a telephone interview with CNA 1 on 5/7/2024 at 8:55 a.m., CNA 1 stated, on 5/1/2024, (unable to recall exact time) Resident 1 went to get a glass of milk from Resident 1 roommate ' s lunch tray, and CNA 1 went towards Resident 1 to grab the glass of milk back from Resident 1. CNA 1 stated CNA 1 told Resident 1 that was not her (Resident 1 ' s) milk. CNA 1 stated, Resident 1 slapped her (CNA 1), and Resident 1 lost her (Resident 1 ' s) balance, but she (CNA 1) was able to catch her (Resident 1) before she Resident 1 fell . CNA 1 stated, she then saw SN 1 in the room after she caught Resident 1 from falling. CNA 1 stated she assisted Resident 1 back to her bed. During an interview with the Social Worker (SW) on 5/7/2024 at 2:30 p.m., the SW stated, Resident 1 was pleasant and cooperative. The SW stated Resident 1 had short term memory loss. The SW stated that ever since she (the SW) had been working with Resident 1, she had not witnessed Resident 1 being physically aggressive with any staff or other residents. The SW stated if Resident 1 became frustrated she was easily redirectable. The SW stated she went to conduct a psychosocial assessment (an evaluation of a person ' s mental, physical, and emotional health) on Resident 1 the day after (5/2/2024) she was notified that SN 1 witnessed CNA 1 hitting and punching Resident 1. The SW stated Resident 1 told her (the SW) that she (Resident 1) did not remember the incident (when CNA 1 hit Resident 1). During an interview with the CI on 5/7/2024 at 3 p.m., the CI stated he (the CI) was on the other side of the facility working with other students, and SN 1 reported to him that when she (SN 1) walked into Resident 1 ' s room, she witnessed CNA 1 with a closed fist punching Resident 1. The CI stated they (The CI and SN 1) both went to notify RN 1. The CI stated they went inside the ADON ' s office with RN 1. The CI stated RN 1 went to assess Resident 1. The CI stated SN 1 was crying about what she witnessed. During an interview with RN 1 on 5/7/2024 at 4 p.m., RN 1 stated Resident 1 was calm and had mood swings especially on shower days (unspecified dates). RN 1 stated Resident 1 did not like to take showers. However, Resident 1 was redirectable. RN 1 stated she (RN 1) had not seen Resident 1 being aggressive toward any of the staff or other residents. RN 1 stated she was at the nurse ' s station when the CI came to tell her (RN 1) that he (the CI) needed to report a serious matter. RN 1 stated SN 1, the CI, and the ADON went into an office, and SN 1 said that she witnessed CNA 1 punching Resident 1 inside Resident 1 ' s room. RN 1 stated SN 1 told them (RN 1, the CI and the ADON) that Resident 1 was trying to protect herself (Resident 1). RN 1 stated SN 1 was visibly upset. RN 1 stated she went to assess Resident 1 and Resident 1 did not have any injuries. During an interview with the ADON on 5/7/2024 at 4:30 p.m., the ADON stated (on 5/1/2024, unable to recall exact time) SN 1 came into her (the ADON ' s) office with her (SN 1 ' s) instructor and reported physical abuse by CNA 1 toward Resident 1. The ADON stated SN 1 said she walked into Resident 1 ' s room, where CNA 1 was, to report a feeding percentage for another resident (Resident 2) and saw CNA 1 punching Resident 1 with a closed fist. The ADON stated SN 1 said she (SN 1) put Resident 1 back on her bed, and then she went to report to her instructor. During a telephone interview with Resident 1 ' s FM 1 on 5/8/2024 at 2 p.m., FM 1 stated the facility called her on 5/1/2024 (unspecified time) and they told her (FM 1) that Resident 1 hit the CNA 1. FM 1 stated the facility did not tell her that SN 1 saw CNA 1 hit Resident 1. FM 1 stated Resident 1 speaks French and communicates better in French. FM 1 stated Resident 1 has been telling her that someone in the facility has been hitting her (Resident 1). During an interview with the DON and a concurrent review of CNA 1 ' s undated employee file, on 5/9/2024 at 8:30 a.m., the DON stated she was not in the building when SN Witnessed CNA 1 hitting and punching Resident 1. The DON stated she was informed by her assistant that SN 1 witnessed CNA 1 punched Resident 1. The DON stated she instructed her (the DON ' s) assistant to notify the ADM. A review of CNA 1 ' s employee file indicated CNA 1 ' s employee file had an unsigned form titled, Abuse Allegation Reporting, dated 4/15/2019. The DON stated this form was the only education on abuse in CNA 1 ' s employee file. The DON stated, the form has CNA 1 ' s name printed, however CNA 1 needed to sign the document to ensure CNA 1 read the information and was agreeable. The DON stated it was the staff developer ' s responsibility to keep the employee charts up to date, but currently the facility does not have a staff developer working in the facility. A review of the current facility-provided P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, indicated Residents have the right to be free from physical abuse. A review of the facility ' s undated P&P titled, Abuse & Mistreatment of Residents, indicated by way of orientation and continuing education sessions, all facility staff shall receive training on issues related to abuse-prohibition practices such as the California Department of Public Health mandated abuse reporting video in the mandated in-service sessions. The P&P indicated employee attendance at orientation shall be verified by a signed and dated receipt of the copy of resident rights, facility P&P on abuse prevention and mandated reporting. A copy of signed receipt shall be maintained in employee file.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the bladder to the outside of the body] and infect the urinary tract), received care and services to prevent UTI. For Resident 1 who had an indwelling urinary catheter (also known as Foley catheter, a hollow flexible tube inserted in the bladder through the urethra to drain urine), the facility failed to: 1. Accurately and continuously monitor Resident 1 for signs (are objective findings that can be seen or measured such as color, clarity, amount, odor, presence of sediments [white blood cells, bacteria, minerals, residual that make the urine cloudy]) and symptoms (are subjective and can be perceived only by the person affected such as burning or pain in the lower abdomen, side, or back; feeling extremely tired [fatigue]) of UTI to prevent complications. 2. Monitor and accurately document Resident 1 ' s urine characteristics (color, transparency, amount, odor, pain or discomfort, presence of blood [hematuria], etc.) to promptly identify UTI and intervene to mitigate the infection and prevent complications as indicated in the plan of care. As a result, on 3/4/2024 at 7:54 p.m., Resident 1 required emergency transfer by paramedics (healthcare professionals trained to give emergency medical care to people who are injured or ill) who found Resident 1 with the indwelling catheter tube (connects the indwelling catheter to the urine drainage bag) dark brown and murky in appearance. At General Acute Care Hospital 1 (GACH 1), Resident 1 was diagnosed with severe sepsis (a life-threatening emergency that happens when the body's response to an infection damages vital organs often causing death) and UTI. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 10/13/2023 and was last readmitted on [DATE]. Resident 1 diagnoses included type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar [glucose] and using it for energy), UTI, and urinary retention. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 3/4/2024, indicated Resident 1 ' s cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 1 needed substantial or maximal assistance (helper does more than half the effort and helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene, toileting hygiene, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 1 was dependent (helper does all the effort) on showering or bathing self. The MDS indicated Resident 1 was admitted with an indwelling catheter. A review of the Physician ' s Orders for Resident 1 ' s re-admitted d 2/21/2024, indicated to provide indwelling catheter care every shift, change bedside drainage bag every Friday and as needed, and change catheter as needed when clogged, soiled, or pulled out. A review of Resident 1 ' s nursing re-admitted d 2/21/2024, assessment indicated Resident 1 was unable to understand and make decisions and required extensive to total care with activities of daily living (ADLs, such as transfers, hygiene, toilet use, and personal hygiene). A review of Resident 1 ' s Change of Condition (COC)/Interactive Assessment form, dated 2/29/2024, indicated Resident 1 pulled out the indwelling catheter and had hematuria. The catheter was replaced, and hematuria was then noted to be flowing into his urinary drainage bag. The physician was informed and ordered to monitor Resident 1. A review of Resident 1 ' s Care Plan, developed on 3/1/2024, regarding Resident 1 ' s pulling out the indwelling catheter, indicated interventions that included monitoring for signs and symptoms of UTI and to notify physician as indicated. A review of Resident 1 ' s Care Plan, developed on 3/1/2024, regarding Resident 1 ' s alteration in urinary elimination and at risk for UTI secondary to use of the indwelling catheter, indicated interventions that included changing catheter / bag as ordered, monitoring urine for sediment, cloudiness, odor, blood and amount of urine output; report urine output findings; and monitor Resident 1 for pain, elevated temperature, increased heart rate, and decreased blood pressure, or change in level of consciousness, promptly to the physician. A review of Resident 1 ' s Total Intake and Output Record from 2/22/2024 to 3/3/2024 indicated recording every shift (7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.) of the intake of liquids and the output of urine. The form included a description of the urine for the week. The forms indicated Resident 1 ' s urine was yellow, clear, and with normal odor. There was no recording of intake and output for 3/4/2024. A review of Resident 1 ' s COC/Interactive Assessment form, dated 3/4/2024, indicated that at 7:40 p.m., Resident 1 was visited by a family member and was seen leaning forward drastically while experiencing vigorous checks. Resident 1 ' s temperature was 99.3 degrees Fahrenheit ( F, normal range is between 97 to 99 F), the blood pressure was 142/92 millimeters of mercury (mmHg, normal range is between 90/60 to 120/80 mmHg), the heart rate was 145 beats per minutes (bpm, normal range is between 60 to 100 bpm), and the blood glucose was 401 milligrams per deciliters (mg/dL, normal range is between 70 to 100 mg/dL), the oxygen saturation (O2 Sat, amount of oxygen a person has circulating in the blood) was 99% (normal level is 95% or higher). The paramedics were called and took Resident 1 to GACH 1. A review of the paramedics Patient Care Report, dated 3/4/2024, indicated an arrival time to Resident 1 ' s bedside at 8 p.m. Resident 1 ' s blood pressure reading was 120/52 mmHg, the heart rate was 130 bpm, and the blood glucose was 401 mg/dL. Resident 1 ' s indwelling catheter tube was dark brown and murky in appearance, the tube seemed to be backed up or clogged. A review of Resident 1 ' s GACH 1 Admission Record, dated 3/4/2024, indicated Resident 1 arrived with altered level of consciousness (ALOC, a change in a patient's state of awareness), fever of 104 F, and O2 Sat of 80%. Resident 1 was assessed with dry mucous membranes and dark orange urine. Resident 1 was diagnosed with sepsis and UTI and was admitted for intravenous (IV) antibiotics (medications given to treat infections). Resident 1 had a computed tomography scan (CT scan, medical imaging technique used to obtain detailed internal images of the body) which showed Resident 1 had upper lobe pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). During an interview on 3/21/2024 at 12:19 p.m., Treatment Nurse 1 (TN 1) stated that a resident with a foley catheter one must flush the catheter as ordered and as needed, monitor catheter, output, sediment, hematuria, and report to the physician, and change it when it is clogged or pulled out. TN 1 stated that if the catheter is not being monitored, one will not be able to determine if there is a change in the resident and can lead to a delay in care. TN 1 stated that the only issue Resident 1 was having with the foley catheter was hematuria. During an interview on 3/21/2024 at 1:40 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was having urinary retention requiring a foley catheter. LVN 1 stated recalling Resident 1 was sent out for hematuria, came back, and was placed on antibiotics. LVN 1 stated she worked on 3/4/2024 but did not recall any changes for Resident 1. LVN 1 stated for residents with catheters one must check urine in the catheter bag per shift, check for signs of infection, and ensure the catheter is below the bladder. LVN 1 stated for sign of infection one must look for blood, cloudiness, and any pain. During an interview on 3/22/2024 at 4 p.m., Licensed Vocational Nurse (LVN 2) stated he worked with Resident 1 on 3/4/2024 before the resident was transferred to the hospital. LVN 2 stated Resident 1 ' s urine was dark. LVN 2 stated around 7 p.m. Resident was shaking and unable to sit straight while sitting up in the wheelchair. LVN 2 stated Resident 1 ' s urine was dark due to the hematuria. LVN 2 stated the treatment nurse is the one that documents about the catheter including any changes or signs of infection. LVN 2 stated for the output it is measured by the certified nursing assistants (CNAs) at the end of the shift and LVNs will document it. During an interview on 3/22/2024 at 4:43 p.m., the Director of Nursing (DON) stated for residents with indwelling catheters all nursing staff observes the catheter. The DON stated the CNAs provide care and if they see hematuria, they will report to the charge nurse. The charge nurses will check the catheter and if there are any changes, they call the physician and inform the RN supervisor. On 3/22/2024 at 5:30 p.m., during an interview with the DON and a concurrent review of Resident 1 ' s nursing notes, care plans, and Total Intake and Output Record forms, the DON stated there was no documented evidence licensed nurses were implementing the physician ' s orders and the care plan by not continuously monitoring and accurately documenting Resident 1 ' s urine status to promptly identify abnormal findings, implement interventions, and prevent complications. A review of the current facility-provided policy and procedure (P&P) titled, Catheter Care, Urinary, last revised on 8/2022, indicated to prevent urinary catheter-associated complication, including urinary tract infections. Observe the resident ' s urine level for noticeable increase or decreases. Follow the facility procedure for measuring and documenting input and output if physician orders. Observer the resident for complications associated with urinary catheters. Report unusual findings to the physician: b. if urine has an usual appearance (i.e. color, blood, etc.) e. if signs and symptoms of urinary tract infection or urinary retention occur.

Based on observation, interview, and record review, the facility failed to prevent falls and injury for six of 11 sampled residents (Residents 8, 1, 2, 9, 11, and 10), who were confused and were identified as high risk for falls and risk for elopement (a confused person leaving the facility unnoticed by staff and does not return, it is the most dangerous type of unsupervised wandering [moving about aimlessly or without a specific purpose]). The facility failed to: 1. Ensure Residents 8, 1, 2, 9, 11, and 10, were assessed as a high fall risk, had wandering behavior (moving around without any clear purpose or direction) and history of falls, were provided with supervision, redirection, and monitoring of their whereabouts. 2. Implement its policies and procedures (P&P) on Wandering and Elopement (a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety), Managing Fall, Fall Risk, Fall Reduction, Accident/Incident Prevention, and Safety and Supervision of Residents, and Abuse, neglect, Exploitation and Misappropriation Prevention and Investigations. 3. Identify interventions related to Resident 8 ' s specific risks and contributing factors to prevent repeated falls and minimize complications from falling. 4. Ensure Residents 1, 9, and 10 were provided with monitoring and supervision to keep them free from physical abuse from Residents 2 (injured Resident 1) and from Resident 11 (injured Residents 9 and 10) and monitor Residents 2 and 11 to prevent them from physically abusing and injuring other residents. As a result: 1. Resident 8 fell 11 times in the facility and on the 11th fall on 2/9/2024, Resident 8 required immediate transfer to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with a linear laceration (cut) of the right on the outer (outside) portion of the right eyebrow, multiple small areas of subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) on the right side of the head, possible small amount of subdural hemorrhage (a pool of blood between the brain and its outermost covering) along the posterior falx (a fold the tough outer layer of the tissue covering the brain) and right frontal scalp hematoma (collection of blood outside of the blood vessels). 2. On 2/1/2024, at 5:10 pm, when Resident 1 attempted to enter Resident 2 ' s room, Resident 2 pushed Resident 1 out of his room causing Resident 1 to fall backwards on the hallway floor hitting the back of her head requiring immediate transfer to GACH 1, where Resident 1 was diagnosed with blunt head trauma (sudden impact involving the head. The impact may be a direct blow to the head or a blow to the body that causes brain movement inside the skull) and acute (conditions are severe and sudden in onset) on chronic (long developing condition) subdural hematoma (a collection of blood between the covering of the brain and the surface of the brain). 3. On 2/10/2024 at 2:30 pm, Resident 11 physically abused Resident 9 by causing a left forearm skin tear. 4. On 2/12/2024 at 7:55 am, Resident 11 physically abused Resident 10 causing a right lower eyelid discoloration. In addition, based on the Reasonable Person Concept (refers to a tool to assist the survey team ' s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Residents 8, 1, 9, and 10 ' s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering), skills and medical condition, an individual subjected to abuse and neglect may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self). On 3/18/2024 at 2:50 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy (IJ) situation (a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR 483.25 (d) Accidents in the presence of the Administrator (ADM) and Director of Nursing (DON). On 3/20/2024 at 3:49 p.m., the IJ was removed in the presence of the ADM and the DON while onsite, after verifying through observation, interview, and record review, the implementation of the facility's submitted and accepted IJ Removal Plan which included the following summarized actions: 1. On 3/18/2024, the ADM and the DON provided immediate education to facility staff on the following topics: a. All staff on the floor are responsible for monitoring and providing visual supervision to be aware of all residents' whereabouts including but not limited to hallways, dining room, activities, residents' rooms, and bathrooms to ensure a safe environment and residents are free from falls and accidents. b. All staff on the floor are responsible for providing effective redirection for wandering residents in the hallways as needed to provide a safe and accident-free environment. c. Nursing staff and designated Hallways Monitors Staff (HMS) are responsible for providing supervision and monitoring for residents in the hallways and in their rooms to ensure a safe and hazard free environment by clearly notating timelines for monitoring. Designated HMS, nurses, and departments managers are responsible in providing supervision of the hallways and rooms at their assigned hallway monitoring time frame. d. Identify interventions to create person-centered care plans as indicated by implementing facility ' s policy and procedures regarding Wandering, Safety/Supervision, Fall Risk Managing, Fall reduction, and Accident/Incident Prevention. 2. On 3/18/2024, the ADM provided a one-to-one (staff assigned to be always with a resident due to safety reasons) in-service to Registered Nurse 1 (RN 1) and Minimum Data Set Nurse (MDSN) regarding the facility ' s protocol of providing supervision and monitoring to residents in their rooms to be aware of residents ' whereabouts to ensure a safe environment and residents are not neglected. 3. On 3/18/2024, the ADM provided a one-to-one in-service to the DON regarding the protocol of proper fall risk managing and identifying interventions related to residents' specific risks and contributing factors to prevent repeated falls and minimize complications from falling; and the importance of staff awareness of the whereabouts of all residents, including ambulatory residents, and to provide a continuous safe environment. 4. On 3/18/2024, the ADM, the DON, and Director of Staff Development Interim (DSDI) provided in-service training to all staff regarding theimplementation of the IJ removal plan to prevent falls by always monitoring the hallways to increase supervision and prevent accidents and hazards. 5. On 3/18/2024, the DON reviewed and revised Resident 8's fall risk and wandering care plan by providing small group activities, placing resident closer to the nurse ' s station where she can be supervised more frequently, providing low bed and floor mat. A lap buddy (a form of restraint [devices that limit a patient's movement] that acts as a reminder for resident to ask for assistance before getting out of their wheelchair) was placed by interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) on 2/16/2024 to prevent falls. The Director of Rehab (DOR) assessed Resident 8 on 3/19/2024 with recommendations to discontinue the order of lap buddy while in wheelchair. Resident 8 will be on every 20 minutes safety checks during the day and night. During activities hours Resident 8 will be directly supervised by activity staff. 6. On 3/18/2024, the DON reviewed and revised Resident 1's care plan to address her wandering behavior, fall risk and contributing factors by providing bed alarms (devices that contain sensors that trigger an alarm or warning light when they detect a change in pressure), low bed with floor mat, and placed in a room where she is closer to the nurse ' s station. A room change was conducted for all female residents to be in Station A for safer environment and to prevent the risk of falls. 7. On 3/18/2024, the DON reviewed and revised Resident 9's care plan to address his wandering behavior, a room change was conducted for all male residents to be in Station B to provide a more suitable environment for the resident. DON updated his wandering care plan to indicate the need for supervision in the hallways by HMS to prevent accidents and incidents. 8. On 3/18/2024, the DON reviewed and revised Resident l0's care plan to address her wandering behavior with a room change in the female station side of the facility to provide a more suitable environment for the resident. DON updated her wandering care plan to indicate the need for supervision in the hallways by HMS to prevent incidents and accidents. 9. On 3/18/2024, the DON reviewed and revised Resident 11's care plan to reflect resident ' s specific risks and contributing factors by conducting a room change in the male side of the station (Station B) to provide a more suitable environment for the resident. The DON updated his wandering care plan to indicate the need for supervision in the hallways by HMS and nursing to prevent altercations. Resident 11 will be on every 20 minutes safety checks during the day and night. Resident 11 was transferred to GACH 4 for further behavior evaluation and treatment on 2/13/2024 and did not return until 3/4/2024. 10. On 3/18/2024, the ADM revised the Quality Assurance/Performance Improvement (QAPI-program to improve the overall quality of life and quality of care and services delivered to nursing home residents) for Fall and Abuse Prevention to reflect facility's current IJ removal plan. 11. On 3/19/2024, the DON, MDSN and designated licensed nurses reviewed all residents who were identified as high risk for fall or had wandering behavior and revised interventions specific to their risks and contributing factors to prevent falls and be free from accidents or hazards. 65 residents were identified at risk for wandering behavior on 3/19/24. 12. On 3/18/2024 and 3/19/2024, RN supervisor conducted random observations rounds to validate sufficient supervision, monitoring and redirection were provided for a safe and accident-free environment. No other residents were identified at risk of the deficient practices and the facility will maximize compliance moving forward with continuous education, monitoring systems, and systemic changes. 13. On 2/14/24, the IDT met and placed residents in appropriate room settings, changed to accommodate their needs and to provide a safe and hazard-free environment. Designated stations for males (Station B) and females (Station A) were implemented to enhance resident safety and awareness by clearly identifying wandering residents from going to other residents ' rooms. Staff will immediately identify resident in the correct station and prevent wanderings residents from entering other unassigned rooms, decreasing the risk for hazard, and free from accidents. 14. On 3/1/24, IDT met and reorganized the activity programs for non-ambulatory and ambulatory residents to maximize staff supervision to provide safe and accident-free environment. Ambulatory residents are now being escorted to the top dining room for activity and the basement activity dining room is being utilized for non-ambulatory residents. This shift in activity rooms will prevent wandering residents from getting in altercations in the basement dining room by giving them enough room to ambulate upstairs and prevent standing by the elevators. Non- ambulatory residents can enjoy a calmer and more soothing environment downstairs free from continuous stimulation of wanderers. 15. On 3/1/2024, Activity Department enhanced their activity program by increasing their working hours from 8:30 a.m. to 9 p.m. daily with room visits to provide a more stimulated activity program centered for memory retention and body mechanics. Activity Hallway Monitors Staff (HMS) will monitor Station A and Station B from 11:30 a.m. to 9 p.m. daily. Each station will have an HMS assigned at the designated time. HMS are to provide supervision in the hallways, redirect residents from entering other rooms other than their assigned rooms and provide visual on all the assigned room to the station they are monitoring. 16. On 3/1/24, the ADM, the DON or the designee assigned specific departments to monitor Station A and Station B from 7 a.m. to 11:30 a.m. on weekdays and the Manager of the Day (MOD) will monitor on weekends from 7 a.m. to 11:30 a.m. From 11:30 a.m. to 9 p.m. daily, a designated activity HMS will be assigned to monitor hallways, redirect residents from wandering to other rooms other than their own and to prevent falls by servicing the hallways from one end to the other. Hallway monitoring will also include monitoring of residents in their rooms with continuous awareness of their whereabouts and safety while creating an environment free from hazard and accidents. 17. On 3/18/24, the ADM and the DON created a designated supervision stations for the nursing staff to be stationed from 9 p.m.to 7 a.m. shift to cover evening supervision and monitoring. Designated charting areas in the hallway were started (in front of each station) for staff to chart by utilizing a laptop and a mobile tablet to have a visual of the hallways. 18. On 3/19/24, the ADM, the DON or designee discussed all fall incidents during daily stand-up meetings to ensure fall managing interventions were implemented specific to residents' contributing risk factors. 19. On 3/19/24, RN supervisor conducted every 30-minutes monitoring observation rounds to enhance and increase resident supervision and provide immediate education as needed to ensure a safe and abuse-free environment. 20. The ADM, the DON or designee will repeat the corrective action in-services to all facility staff monthly for three months for ongoing education and follow up. 21. The DON or designee will review all fall incidents as they occur to ensure all fall management interventions are specific to residents' contributing factor to prevent falls and to ensure their right to be free from abuse and neglect. Immediate action and re-education to be provided as needed. 22. The ADM, the DON or designee will conduct random observation rounds three times a day, five times a week to oversee compliance of IJ removal plan to ensure residents' right to be from accidents, abuse, and neglect. Immediate action and re-education to be provided as needed. 23. MDSN or designee will monitor, review and revise residents comprehensive care plans upon admission, quarterly and as needed to ensure a person-centered care plan is developed. 24. The ADM and the DON will present the recapitulations of the findings to the monthly QAPI committee for three months for review and action as needed or until compliance. Findings: 1. A review of Resident 8 ' s Admission Record indicated the facility admitted the resident on 8/14/2020 with diagnoses including unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), atherosclerosis of aorta (a material called plaque [fat and calcium] has built up in the inside wall of a large blood vessel called the aorta), and unspecified bilateral (both sides) hearing loss. A review of Resident 8 ' s Care Plan, developed on 8/15/2020, for Resident 8 ' s risk of elopement (an individual's behavior of leaving an area without permission or supervision) included in the interventions was monitoring Resident 8 at frequent intervals (specific times not included) and redirect to alternatives such as activities, watching television, calling family and offer magazine, provide one to one (staff assigned to be always with a resident due to safety reasons) supervision if indicated to redirect behavior on interim (temporary) basis. A review of Resident 8 ' s Care Plan, developed on 8/24/2020, for Resident 8 ' s risk for spontaneous (sudden) stress fractures (tiny cracks in the bone), included an intervention to assist Resident 8 with all transfers and walking as needed. A review of Resident 8 ' s Care Plan, developed on 8/24/2020 for Resident 8 about self-care deficits (condition where an individual has difficulty performing self-care activities), indicated resident needed supervision during ambulation. The Care Plan indicated an intervention to assists Resident 8 with activities of daily living as needed. A review of Resident 8 ' s Change of Condition (COC)/Interact Assessment Form (communication form between members of the health care team providing care to a resident about his/her condition), dated 10/2/2020, indicated at 7:40 p.m., found Resident 8 lying down on the floor mat beside her bed (first fall). Resident 8 had a swollen hematoma (happens when an injury causes blood to collect and pool under the skin) and a laceration (a deep cut or skin tear) measuring 1 cm long by 1 cm wide on the right forehead and skin tear measuring 3 cm x 2 cm on the right hand with scant (minimal) bleeding. The COC indicated the Medical Doctor 1 (MD 1) ordered to transfer Resident 8 via 911 (a telephone number to call for help in case of emergencies) to GACH 2 Emergency Department for a Computed Tomography (CT - an imaging test that helps healthcare providers detect diseases and injuries) scan of the head. The COC indicated paramedics (trained personnel that provide urgent medical care to people who are injured or ill) arrived at 8 p.m., spoke to Family Member 3 (FM 3) about the risk for Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease that spreads from person to person through droplets released when an infected person coughs, sneezes or talks) and FM 3 agreed not to transfer Resident 8 to GACH 2. A review of Resident 8 ' s Care Plan, developed on 10/2/2020 for Resident 8 ' s actual fall, included interventions to observe resident frequently (specific times not included) and to provide Resident 8 with proper fitting shoes. A review of Resident 8 ' s Rehabilitation (Rehab, health care professional who helps people recover from an illness or injury and return to daily life) Fall Risk Assessment, dated 10/2/2020, indicated low bed intervention and Physical Therapy (PT - healthcare professionals trained to provide therapy to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability) evaluation. A review of Resident 8 ' s PT Evaluation and Plan of Treatment, dated 10/5/2020, indicated a short-term goal for Resident 8 to safely ambulate on level surfaces of 100 feet (ft) not using assistive device and with standby assist and 20% verbal cues. The PT Evaluation and Plan of Treatment indicated Resident 8 walked 75 feet. A review of Resident 8 ' s Progress Note, dated 10/5/2024, indicated Physical Therapist 1 (PT 1) recommended the use of a front wheeled walker (walker-walking assistive device) for ambulation (walking) and safety but Resident 8 refused its use. A review of Resident 8 ' s COC/Interact Assessment Form, dated 1/13/2022, indicated at 10:30 a.m., Treatment Nurse 1 (TX 1) heard a noise in Station B hallway. The COC form indicated TX 1 found Resident 8 lying on her back with no injury (second fall). The COC indicated TX 1 notified Nurse Practitioner 1 (NP 1) of Resident 8 ' s unwitnessed fall. A review of Resident 8 ' s Fall Risk Assessment, dated 1/13/2022, indicated Resident 8 was a high fall risk. A review of Resident 8 ' s Care Plan, developed on 1/13/2022 for Resident 8 ' s actual fall, included in the interventions was to place Resident 8 near the Nursing Station for close supervision, placing the bed against the wall, using a low bed, and providing nonskid (anti-slip) proper fitting socks or shoes, as indicated. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 1/14/2022, indicated Resident 8 was on supervised ambulation and refused using a walker even when informed of the importance of using an assistive device for safe walking. The Rehab Fall Risk Assessment included interventions for Resident 8 to use non-skid socks or shoes and placing Resident 8 ' s bed against the wall. A review of Resident 8 ' s Investigation of Incident/Accident Known/Unknown Origin (Investigation Report), dated 1/13/2022, indicated the resident needed frequent reorientation and redirections. The Investigation Report indicated Resident 8 was wearing proper footwear. A review of Resident 8 ' s COC/Interact Assessment Form, dated 2/11/2022, indicated at 9:35 a.m., Resident 8 (who was from Station B) was found on the floor of Station A lying on her left side (third fall). The COC indicated Resident 8 reported she tripped and fell . A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 2/11/2022, indicated Resident 8 was on supervised ambulation. The interventions included using a floor mat (a cushioned mat at bedside to minimize injuries if the resident fell from bed), low bed, non-skid socks/shoes, bed against the wall, and for rehab to evaluate and treat. A review of Resident 8 ' s PT Evaluation and Plan of Treatment, dated 2/11/2022, indicated a short-term goal for Resident 8 to safely ambulate on level surfaces of 100 ft with standby assist. The PT Evaluation and Plan of Treatment indicated Resident 8 walked 60 feet. A review of Resident 8 ' s Care Plan, developed on 2/11/2022 for Resident 8 ' s fall risk, included interventions to observe restlessness and redirect as needed. A review of Resident 8 ' s Investigation Report, dated 2/11/2022, indicated Resident 8 needed frequent reorientation and redirections. The Investigation Report indicated Resident 8 was wearing proper footwear. A review of Resident 8 ' s COC/Interact Assessment Form, dated 7/31/2022, indicated at 5:20 p.m. resident had an unwitnessed fall (fourth fall). Resident 8 was lying on the floor by her room doorway, had pain on the left thigh and unable to tolerate any movement from left lower extremity. The COC indicated the MD ordered a stat (immediate) bilateral hip x-rays (imaging creates pictures of inside of the body). A review of Resident 8 ' s Radiology Report, dated 7/31/2022, indicated Resident 8 had no fractures. A review of Resident 8 ' s Care Plan, developed on 7/31/2022 for Resident 8 ' s actual fall, included interventions using the low bed with floor mat and proper fitting socks or shoes. A review of Resident 8 ' s Investigation Report, dated 7/31/2022, indicated Resident 8 needed frequent reorientation and redirection. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 8/2/2022, indicated Resident 8 needed extensive assistance with walking, low bed with floor mat, and for PT to evaluate and treat. A review of Resident 8 ' s PT Evaluation and Plan of Treatment, dated 8/2/2022, indicated as a short-term goal for Resident 8 to safely ambulate 50 ft with stand by assist with increased cadence without using assistive devices. The PT Evaluation and Plan of Treatment indicated the resident walked zero ft (could not walk). A review of Resident 8 ' s COC/Interact Assessment Form, dated 8/10/2022, indicated that at 5 p.m., Resident 8 was found on the floor in the hallway next to Station B, lying on her left side (fifth fall). The COC indicated Resident 8 reported that she was holding on the food cart when it moved forward causing her to fall. A review of Resident 8 ' s Care Plan, developed on 8/10/2022 for Resident 8 ' s actual fall, included in the interventions using a low bed, proper fitting socks or shoes and non-skid Dycem (non-slip material used to help stabilize objects, hold objects firmly in place, or to provide a better grip; usually placed in bed or wheelchair) in Resident 8 ' s bed. A review of Resident 8 ' s Investigation Report, dated 8/10/2022, indicated Resident 8 needed frequent reorientation and redirections. The Investigation Report indicated staff (not identified) were serving dinner and witnessed Resident 8 pushing a food cart and losing her balance. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 8/12/2022, indicated Resident 8 was on supervised walking and rehab recommended non-skid Dycem in bed. A review of Resident 8 ' s COC/Interact Assessment Form, dated 8/15/2022, indicated that at 4:40 p.m., Certified Nursing Assistant 13 (CNA 13) witnessed resident slipped in her room doorway onto her buttocks (sixth floor). The COC indicated CNA 13 caught Resident 8 and prevented her head from hitting the floor. The COC indicated Resident 8 complained of mild pain, level 2/10 pain (pain rating scale from zero indicating no pain and 10 indicating the worst possible pain). MD ordered to apply Resident 8 a cold compress. A review of Resident 8 ' s Care Plan, developed on 8/15/2022 for Resident 8 ' s actual fall, included interventions to use a low bed and proper fitting socks or shoes, and bed against the wall. A review of Resident 8 ' s Investigation Report, dated 8/15/2022, indicated Resident 8 needed frequent reorientation and redirections. The Investigation Report indicated the staff were serving dinner, and CNA 13 witnessed Resident 8 slipped in the doorway and CNA 13 caught Resident 8 preventing Resident 8 ' s head from hitting the floor. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 8/17/2022, indicated Resident 8 needed limited assistance from staff. PT recommended the use of a bed pad alarm (device placed under resident on the bed and when the resident gets up from the pad, a wireless signal is sent to the monitor, setting off the bed pad alarm to alert the caregiver) and for PT to evaluate and treat. A review of Resident 8 ' s PT Evaluation and Plan of Treatment, dated 8/17/2022, indicated as a short-term goal for Resident 8 to safely ambulate 50 ft with stand by assist. The PT Evaluation and Plan of Treatment indicated Resident 8 walked 15 feet. A review of Resident 8 ' s COC/Interact Assessment Form, dated 5/21/2023, indicated that at 5:10 p.m., Resident 8 fell on the hallway while trying to walk between two food trolleys and fell on her buttocks (seventh fall). A review of Resident 8 ' s Care Plan, developed on 5/21/2023 for Resident 8 ' s actual fall, included interventions to provide Resident 8 with night light and proper fitting socks or shoes. A review of Resident 8 ' s Fall Report, dated 5/21/2023, indicated Resident 8 lost her balance when another resident pulled her sweater. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 5/24/2023, indicated resident on supervised ambulation with rehab recommendation to redirect patient to activities. A review of Resident 8 ' s COC/Interact Assessment Form, dated 7/10/2023, indicated that at 10:05 a.m., Resident 8 was found in the dining room lying on her back (eighth fall). Resident 8 was holding her nose. The COC indicated Resident 8 ' s nose was red and had a 7/10 pain level (moderate). The COC indicated the MD ordered to transfer Resident 8 to GACH 2 for assessment. A review of Resident 8 ' s Care Plan, developed on 7/10/202, Resident 8 ' s actual fall, included interventions to provide Resident 8 with night light, frequent visual monitoring, and PT to evaluate and treat. A review of Resident 8 ' s GACH 2 ED Provider Notes, dated 7/10/2023, indicated the resident suffered an unwitnessed fall forward causing a bruising on her nasal bridge with some bleeding. The ED Note indicated Resident 8 ' s nose had ecchymosis (bruise, when blood pools under the skin) to nasal bridge and mild swelling. The ED Note indicated a head CT scan showed a nasal bone fracture (broken nose). A review of Resident 8 ' s Fall Report, dated 7/10/2023, indicated Resident 8 tripped on one of the resident ' s wheelchair anti-tips (are wheelchair accessories designed to enhance stability and prevent tipping over backwards) portion, lost her balance and sustained a fall. Resident 8 was sent out to GACH 2 for further evaluation and returned the same day at the facility with diagnosis of nose fracture. A review of Resident 8 ' s (Re)Admission Assessment, dated 7/10/2023, indicated Resident 8 was admitted with broken nose and discoloration. A review of Resident 8 ' s Care Plan, developed on 7/11/2023, Resident 8 ' s nasal bone fracture included interventions to assists with transfers and ambulation and PT to evaluate and treat. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 7/11/2023, indicated Resident 8 needed extensive assistance for ambulation. A review of Resident 8 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/17/2023, indicated Resident 8 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 8 required supervision or touch assistance from staff when walking. A review of Resident 8 ' s Elopement Risk Evaluation, dated 11/18/2023, indicated resident was at risk for elopement and wandering. The Elopement Risk Evaluation indicated Resident 8 wandered throughout the hallways and required redirection and assistance with activities of daily living (ADLs, such as walking, transfers, mobility, personal hygiene, toilet use, and bathing). A review of Resident 8 ' s COC/Interact Assessment Form, dated 12/12/2023, indicated that at 6 p.m., a scream was heard from the hallway and Resident 8 was found lying on the ground near Room E of Station A (ninth fall). The COC indicated CNA 14 was assisting another resident in the hallway, witnessed Resident 8 losing her balance while walking and fell . The COC indicated Resident 8 had a small lump (bumps or swellings under the skin) to the back of the head and skin tear to left elbow with continuous pain. The COC indicated the MD ordered to transfer Resident 8 to GACH 3 via 911 for further treatment and evaluation. A review of Resident 8 ' s Care Plan, developed on 12/12/2023 for Resident 8 ' s actual fall, included an intervention to provide Resident 8 a low bed, if indicated. A review of Resident 8 ' s GACH 3 Patient Visit Information, dated 12/12/2023, indicated resident was evaluated in the ED for a fall with a left elbow contusion (deep bruise due to a blunt injury to tissues under the skin) and head injury. The Patient Visit Information indicated the CT scan did not show signs of bleeding or fracture. A review of Resident 8 ' s (Re)Admission Assessment, dated 12/13/2023, indicated Resident 8 was readmitted with left elbow contusion and left elbow skin tear. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 12/13/2023, indicated Resident 8 needed supervised walking and PT recommended proper shoes. A review of Resident 8 ' s COC/Interact Assessment Form, dated 1/25/2024, indicated that at 8 p.m., Resident 8 was walking in the hallway and fell (tenth fall). Resident 8 had no injuries. A review of Resident 8 ' s Licensed Nurses Note, dated 1/25/2024, indicated Resident 8 had an unwitnessed fall. A review of Resident 8 ' s Care Plan, developed on 1/25/2024 for Resident 8 ' s actual fall, included interventions to provide night light and for rehab to evaluate and treat. A review of Resident 8 ' s Fall Risk Assessment, dated 1/25/2024, indicated Resident 8 was a high risk for fall. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 1/26/2024, indicated Resident 8 needed supervised walking. PT recommended proper or supportive shoes and PT evaluation and treatment was not indicated at the time. A review of Resident 8 ' s COC/Interact Assessment Form, dated 2/9/2024 indicated at 8:23 p.m., Licensed Vocational Nurse 3 (LVN 3) heard a call light at Room Z at Nursing Station B. The COC indicated LVN 3 found Resident 8, who lived in Room D at Station A, lying on the floor of Room Z (11th fall). Resident 8 had bright red blood under her head. The COC indicated LVN

Based on observation, interview, and record review, the facility failed to protect the residents ' rights to be free from neglect (a form of abuse where the perpetrator, who is responsible for caring for persons unable to care for themselves, fails to do so) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) inflicted by another resident for six of 11 sampled residents (Residents 8, 1, 2, 9, 11, and 10). The facility failed to: 1. Ensure Residents 8, 1, 2, 9, 11, and 10, who were confused, were assessed as a high fall risk, had wandering behavior (moving around without any clear purpose or direction) and history of falls, were provided with supervision, redirection, and monitoring of their whereabouts. 2. Implement its policies and procedures (P&P) on Wandering and Elopement (a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety), Managing Fall, Fall Risk, Fall Reduction, Accident/Incident Prevention, and Safety and Supervision of Residents, and Abuse, neglect, Exploitation and Misappropriation Prevention and Investigations. 3. Identify interventions related to Resident 8 ' s specific risks and contributing factors to prevent repeated falls and minimize complications from falling. 4. Ensure Residents 1, 9, and 10 were provided with monitoring and supervision to keep them free from physical abuse from Residents 2 (injured Resident 1) and from Resident 11 (injured Residents 9 and 10) and monitor Residents 2 and 11 to prevent them from physically abusing other residents. As a result: 1. Resident 8 fell 11 times in the facility and on the 11th fall on 2/9/2024, Resident 8 required immediate transfer to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with a linear laceration (cut) of the right on the outer (outside) portion of the right eyebrow, multiple small areas of subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) on the right side of the head, possible small amount of subdural hemorrhage (a pool of blood between the brain and its outermost covering) along the posterior falx (a fold the tough outer layer of the tissue covering the brain) and right frontal scalp hematoma (collection of blood outside of the blood vessels). 2. On 2/1/2024, at 5:10 pm, when Resident 1 attempted to enter Resident 2 ' s room, Resident 2 pushed Resident 1 out of his room causing Resident 1 to fall backwards on the hallway floor hitting the back of her head requiring immediate transfer to GACH 1, where Resident 1 was diagnosed with blunt head trauma (sudden impact involving the head. The impact may be a direct blow to the head or a blow to the body that causes brain movement inside the skull) and acute (conditions are severe and sudden in onset) on chronic (long developing condition) subdural hematoma (a collection of blood between the covering of the brain and the surface of the brain). 3. On 2/10/2024 at 2:30 pm, Resident 11 physically abused Resident 9 by causing a left forearm skin tear. 4. On 2/12/2024 at 7:55 am, Resident 11 physically abused Resident 10 causing a right lower eyelid discoloration Based on the Reasonable Person Concept (refers to a tool to assist the survey team ' s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Residents 8, 1, 9, and 10 ' s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering), skills and medical condition, an individual subjected to abuse and neglect may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self). On 3/18/2024 at 2:50 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy (IJ) situation (a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation, in the presence of the Administrator (ADM) and Director of Nursing (DON). On 3/20/2024 at 3:49 p.m., the IJ was removed in the presence of the ADM and the DON while onsite, after verifying through observation, interview, and record review, the implementation of the facility's submitted and accepted IJ Removal Plan which included the following summarized actions: 1. On 3/18/2024, the ADM and the DON provided immediate education to facility staff on the following topics: a. All staff on the floor are responsible for monitoring and providing visual supervision to be aware of all residents' whereabouts including but not limited to hallways, dining room, activities, residents' rooms, and bathrooms to ensure a safe environment and residents are free from falls and accidents. b. All staff on the floor are responsible for providing effective redirection for wandering residents in the hallways as needed to provide a safe and accident-free environment. c. Nursing staff and designated Hallways Monitors Staff (HMS) are responsible for providing supervision and monitoring for residents in the hallways and in their rooms to ensure a safe and hazard free environment by clearly notating timelines for monitoring. Designated HMS, nurses and departments managers are responsible in providing supervision of the hallways and rooms at their assigned hallway monitoring time frame. d. Identify interventions to create person-centered care plans as indicated by implementing facility ' s policy and procedures regarding Wandering, Safety/Supervision, Fall Risk Managing, Fall reduction, and Accident/Incident Prevention. 2. On 3/18/2024, the ADM provided a one-to-one (staff assigned to be always with a resident due to safety reasons) in-service to Registered Nurse 1 (RN 1) and Minimum Data Set Nurse (MDSN) regarding the facility ' s protocol of providing supervision and monitoring to residents in their rooms to be aware of residents ' whereabouts to ensure a safe environment and residents are not neglected. 3. On 3/18/2024, the ADM provided a one-to-one in-service to the DON regarding the protocol of proper fall risk managing and identifying interventions related to residents' specific risks & contributing factors to prevent repeated falls and minimize complications from falling; and the importance of staff awareness of the whereabouts of all residents, including ambulatory residents, to provide a continuous safe environment. 4. On 3/18/2024, the ADM, the DON, and Director of Staff Development Interim (DSDI) provided in-service training to all staff regarding the implementation of the IJ removal plan to prevent falls by always monitoring the hallway to increase supervision and prevent accidents and hazards. 5. On 3/18/2024, the DON reviewed and revised Resident 8's fall risk and wandering care plan by providing small group activities, placing resident closer to the nurse ' s station where she can be supervised more frequently, providing low bed and floor mat. A lap buddy (a form of restraint [devices that limit a patient's movement] that acts as a reminder for resident to ask for assistance before getting out of their wheelchair) was placed by interdisciplinary team (IDT - a coordinated group of healthcare professionals from different fields who work together for the residents) on 2/16/2024 to prevent falls. The Director of Rehabilitation (DOR) assessed Resident 8 on 3/19/2024 with recommendations to discontinue the order of lap buddy while in wheelchair. Resident 8 will be on every 20 minutes safety checks during the day and night. During activities hours Resident 8 will be directly supervised by activity staff. 6. On 3/18/2024, the DON reviewed and revised Resident 1's care plan to address her wandering behavior, fall risk, and contributing factors by providing bed alarms (devices that contain sensors that trigger an alarm or warning light when they detect a change in pressure), low bed with floor mat and placed in a room where she is closer to the nurse ' s station. A room change was conducted for all female residents to be in Station A for a safer environment and to prevent the risk of falls. 7. On 3/18/2024, the DON reviewed and revised Resident 9's care plan to address his wandering behavior, a room change was conducted for all male residents to be in Station B to provide a more suitable environment for the resident. The DON updated Resident 9 ' s wandering care plan to indicate the need for supervision in the hallways by HMS to prevent accidents and incidents. 8. On 3/18/2024, the DON reviewed and revised Resident l0's care plan to address her wandering behavior with a room change in the female station side of the facility to provide a more suitable environment for the resident. The DON updated Resident 10 ' s wandering care-plan to indicate the need for supervision in the hallways by HMS to prevent incidents and accidents. 9. On 3/18/2024, the DON reviewed and revised Resident 11's care plan to reflect residents' specific risks and contributing factors by conducting a room change in the male side of the station (Station B) to provide a more suitable environment for the resident. The DON updated Resident 11 ' s wandering care-plan to indicate the need for supervision in the hallways by HMS and nursing to prevent altercations. Resident 11 will be on every 20 minutes safety checks during the day and night. Resident 11 was transferred to GACH 4 for further behavior evaluation and treatment on 2/13/2024 and did not return until 3/4/2024. 10. On 3/18/2024, the ADM revised the Quality Assurance/Performance Improvement (QAPI-program to improve the overall quality of life and quality of care and services delivered to nursing home residents) for Fall and Abuse Prevention to reflect facility's current IJ removal plan. 11. On 3/19/2024, the DON, MDSN, and designated licensed nurses reviewed all residents who were identified as high risk for fall or had wandering behavior and revised interventions specific to their risks and contributing factors to prevent falls and be free from accidents or hazards. 65 residents were identified as at risk for wandering behavior on 3/19/24. 12. On 3/18/2024 and 3/19/2024, RN supervisor conducted random observations rounds to validate sufficient supervision, monitoring and redirection were provided for a safe and accident-free environment. No other residents were identified at risk of the deficient practices and the facility will maximize compliance moving forward with continuous education, monitoring systems, and systemic changes. 13. On 2/14/24, the IDT met and placed residents in appropriate room settings, changed to accommodate their needs and to provide a safe and hazard free environment. Designated stations for males (Station B) and females (Station A) were implemented to enhance resident safety and awareness by clearly identifying wandering residents from going to other residents ' rooms. Staff will immediately identify resident in the correct station and prevent wanderings residents from entering other unassigned rooms, decreasing the risk for hazard and free from accidents. 14. On 3/1/24, IDT met and reorganized the activity programs for non-ambulatory and ambulatory residents to maximize staff supervision to provide safe and accident-free environment. Ambulatory residents are now being escorted to the top dining room for activity and the basement activity dining room is being utilized for non-ambulatory residents. This shift in activity rooms will prevent wandering residents from getting in altercations in the basement dining room by giving them enough room to ambulate upstairs and prevent standing by the elevators. Non- ambulatory residents can enjoy a calmer and more soothing environment downstairs free from continuous stimulation of wanderers. 15. On 3/1/2024, Activity Department enhanced their activity program by increasing their working hours from 8:30 a.m. to 9 p.m. daily with room visits to provide a more stimulated activity program centered for memory retention and body mechanics. Activity Hallway Monitors Staff (HMS) will monitor Station A and Station B from 11:30 a.m. to 9 p.m. daily. Each station will have an HMS assigned at the designated time. HMS are to provide supervision in the hallways, redirect residents from entering other rooms other than their assigned rooms and provide visual on all the assigned room to the station they are monitoring. 16. On 3/01/24, the ADM, the DON or the designee assigned specific departments to monitor Station A and Station B from 7 a.m. to 11:30 a.m. on weekdays and the Manager of the Day (MOD) will monitor on weekends from 7 a.m. to 11:30 a.m. From 11:30 a.m. to 9 p.m. daily, a designated activity HMS will be assigned to monitor hallways, redirect residents from wandering to other rooms other than their own and to prevent falls by servicing the hallways from one end to the other. Hallway monitoring will also include monitoring of residents in their rooms with continuous awareness of their whereabouts and safety while creating an environment free from hazard and accidents. 17. On 3/18/24, the ADM and the DON created a designated supervision stations for the nursing staff to be stationed from 9 p.m.to 7 a.m. shift to cover evening supervision and monitoring. Designated charting areas in the hallway were started (in front of each station) for staff to chart by utilizing a laptop and a mobile tablet to have a visual of the hallways. 18. On 3/19/24, the ADM, the DON or designee discussed all fall incidents during daily stand-up meetings to ensure fall managing interventions were implemented specific to residents' contributing risk factors. 19. On 3/19/24, RN supervisor conducted every 30-minute monitoring observation rounds to enhance and increase resident supervision and provide immediate education as needed to ensure a safe and abuse-free environment. 20. The ADM, the DON or designee will repeat the corrective action in-services to all facility staff monthly for three months for ongoing education and follow up. 21. The DON or designee will review all fall incidents as they occur to ensure all fall management interventions are specific to residents' contributing factor to prevent falls and to ensure their right to be free from abuse and neglect. Immediate action and re-education to be provided as needed. 22. The ADM, the DON or designee will conduct random observation rounds three times a day, five times a week to oversee compliance of IJ removal plan to ensure residents' right to be from accidents, abuse, and neglect. Immediate action and re-education to be provided as needed. 23. MDSN or designee will monitor, review, and revise residents comprehensive care plans upon admission, quarterly and as needed to ensure a person-centered care plan is developed. 24. The ADM and the DON will present the recapitulations of the findings to the monthly QAPI committee for three months for review and action as needed or until compliance. Findings: 1. A review of Resident 8 ' s Admission Record indicated the facility admitted the resident on 8/14/2020 with diagnoses including unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), atherosclerosis of aorta (a material called plaque [fat and calcium] has built up in the inside wall of a large blood vessel called the aorta), and unspecified bilateral (both sides) hearing loss. A review of Resident 8 ' s Care Plan, developed on 8/15/2020, for Resident 8 ' s risk of elopement (an individual's behavior of leaving an area without permission or supervision) included in the interventions was monitoring Resident 8 at frequent intervals (specific times not included) and redirect to alternatives such as activities, watching television, calling family and offer magazine, provide one to one (staff assigned to be always with a resident due to safety reasons) supervision if indicated to redirect behavior on interim (temporary) basis. A review of Resident 8 ' s Care Plan, developed on 8/24/2020, for Resident 8 ' s risk for spontaneous (sudden) stress fractures (tiny cracks in the bone), included intervention was to assisting Resident 8 with all transfers and walking as needed. A review of Resident 8 ' s Care Plan, developed on 8/24/2020 for Resident 8 about self-care deficits (condition where an individual has difficulty performing self-care activities), indicated resident needed supervision during ambulation. The Care Plan indicated an intervention to assists Resident 8 with activities of daily living as needed. A review of Resident 8 ' s Change of Condition (COC)/Interact Assessment Form (communication form between members of the health care team providing care to a resident about his/her condition), dated 10/2/2020, indicated at 7:40 p.m., found Resident 8 lying down on the floor mat beside her bed (first fall). Resident 8 had a swollen hematoma (happens when an injury causes blood to collect and pool under the skin) and a laceration (a deep cut or skin tear) measuring 1 cm long by 1 cm wide on the right forehead and skin tear measuring 3 cm x 2 cm on the right hand with scant (minimal) bleeding. The COC indicated the Medical Doctor 1 (MD 1) ordered to transfer Resident 8 via 911 (a telephone number to call for help in case of emergencies) to GACH 2 Emergency Department for a Computed Tomography (CT - an imaging test that helps healthcare providers detect diseases and injuries) scan of the head. The COC indicated paramedics (trained personnel that provide urgent medical care to people who are injured or ill) arrived at 8 p.m., spoke to Family Member 3 (FM 3) about the risk for Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease that spreads from person to person through droplets released when an infected person coughs, sneezes or talks) and FM 3 agreed not to transfer Resident 8 to GACH 2. A review of Resident 8 ' s Care Plan, developed on 10/2/2020 for Resident 8 ' s actual fall, included interventions were to observe resident frequently (specific times not included) and to provide Resident 8 with proper fitting shoes. A review of Resident 8 ' s Rehabilitation (Rehab, health care professional who helps people recover from an illness or injury and return to daily life) Fall Risk Assessment, dated 10/2/2020, indicated low bed intervention and Physical Therapy (PT - healthcare professionals trained to provide therapy to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability) evaluation. A review of Resident 8 ' s PT Evaluation and Plan of Treatment, dated 10/5/2020, indicated a short-term goal for Resident 8 to safely ambulate on level surfaces of 100 feet (ft) not using assistive device and with standby assist and 20% verbal cues. The PT Evaluation and Plan of Treatment indicated Resident 8 walked 75 feet. A review of Resident 8 ' s Progress Note, dated 10/5/2024, indicated Physical Therapist 1 (PT 1) recommended the use of a front wheeled walker (walker-walking assistive device) for ambulation (walking) and safety but Resident 8 refused its use. A review of Resident 8 ' s COC/Interact Assessment Form, dated 1/13/2022, indicated at 10:30 a.m., Treatment Nurse 1 (TX 1) heard a noise in Station B hallway. The COC form indicated TX 1 found Resident 8 lying on her back with no injury (second fall). The COC indicated TX 1 notified Nurse Practitioner 1 (NP 1) of Resident 8 ' s unwitnessed fall. A review of Resident 8 ' s Fall Risk Assessment, dated 1/13/2022, indicated Resident 8 was a high fall risk. A review of Resident 8 ' s Care Plan, developed on 1/13/2022 for Resident 8 ' s actual fall, included in the interventions was to place Resident 8 near the Nursing Station for close supervision, placing the bed against the wall, using a low bed, and providing nonskid (anti-slip) proper fitting socks or shoes, as indicated. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 1/14/2022, indicated Resident 8 was on supervised ambulation and refused using a walker even when informed of the importance of using an assistive device for safe walking. The Rehab Fall Risk Assessment included interventions for Resident 8 to use non-skid socks or shoes and placing Resident 8 ' s bed against the wall. A review of Resident 8 ' s Investigation of Incident/Accident Known/Unknown Origin (Investigation Report), dated 1/13/2022, indicated the resident needed frequent reorientation and redirections. The Investigation Report indicated Resident 8 was wearing proper footwear. A review of Resident 8 ' s COC/Interact Assessment Form, dated 2/11/2022, indicated at 9:35 a.m., Resident 8 (who was from Station B) was found on the floor of Station A lying on her left side (third fall). The COC indicated Resident 8 reported she tripped and fell . A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 2/11/2022, indicated Resident 8 was on supervised ambulation. The interventions included using a floor mat (a cushioned mat at bedside to minimize injuries if the resident fell from bed), low bed, non-skid socks/shoes, bed against the wall, and for rehab to evaluate and treat. A review of Resident 8 ' s PT Evaluation and Plan of Treatment, dated 2/11/2022, indicated a short-term goal for Resident 8 to safely ambulate on level surfaces of 100 ft with standby assist. The PT Evaluation and Plan of Treatment indicated Resident 8 walked 60 feet. A review of Resident 8 ' s Care Plan, developed on 2/11/2022 for Resident 8 ' s fall risk, included interventions to observe restlessness and redirect as needed. A review of Resident 8 ' s Investigation Report, dated 2/11/2022, indicated Resident 8 needed frequent reorientation and redirections. The Investigation Report indicated Resident 8 was wearing proper footwear. A review of Resident 8 ' s COC/Interact Assessment Form, dated 7/31/2022, indicated at 5:20 p.m. resident had an unwitnessed fall (fourth fall). Resident 8 was lying on the floor by her room doorway, had pain on the left thigh and unable to tolerate any movement from left lower extremity. The COC indicated the MD ordered a stat (immediate) bilateral hip x-rays (imaging creates pictures of inside of the body). A review of Resident 8 ' s Radiology Report, dated 7/31/2022, indicated Resident 8 had no fractures. A review of Resident 8 ' s Care Plan, developed on 7/31/2022 for Resident 8 ' s actual fall, included interventions using the low bed with floor mat and proper fitting socks or shoes. A review of Resident 8 ' s Investigation Report, dated 7/31/2022, indicated Resident 8 needed frequent reorientation and redirection. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 8/2/2022, indicated Resident 8 needed extensive assistance with walking, low bed with floor mat, and for PT to evaluate and treat. A review of Resident 8 ' s PT Evaluation and Plan of Treatment, dated 8/2/2022, indicated as a short-term goal for Resident 8 to safely ambulate 50 ft with stand by assist with increased cadence without using assistive devices. The PT Evaluation and Plan of Treatment indicated the resident walked zero ft (could not walk). A review of Resident 8 ' s COC/Interact Assessment Form, dated 8/10/2022, indicated that at 5 p.m., Resident 8 was found on the floor in the hallway next to Station B, lying on her left side (fifth fall). The COC indicated Resident 8 reported that she was holding on the food cart when it moved forward causing her to fall. A review of Resident 8 ' s Care Plan, developed on 8/10/2022 for Resident 8 ' s actual fall, included in the interventions using a low bed, proper fitting socks or shoes and non-skid Dycem (non-slip material used to help stabilize objects, hold objects firmly in place, or to provide a better grip; usually placed in bed or wheelchair) in Resident 8 ' s bed. A review of Resident 8 ' s Investigation Report, dated 8/10/2022, indicated Resident 8 needed frequent reorientation and redirections. The Investigation Report indicated staff (not identified) were serving dinner and witnessed Resident 8 pushing a food cart and losing her balance. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 8/12/2022, indicated Resident 8 was on supervised walking and rehab recommended non-skid Dycem in bed. A review of Resident 8 ' s COC/Interact Assessment Form, dated 8/15/2022, indicated that at 4:40 p.m., Certified Nursing Assistant 13 (CNA 13) witnessed resident slipped in her room doorway onto her buttocks (sixth floor). The COC indicated CNA 13 caught Resident 8 and prevented her head from hitting the floor. The COC indicated Resident 8 complained of mild pain, level 2/10 pain (pain rating scale from zero indicating no pain and 10 indicating the worst possible pain). MD ordered to apply Resident 8 a cold compress. A review of Resident 8 ' s Care Plan, developed on 8/15/2022 for Resident 8 ' s actual fall, included interventions to use a low bed and proper fitting socks or shoes, and bed against the wall. A review of Resident 8 ' s Investigation Report, dated 8/15/2022, indicated Resident 8 needed frequent reorientation and redirections. The Investigation Report indicated the staff were serving dinner, and CNA 13 witnessed Resident 8 slipped in the doorway and CNA 13 caught Resident 8 preventing Resident 8 ' s head from hitting the floor. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 8/17/2022, indicated Resident 8 needed limited assistance from staff. PT recommended the use of a bed pad alarm (device placed under resident on the bed and when the resident gets up from the pad, a wireless signal is sent to the monitor, setting off the bed pad alarm to alert the caregiver) and for PT to evaluate and treat. A review of Resident 8 ' s PT Evaluation and Plan of Treatment, dated 8/17/2022, indicated as a short-term goal for Resident 8 to safely ambulate 50 ft with stand by assist. The PT Evaluation and Plan of Treatment indicated Resident 8 walked 15 feet. A review of Resident 8 ' s COC/Interact Assessment Form, dated 5/21/2023, indicated that at 5:10 p.m., Resident 8 fell on the hallway while trying to walk between two food trolleys and fell on her buttocks (seventh fall). A review of Resident 8 ' s Care Plan, developed on 5/21/2023 for Resident 8 ' s actual fall, included interventions to provide Resident 8 with night light and proper fitting socks or shoes. A review of Resident 8 ' s Fall Report, dated 5/21/2023, indicated Resident 8 lost her balance when another resident pulled her sweater. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 5/24/2023, indicated resident on supervised ambulation with rehab recommendation to redirect patient to activities. A review of Resident 8 ' s COC/Interact Assessment Form, dated 7/10/2023, indicated that at 10:05 a.m., Resident 8 was found in the dining room lying on her back (eighth fall). Resident 8 was holding her nose. The COC indicated Resident 8 ' s nose was red and had a 7/10 pain level (moderate). The COC indicated the MD ordered to transfer Resident 8 to GACH 2 for assessment. A review of Resident 8 ' s Care Plan, developed on 7/10/202, Resident 8 ' s actual fall, included interventions to provide Resident 8 with night light, frequent visual monitoring, and PT to evaluate and treat. A review of Resident 8 ' s GACH 2 ED Provider Notes, dated 7/10/2023, indicated the resident suffered an unwitnessed fall forward causing a bruising on her nasal bridge with some bleeding. The ED Note indicated Resident 8 ' s nose had ecchymosis (bruise, when blood pools under the skin) to nasal bridge and mild swelling. The ED Note indicated a head CT scan showed a nasal bone fracture (broken nose). A review of Resident 8 ' s Fall Report, dated 7/10/2023, indicated Resident 8 tripped on one of the resident ' s wheelchair anti-tips (are wheelchair accessories designed to enhance stability and prevent tipping over backwards) portion, lost her balance and sustained a fall. Resident 8 was sent out to GACH 2 for further evaluation and returned the same day at the facility with diagnosis of nose fracture. A review of Resident 8 ' s (Re)Admission Assessment, dated 7/10/2023, indicated Resident 8 was admitted with broken nose and discoloration. A review of Resident 8 ' s Care Plan, developed on 7/11/2023, Resident 8 ' s nasal bone fracture included interventions to assists with transfers and ambulation and PT to evaluate and treat. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 7/11/2023, indicated Resident 8 needed extensive assistance for ambulation. A review of Resident 8 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/17/2023, indicated Resident 8 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 8 required supervision or touch assistance from staff when walking. A review of Resident 8 ' s Elopement Risk Evaluation, dated 11/18/2023, indicated resident was at risk for elopement and wandering. The Elopement Risk Evaluation indicated Resident 8 wandered throughout the hallways and required redirection and assistance with activities of daily living (ADLs, such as walking, transfers, mobility, personal hygiene, toilet use, and bathing). A review of Resident 8 ' s COC/Interact Assessment Form, dated 12/12/2023, indicated that at 6 p.m., a scream was heard from the hallway and Resident 8 was found lying on the ground near Room E of Station A (ninth fall). The COC indicated CNA 14 was assisting another resident in the hallway, witnessed Resident 8 losing her balance while walking and fell . The COC indicated Resident 8 had a small lump (bumps or swellings under the skin) to the back of the head and skin tear to left elbow with continuous pain. The COC indicated the MD ordered to transfer Resident 8 to GACH 3 via 911 for further treatment and evaluation. A review of Resident 8 ' s Care Plan, developed on 12/12/2023 for Resident 8 ' s actual fall, included an intervention to provide Resident 8 a low bed, if indicated. A review of Resident 8 ' s GACH 3 Patient Visit Information, dated 12/12/2023, indicated resident was evaluated in the ED for a fall with a left elbow contusion (deep bruise due to a blunt injury to tissues under the skin) and head injury. The Patient Visit Information indicated the CT scan did not show signs of bleeding or fracture. A review of Resident 8 ' s (Re)Admission Assessment, dated 12/13/2023, indicated Resident 8 was readmitted with left elbow contusion and left elbow skin tear. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 12/13/2023, indicated Resident 8 needed supervised walking and PT recommended proper shoes. A review of Resident 8 ' s COC/Interact Assessment Form, dated 1/25/2024, indicated that at 8 p.m., Resident 8 was walking in the hallway and fell (tenth fall). Resident 8 had no injuries. A review of Resident 8 ' s Licensed Nurses Note, dated 1/25/2024, indicated Resident 8 had an unwitnessed fall. A review of Resident 8 ' s Care Plan, developed on 1/25/2024 for Resident 8 ' s actual fall, included interventions to provide night light and for rehab to evaluate and treat. A review of Resident 8 ' s Fall Risk Assessment, dated 1/25/2024, indicated Resident 8 was a high risk for fall. A review of Resident 8 ' s Rehab Fall Risk Assessment, dated 1/26/2024, indicated Resident 8 needed supervised walking. PT recommended proper or supportive shoes and PT evaluation and treatment was not indicated at the time. A review of Resident 8 ' s COC/Interact A[TRUNCATED]

Based on interview and record review, the facility failed to prevent a fall and injury for two of five sampled residents (Resident 1 and Resident 4), who was identified as a high fall riskwith poor safety awareness. The facility failed to: 1a. Ensure Resident 1 was assisted safely to the dining table while the resident held on a wheelchair. Certified Nursing Assistant 3 (CNA 3) swung her arm backwards releasing Resident 1 ' s grip on her. 1b. Ensure Resident 1 was not left unattended after CNA 3 witnessed the resident fall in the dining room. As a result, Resident 1 lost the balance and fell on the floor. These deficient practices had the potential for Resident 1 to sustain a fracture which could lead to death. 2a. Provide Resident 4 with contact guard assistance (CGA, the contact is made to help steady the body and help with balance) on transfers and stand by assist (SBA - the assisting person does not touch the resident or provide any assistance but should be close by for safety in case the resident lose balance) while walking, as assessed by the physical therapist (PT, a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities). As a result, on 11/27/2023, Resident 4 fell on the floor and sustained a left shoulder fracture (broken bone) and a left forehead laceration (a cut to the skin). Findings: 1. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 8/18/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety disorder (persistent and excessive worry that interferes with daily activities), and osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time causing pain and stiffness of the joints). A review of Resident 1 ' s Care Plan for Fall Risk, initiated on 8/19/2023, indicated the resident was at risk for falls related to cognitive impairment, decreased strength and endurance, and spontaneous movements. The care plan intervention indicated frequent visual monitoring and to respect Resident 1 ' s wishes for independence and dignity. A review of Resident 1 ' s Care Plan on anxiety, initiated on 8/19/2023, indicated the resident had periods of anxiety as manifested by inability to cope with daily living activities causing anger. The care plan interventions included to keep Resident 1 away from stressful situations. A review of Resident 1 ' s Care Plan on episodes of bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs or mania [a condition with periods of abnormally elevated changes in the mood or emotions, energy level, or activity] to lows or depression [persistent sadness and lack of interest or pleasure in previously rewarding or enjoyable activities]), initiated on 8/19/2023, indicated the resident had inability to process internal stimuli causing anger outburst or stress affecting daily living activities. The care plan interventions included to approach Resident 1 calmly, unhurriedly, and speak in a calm voice. The care plan intervention also indicated to encourage Resident 1 to perform independent activities of daily living (ADL) and listen to the resident attentively. A review of Resident 1 ' s History and Physical, dated 8/20/2023, indicated the resident was on fall precautions and does not have the capacity to make decisions. A review of Resident 1 ' s Rehab Fall Risk Assessment, dated 8/21/2023, indicated the resident used a four wheeled walker and required supervision on ambulation. The assessment indicated that Resident 1 did not have sufficient strength and correct posture in standing. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/25/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. Resident 1 required limited assistance on transfer, locomotion on and off unit (how resident moves between locations in the resident ' s room, adjacent corridor, and off-unit locations on same floor), dressing, and toilet use. The balance during transition and walking section of the MDS indicated that Resident 1 was not steady on walking and turning around. A review of Resident 1 ' s Internal Medicine Progress Notes, dated 9/29/2023 and 10/6/2023, indicated the resident had unstable gait. The progress notes indicated that Resident 1 required fall precautions. A review of Resident 1 ' s Fall Risk Assessment, dated 11/18/2023, indicated the resident had a total score of 14 which indicated the resident had a low fall risk. The assessment indicated Resident 1 had intermittent confusion or poor safety awareness, wandering without purpose, and impulsiveness. A review of Resident 1 ' s Change of Condition (COC) / Interact Assessment Form, dated 11/20/2023, indicated the resident had an unwitnessed fall. The COC form indicated that Resident 1 was found sitting on the floor in the dining room. Registered Nurse 2 (RN 2) documented that Resident 1 did not sustain injuries and the resident was able to stand up and sat on the chair. The physician (MD 1) and Resident 1 ' s responsible party were notified. On 12/7/2023 at 11:26 a.m., during an observation of the surveillance video and concurrent interview with the Administrator (ADM), on 11/20/2023 at 5:18 p.m., Resident 1 walked in the dining room using her four-wheeled walker. Resident 1 went to the second table and there was no chair on Resident 1 ' s side of the table. On 11/20/2023 at 5:21:02 p.m., Resident 1 walked without the four-wheeled walker to the middle of the dining room and pushed an empty wheelchair towards the resident ' s side of the table. On 11/20/2023 at 5:21:06 p.m., Certified Nursing Assistant 3 (CNA 3) was on Resident ' s right side removing the resident ' s grip on the wheelchair handle. On 11/20/2023 at 5:21:25 p.m., CNA 3 removed Resident 1 ' s right hand from the wheelchair and the resident grabbed CNA 3 ' s right hand. CNA 3 swung her arm to release Resident 1 ' s grip on her hand and the resident fell on the floor. On 11/20/2023 at 5:21:31 p.m., CNA 3 looked down at Resident 1 on the floor and proceeded to walk away with the wheelchair. On 11/20/2023 at 5:21:43 p.m., CNA 4 saw Resident 1 on the floor and went to CNA 3 pointing to Resident 1. CNA 3 went closer to Resident 1, stood beside the resident, and looked down on the resident who was still on the floor. CNA 3 turned around and walked away from Resident 1. CNA 4 called the Director of Staff Development (DSD) for assistance. On 12/11/2023 at 12:53 p.m., during a telephone interview, CNA 3 stated that she was not assigned to Resident 1 and did not know Resident 1 ' s condition. CNA 3 stated that Resident 1 took the wheelchair from the middle of the dining room and refused to give the wheelchair back to her. CNA 3 stated that Resident 1 struggled with her, and the resident did not allow her to take the wheelchair. CNA 3 stated that she carefully removed Resident 1 ' s hand from the wheelchair but the resident attempted to bite and hit her. CNA 3 stated that after she was able to carefully remove Resident 1 ' s hand from the wheelchair, the resident lost balance and fell on the floor hitting her let side first. CNA 3 stated that she left Resident 1 on the floor because she thought CNA 4 would help the resident. CNA 3 later stated that she did not see Resident 1 fall and it was CNA 4 who informed her that the resident was on the floor. CNA 3 was not able to state what could have been done differently and what could potentially happen to Resident 1. On 12/11/2023 at 1:34 p.m., during a telephone interview, Registered Nurse 2 (RN 2) stated that she saw Resident 1 sitting on the floor and leaning on a chair in the dining room. RN 2 stated that Resident 1 did not have any visible injuries. RN 2 stated that Resident 1 stood up and walked using the resident ' s own walker. RN 2 stated that CNA 3 informed her that Resident 1 had an unwitnessed fall. RN 2 stated that CNA 3 later informed her that Resident 1 struggled with her trying to take the wheelchair which potentially have caused Resident 1 ' s fall. RN 2 stated that CNA 3 should have been gentle and careful with Resident 1 to prevent the fall. RN 2 stated that Resident 1 had the potential for fall with injury. On 12/11/2023 at 1:56 p.m., CNA 4 was called but did not answer. CNA 4 did not return the call. On 12/12/2023 at 10:30 a.m., during an interview, the DSD stated that Resident 1 was confused most of the time and takes things that seem to be abandoned. The DSD stated that CNA 3 should not argue with Resident 1 and should redirect the resident to prevent the fall. The DSD stated that CNA 3 left Resident 1 on the floor after the fall. The DSD stated that Resident 1 had the potential for fracture which could lead to death. The DSD stated that Resident 1 had the potential to be affected emotionally, mentally, and lose trust on the facility staff. On 12/12/2023 at 11:44 a.m., during an interview, the Director of Nursing (DON) stated that CNA 3 argued and struggled in taking the wheelchair from Resident 1which led to the resident ' s fall. The DON stated that CNA 3 failed to follow the facility procedures on care of fall risk residents. The DON stated that Resident 1 had the potential to be affected emotionally and mentally. A review of the facility ' s policy and procedure titled, Safety and Supervision of Residents, dated July 2023, indicated that the facility strive to make the environment as free from accident hazards as possible. The policy indicated that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The policy indicated the individualized resident-centered approach to safety included implementing interventions to reduce accident risks and hazards. A review of the facility ' s policy and procedure titled, Resident Rights - Exercise of Rights, dated July 2023, indicated that the facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes safety and maintenance or enhancement of his or her quality of life, recognizing each resident individuality. 2. A review of Resident 4 ' s Admission Record indicated the facility admitted the resident on 8/2/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time causing pain and stiffness of the joints), and peripheral vertigo (dizziness or a spinning sensation). A review of Resident 4 ' s Care Plan on falls, initiated on 8/3/2023, indicated the resident was at risk for falls related to difficulty walking, generalized weakness, and impaired cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 4 ' s care plan interventions included to respect the resident ' s wishes for independence and dignity. The care plan also indicated to visibly observe Resident 4 frequently and provide the resident with a safe and clutter-free environment. A review of Resident 4 ' s Care Plan on risk for unavoidable declines, initiated on 8/3/2023, indicated interventions to assist the resident with activities of daily living (ADL). The care plan intervention indicated to provide Resident 4 with a safe environment. A review of Resident 4 ' s History and Physical, dated 8/8/2023, indicated the resident does not have the capacity to make decisions. A review of Resident 4 ' s Physical Therapy (PT) Discharge Summary, dated 9/7/2023, indicated the resident had a treatment diagnosis of unspecified abnormalities of gait (a manner of walking or moving on foot) and mobility. The discharge summary indicated Resident 4 required CGA on transfers and SBA on walking. A review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/9/2023, indicated the resident ' s cognition was severely impaired. Resident 4 required partial or moderate assistance (helper lifts, holds, or supports the trunk or limbs but provides less than half the effort) on sit to stand and chair or bed to chair transfer. Resident 4 required substantial or maximal assistance (helper lifts, holds, or supports the trunk or limbs but provides more than half the effort) on walking. A review of Resident 4 ' s Fall Risk Assessment, dated 11/11/2023, indicated the resident ' s score was 20. A total score of 18 or more was high risk for falls. The gait and balance section indicated that Resident 4 was unable to stand without assistance, unsteady gait, and poor sitting or standing balance. A review of Resident 4 ' s Change of Condition (COC) Interact Assessment Form, dated 11/27/2023, indicated the resident had an unwitnessed fall with laceration on the left forehead and complaints of left shoulder pain. The COC indicated that Resident 4 was found on the floor in the hallway in front of the resident ' s wheelchair. The COC indicated that Resident 4 had a tense and grimacing look with a visible deformity (disfigurement or distortion that made a part of the body a different size or shape than it would normally be) on the left chest. Resident 4 was given pain medication. Physician 1 (MD 1) was notified and gave an order to transfer Resident 4 to the hospital for further evaluation. A review of Resident 1 ' s General Acute care Hospital (GACH) Patient Visit Information, dated 11/27/2023, indicated the resident was seen for head injury, laceration care, and shoulder dislocation (an injury in which the upper arm bone pops out of the cup-shaped socket that was part of the shoulder blade). On 12/7/2023 at 2:07 p.m., during an observation of the surveillance video and concurrent interview with the Administrator (ADM), on 11/27/2023 at 8:07 p.m., The ADM stated that Resident 4 was self-wheeling in the hallway. On 11/27/2023 at 8:28 p.m., facility staff were inside nurse station 1. There were no facility staff in the hallway. On 11/27/2023 at 8:30 p.m., Certified Nursing Assistant 2 (CNA 2) was observed coming out of another resident ' s room. CNA 2 found Resident 4 on the floor outside the resident ' s room. On 12/11/2023 at 3:10 p.m., during an interview, CNA 2 stated that Resident 4 could not walk without assistance. CNA 2 stated that other CNAs were in other resident ' s rooms and there were no facility staff in the hallway. On 12/11/2023 at 3:27 p.m., during a concurrent interview and record review, Resident 4 ' s PT discharge summary were reviewed with the Rehabilitation Director (RD). The RD stated that Resident 4 was for SBA on walking and CGA on transfers. The RD defined SBA as no physical assistance needed while walking. The RD defined CGA as guarding a resident in proximity. On 12/11/2023 at 4:27 p.m., during an interview, the Director of Nursing (DON) stated that Resident 4 had an unwitnessed fall in front of the Resident 4 ' s room and sustained a left shoulder fracture and a left eyebrow laceration. The DON stated there were no facility staff in the hallway at the time of Resident 4 ' s fall. The DON stated that the CNA 2 was providing care to the other resident in the adjacent room. On 12/12/2023 at 10:45 a.m., during an interview, The Director of Staff Development (DSD) stated that the facility staff should be in the hallway watching the residents. The DSD stated that there was lack of supervision of residents and could potentially place the residents at risk for falls and injury. A review of the facility ' s policy and procedure titled, Safety and Supervision of Residents, dated July 2023, indicated that the facility strive to make the environment as free from accident hazards as possible. The policy indicated that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The policy indicated the individualized resident-centered approach to safety included implementing interventions to reduce accident risks and hazards. A review of the facility ' s policy and procedure titled, Resident Rights - Exercise of Rights, dated July 2023, indicated that the facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes safety and maintenance or enhancement of his or her quality of life, recognizing each resident individuality.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) and neglect for two of five sampled residents (Resident 1 and Resident 3). The facility failed to: 1a. Ensure Certified Nursing Assistant 3 (CNA 3) did not leave Resident 1 on the floor after CNA 3 witnessed the resident fall. 1b. Ensure CNA 3 provided supervision and appropriate care to Resident 1 to prevent the resident ' s fall. This deficient practice resulted in Resident 1 being neglected by CNA 3 while under the care of the facility and was placed at a high risk of increased feelings of anxiety (feeling of worry, nervousness, or uneasiness) because of the resident ' s diagnoses of anxiety disorder (persistent and excessive worry that interferes with daily activities). 2. Ensure that Resident 2 and Resident 3 were supervised in the hallway. Resident 2 pulled and scratched Resident 3 ' s face causing pain and bleeding of Resident 3 ' s face which needed treatment and pain medication. This deficient practice resulted in Resident 3 being subjected to physical abuse by Resident 2 while under the care of the facility and caused Resident 3 to report pain and feelings of anxiety (feeling of worry, nervousness, or uneasiness) because of the altercation with Resident 2. Resident 3 was placed at high risk of increased feelings of anxiety and possible suicide because of the resident ' s diagnoses of anxiety disorder (persistent and excessive worry that interferes with daily activities) and history of suicidal ideation (a range of contemplations, wishes, and preoccupations with death and suicide). Findings: 1. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 8/18/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety disorder, and osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time causing pain and stiffness of the joints). A review of Resident 1 ' s Interdisciplinary Team (IDT) Behavior Management / Psychotropic Regimen (medications that affects behavior, mood, thoughts, or perception) Review Update, dated 8/19/2023, indicated the resident was taking Seroquel (a psychotropic medication used to treat episodes of mania [a condition with periods of abnormally elevated changes in the mood or emotions, energy level, or activity] and depression [persistent sadness and lack of interest or pleasure in previously rewarding or enjoyable activities]) 50 milligrams (mg - unit of measurement) for inability to process internal stimuli causing anger outburst or stress affecting daily living activities. Resident 1 was also taking Zoloft (a psychotropic medication used to manage depression) 25 mg for inability to cope with daily living activities causing sadness and verbalizing not feeling safe. The nonpharmacological (treatments without the use of medications) interventions indicated providing Resident 1 with a quiet and calm environment, verbal cues, prompting, redirection, diversion, and reassurance. A review of Resident 1 ' s Care Plan on unavoidable decline, initiated on 8/19/2023, indicated the resident was at risk for unavoidable decline related to dementia and general weakness. The care plan intervention indicated to encourage Resident 1 to do as much as possible to increase independence, provide a safe environment, and allow the resident to be active in decision-making process involving care. A review of Resident 1 ' s Care Plan for Fall Risk, initiated on 8/19/2023, indicated the resident was at risk for falls related to cognitive impairment, decreased strength and endurance, and spontaneous movements. The care plan intervention indicated frequent visual monitoring and to respect Resident 1 ' s wishes for independence and dignity. A review of Resident 1 ' s Care Plan on anxiety, initiated on 8/19/2023, indicated the resident had periods of anxiety as manifested by inability to cope with daily living activities causing anger. The care plan interventions included to keep Resident 1 away from stressful situations. A review of Resident 1 ' s Care Plan on episodes of bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs or mania to lows or depression), initiated on 8/19/2023, indicated the resident had inability to process internal stimuli causing anger outburst or stress affecting daily living activities. The care plan interventions included to approach Resident 1 calmly, unhurriedly, and speak in a calm voice. The care plan intervention also indicated to encourage Resident 1 to perform independent activities of daily living (ADL) and listen to the resident attentively. A review of Resident 1 ' s History and Physical, dated 8/20/2023, indicated the resident was on fall precautions and does not have the capacity to make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/25/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. Resident 1 required limited assistance on transfer, locomotion on and off unit (how resident moves between locations in the resident ' s room, adjacent corridor, and off-unit locations on same floor), dressing, and toilet use. The balance during transition and walking section of the MDS indicated that Resident 1 was not steady on walking and turning around. A review of Resident 1 ' s Change of Condition (COC) / Interact Assessment Form, dated 11/20/2023, indicated the resident had an unwitnessed fall. The COC form indicated that Resident 1 was found sitting on the floor in the dining room. Registered Nurse 2 (RN 2) documented that Resident 1 did not sustain injuries and the resident was able to stand up and sat on the chair. The physician (MD 1) and Resident 1 ' s responsible party were notified. On 12/7/2023 at 11:26 a.m., during an observation of the surveillance video and concurrent interview with the Administrator (ADM), on 11/20/2023 at 5:18 p.m., Resident 1 walked in the dining room using her four-wheeled walker. Resident 1 went to the second table and there was no chair on Resident 1 ' s side of the table. On 11/20/2023 at 5:21:02 p.m., Resident 1 walked without the four-wheeled walker to the middle of the dining room and pushed an empty wheelchair towards the resident ' s side of the table. On 11/20/2023 at 5:21:06 p.m., CNA 3 was on Resident ' s right side removing the resident ' s grip on the wheelchair handle. On 11/20/2023 at 5:21:25 p.m., CNA 3 removed Resident 1 ' s right hand from the wheelchair and the resident grabbed CNA 3 ' s right hand. CNA 3 swung her arm to release Resident 1 ' s grip on her hand and the resident fell on the floor. On 11/20/2023 at 5:21:31 p.m., CNA 3 looked down at Resident 1 on the floor and proceeded to walk away with the wheelchair. On 11/20/2023 at 5:21:43 p.m., CNA 4 saw Resident 1 on the floor and went to CNA 3 pointing to Resident 1. CNA 3 went closer to Resident 1, stood beside the resident, and looked down on the resident who was still on the floor. CNA 3 turned around and walked away from Resident 1. CNA 4 called the Director of Staff Development (DSD) for assistance. On 12/11/2023 at 12:53 p.m., during a telephone interview, CNA 3 stated that she was not assigned to Resident 1 and did not know Resident 1 ' s condition. CNA 3 stated that Resident 1 took the wheelchair from the middle of the dining room and refused to give the wheelchair back to her. CNA 3 stated that Resident 1 struggled with her, and the resident did not allow her to take the wheelchair. CNA 3 stated that she carefully removed Resident 1 ' s hand from the wheelchair but the resident attempted to bite and hit her. CNA 3 stated that after she was able to carefully remove Resident 1 ' s hand from the wheelchair, the resident lost balance and fell on the floor hitting her let side first. CNA 3 stated that she left Resident 1 on the floor because she thought CNA 4 would help the resident. CNA 3 later stated that she did not see Resident 1 fall and it was CNA 4 who informed her that the resident was on the floor. CNA 3 was not able to state what could have been done differently and what could potentially happen to Resident 1. On 12/11/2023 at 1:34 p.m., during a telephone interview, Registered Nurse 2 (RN 2) stated that she saw Resident 1 sitting on the floor and leaning on a chair in the dining room. RN 2 stated that Resident 1 did not have any visible injuries. RN 2 stated that Resident 1 stood up and walked using the resident ' s own walker. RN 2 stated that CNA 3 informed her that Resident 1 had an unwitnessed fall. RN 2 stated that CNA 3 later informed her that Resident 1 struggled with her trying to take the wheelchair which potentially have caused Resident 1 ' s fall. RN 2 stated that CNA 3 should have been gentle and careful with Resident 1 to prevent the fall. RN 2 stated that Resident 1 had the potential for fall with injury. On 12/11/2023 at 1:56 p.m., CNA 4 was called but did not answer. CNA 4 did not return the call. On 12/12/2023 at 10:30 a.m., during an interview, the DSD stated that Resident 1 was confused most of the time and takes things that seem to be abandoned. The DSD stated that CNA 3 should not argue with Resident 1 and should redirect the resident to prevent the fall. The DSD stated that CNA 3 left Resident 1 on the floor after the fall and neglected the resident. The DSD stated that Resident 1 had the potential for fracture which could lead to death. The DSD stated that Resident 1 had the potential to be affected emotionally, mentally, and lose trust on the facility staff. On 12/12/2023 at 11:44 a.m., during an interview, the Director of Nursing (DON) stated that CNA 3 argued and struggled in taking the wheelchair from Resident 1which led to the resident ' s fall. The DON stated that CNA 3 left the Resident 1 on the floor and neglected to call for help. CNA 3 turned away from Resident 1 and proceeded to attend to the other residents in the dining room. The DON stated that CNA 3 failed to follow the facility procedures on care of fall risk residents. The DON stated that Resident 1 had the potential to be affected emotionally and mentally. A review of the facility ' s policy and procedure titled, Abuse and Mistreatment of Residents, dated July 2023, indicated the purpose to uphold the resident ' s right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The facility defined abuse as the willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm, pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. A review of the facility ' s policy and procedure titled, Safety and Supervision of Residents, dated July 2023, indicated that the facility strive to make the environment as free from accident hazards as possible. The policy indicated that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The policy indicated the individualized resident-centered approach to safety included implementing interventions to reduce accident risks and hazards. A review of the facility ' s policy and procedure titled, Resident Rights - Exercise of Rights, dated July 2023, indicated that the facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes safety and maintenance or enhancement of his or her quality of life, recognizing each resident individuality. 2. A review of Resident 2 ' s Admission Record indicated the facility admitted the resident on 8/2/2023 with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar is too high), psychosis (occurs when people lose contact with reality), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 2 ' s History and Physical, dated 8/7/2023, indicated the resident had unspecified psychosis and schizophrenia. The history and physical indicated that Resident 4 does not have the capacity to make decisions. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/10/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. The behavior section of the MDS indicated that Resident 2 had delusions (misconceptions or beliefs that were firmly held, contrary to reality). A review of Resident 2 ' s Care Plans on schizophrenia, initiated on 8/3/2023, indicated that the resident had episodes of inability to process internal stimuli causing anger or stress affecting daily living activities. The care plan interventions indicated to approach Resident 2 calmly, unhurriedly, and speak in a calm voice. The care plan intervention also indicated to observe and document occurrence of increased agitation and restlessness. A review of Resident 2 ' s Care Plans on activity participation, initiated on 8/7/2023, indicated that the resident had behavioral symptoms manifested by inability to process internal stimuli causing anger or stress affecting daily living activities. The care plan indicated that activity participation was challenged because of impaired cognition as manifested by Resident 2 ' s psychosis. The care plan intervention included facility staff to conduct rounds to monitor Resident 1 ' s activity needs and offer appropriate interventions. A review of Resident 2 ' s Care Plans did not address the resident ' s wandering behavior as stated by the Director of Nursing (DON). A review Resident 2 ' s Change of Condition (COC) / Interact Assessment Form, dated 11/24/2023, indicated that Resident 2 had a physical altercation with Resident 3 at the hallway in station 2. The COC indicated that Certified Nursing Assistant 1 (CNA 1) saw Resident 2 punched Resident 3 with a closed fist and Resident 2 motioned that the resident scratched Resident 3. A review of Resident 2 ' s Interdisciplinary Team (IDT) Behavior Management / Psychotropic Regimen (medications that affects behavior, mood, thoughts, or perception) Review Update, dated 8/3/2023, indicated the resident was taking Risperdal (a psychotropic medication used to treat schizophrenia) 1 milligram (mg - unit of measurement) for inability to process internal stimuli causing anger outburst or stress affecting daily living activities. The nonpharmacological (treatments without the use of medications) interventions indicated providing Resident 2 with redirection or diversion, remove the stimuli, and reassurance. A review of Resident 3 ' s Admission Record indicated the facility admitted the resident on 5/30/2023 with diagnoses including schizophrenia, suicidal ideations, and anxiety disorder. A review of Resident 3 ' s History and Physical, dated 5/31/2023, indicated the resident was on fall precautions and does not have the capacity to make decisions. A review of Resident 3 ' s Care Plan on falls or injury related to dementia, general weakness, and impaired cognition, revised on 10/01/2023, indicated interventions such as to visibly observe the resident frequently. The care plan interventions indicated to provide Resident 3 with a safe environment. A review of Resident 3 ' s MDS, dated [DATE], indicated the resident ' s cognition was moderately impaired. The MDS indicated that Resident 3 required limited assistance (facility staff provide guided maneuvering of limbs or other non-weight bearing assistance) on walking in room and corridor. The balance during transition and walking section of the MDS indicated that Resident 3 was not steady and was only able to stabilize with staff assistance on walking and turning around. A review of Resident 3 ' s Care Plan on self-care deficits, revised on 10/1/2023, indicated that the resident ' s self-care deficits were related to dementia and poor safety awareness. The care plan intervention included providing safe environment. A review of Resident 2 ' s Care Plans did not address the resident ' s wandering behavior as stated by the Director of Nursing (DON). A review of Resident 3 ' s Physician Order, dated 11/24/2023, indicated that the resident had skin scratches on the face. The physician order indicated to cleanse Resident 3 ' s face with normal saline (a mixture of table salt and water), pat dry, apply vitamin A and D ointment, leave open to air daily for 14 days. A review Resident 3 ' s Change of Condition (COC) / Interact Assessment Form, dated 11/24/2023, indicated that Resident 3 had a physical altercation with Resident 2 at the hallway in station 2. The COC indicated that Certified Nursing Assistant 1 (CNA 1) saw Resident 2 punched Resident 3 with a closed fist and Resident 2 motioned that the resident scratched Resident 3. A review of Resident 3 ' s Licensed Nursing Note, dated 11/24/2023, indicated that the resident refused to go to the hospital for further evaluation. Resident 3 ' s responsible party was notified. A review of Resident 3 ' s Medication Administration Record (MAR), dated 11/2023, indicated that at 12 p.m., Resident 3 received Tylenol (medication that relieves pain) 325 milligram (mg - unit of measurement) as needed for pain. On 12/7/2023 at 12:40 p.m., during an observation of the surveillance video and concurrent interview with the Administrator (ADM), on 11/24/2023 at 11:44 a.m., Resident 2 was walking in the hallway and Resident came out of another resident ' s room. Resident 2 reached over and pulled Resident 3 ' s arm. Resident 2 proceeded to walk away and went towards the opposite side of the hallway. Resident 3 approached Resident 2 and the two residents were pulling and swing each other around. The surveillance video showed that there were several residents walking in the hallway and there were no facility staff present. On 11/24/2023 at 11:45 a.m., CNA 1 walked out from another resident ' s room, into the hallway and separated Resident 2 and Resident 3. RN 1 went to the hallway where Resident 2 and Resident 3 were and assessed both residents. On 12/11/2023 at 11:42 a.m., during an interview, CNA 1 stated that she was in another resident ' s room when she heard a banging sound in the hallway. CNA 1 stated that she went out of the room and saw Resident 2 and Resident 3 pushing each other. CNA 1 stated that Resident 3 had blood on the face. CNA 1 stated that she yelled for help, but no one heard her. CNA 1 stated that there were no facility staff in the hallway during Resident 2 and Resident 3 ' s altercation. CNA 1 stated that she stayed with Resident 2 while she used her personal phone to call RN 1. CNA 1 stated that the licensed nurses attended to Resident 3 ' s wound on the face. On 12/11/2023 at 2:45 p.m., during an interview, RN 1 stated that she received a call from CNA 1 asking for help. RN 1 stated that she went to the hallway in station 2 and saw Resident 3 with red discoloration and bleeding on the face. RN 1 stated that CNA 1 stayed with Resident 2 because the resident had a behavior of touching other people but not in an aggressive way. RN 1 stated that there were no facility staff besides CNA 1 in the hallway when she arrived. RN 1 stated that there should be additional supervision in the hallways to prevent resident altercations from happening and to keep the residents safe. On 12/11/2023 at 4:10 p.m., during an interview, the DON stated that Resident 2 and Resident 3 did not have any history of aggressive behaviors. The DON stated that Resident 2 and Resident 3 had a behavior of constant walking and wanders in the hallways. The DON stated that because of the kind of residents the facility has, it would be hard to and impossible to prevent resident altercations from happening. A review of the facility ' s policy and procedure titled, Abuse and Mistreatment of Residents, dated July 2023, indicated the purpose to uphold the resident ' s right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The facility defined abuse as the willful infliction of injury, unreasonable confinement, or punishment with resulting physical harm, pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. A review of the facility ' s policy and procedure titled, Safety and Supervision of Residents, dated July 2023, indicated that the facility strive to make the environment as free from accident hazards as possible. The policy indicated that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The policy indicated the individualized resident-centered approach to safety included implementing interventions to reduce accident risks and hazards. A review of the facility ' s policy and procedure titled, Resident Rights - Exercise of Rights, dated July 2023, indicated that the facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes safety and maintenance or enhancement of his or her quality of life, recognizing each resident individuality.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) when on 11/8/2023, at 6:45 p.m., Resident 2 hit Resident 1 on the face. Resident 1 was lying in bed and Resident 2, while standing at Resident 1 ' s bedside punched Resident 1 several times on the face and body, causing pain and redness to the right eye area which needed ice pack application and pain medication. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility and caused Resident 1 to report pain and feelings of anxiety (feeling of worry, nervousness, or uneasiness) because of the altercation with Resident 2. Resident 1 was placed at high risk of increased feelings of depression (constant feeling of sadness and loss of interest, which stops a person from doing normal activities), with symptoms of sadness, irritability, frustration, because of his diagnoses of depression and anxiety. Findings: A review of Resident 1 ' s Admission Record indicated the facility initially admitted Resident 1 on 6/24/2021 with a readmitted on 1/26/2022. Resident 1 ' s diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), dementia (is the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/21/2023, indicated the resident ' s cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 1 required supervision or touching assistance for showering, dressing, transferring, walking, and rolling left to right in bed. A review of Resident 1's Change in Condition Evaluation (COC), dated 11/8/2023, timed at 6:45 p.m., indicated Resident 1 was seen getting hit in the face by Resident 2. The COC indicated Certified Nursing Assistant 1 (CNA 1) heard Resident 1 screaming at another resident (Resident 2) from Resident 1's room. Upon arrival CNA 1 found Resident 1 in his bed and Resident 2 was punching Resident 2. CNA 1 immediately separated the two residents, and more staff arrived on site at this time for further assistance and redirection. Licensed Vocational Nurse 1 (LVN 1) immediately checked Resident 1 noted the resident tense (manifestation of stress or anxiety), with redness at right eye, no other visible injuries noted. A review of Resident 1 ' s Medication Administration Record (MAR - medications administered to the residents), indicated Tylenol (pain medication) 1,000 milligrams (mg - a unit of measurement) was given on 11/8/2023 at 6:51 p.m. A review of Resident 1's Social Services Note, dated 11/9/2023, at 1:07 p.m., indicated Resident 1 talked with the Social Services Designee (SSD). The Social Services note indicated Resident 1 stated that the other resident (Resident 2) had come into his room and started punching him. The note indicated Resident 1 stated he felt nervous during the time of the incident, but now he was doing fine and felt better. A review of Resident 2 ' s Admission Record indicated the facility admitted Resident 2 on 10/4/2023 with diagnoses of Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), major depressive disorder, psychosis, and dementia. A review of Resident 2's MDS, dated [DATE], indicated the resident had severely impaired cognition, and required moderate assistance with showering, dressing, transferring, walking, and personal hygiene. A review of Resident 2's Change in Condition Evaluation, dated on 11/8/2023 and timed at 11:03 p.m. indicated Resident 2 was standing over another resident (Resident 1) punching him. Resident 2 was confused and aggressive. The COC indicated Resident 2 did not remember the physical assault. On 11/9/2023 at 12:15 p.m. during an interview, Resident 1 stated yesterday (11/8/2023) Resident 2 went into his room and sat on his bed. Resident 1 stated that he told Resident 2 to go back to his room and not to come back and Resident 2 started hitting him on the face and did not give him a chance to stand or defend himself. When asked how the incident made him feel, Resident 1 did not want to elaborate. On 11/9/2023 at 1:05 p.m. during an interview, CNA 1 stated on 11/8/2023 at around 6:45 p.m. she heard yelling coming from Resident 1 ' s room and she immediately went to the room. CNA 1 stated that she saw Resident 1 lying in his bed with his legs cramped up defending himself against Resident 2 who was punching him in his face and body. CNA 1 stated that Resident 1 was trying to block Resident 2. She stated that she immediately separated the residents and took Resident 2 outside the room. CNA 1 stated LVN 1 came into the room and assessed Resident 1. CNA 1 stated that she later saw Resident 1 ' s right eye and it was red. CNA 1 stated that Resident 1 had complained of pain to his right eye and LVN 1 gave him medication and an ice pack. CNA 1 stated that no resident should ever get hit by another resident in facility. On 11/9/2023 at 1:18 p.m., during an interview, Social Services Designee (SSD) stated he talked to Resident 1 in the morning. Resident 1 told him (SSD) that Resident 2 went inside his room and sat beside him on the bed. The SSD stated that Resident 1 told Resident 2 to leave, Resident 2 became mad and started punching him. The SSD stated that Resident 1 had some redness around his right eye this morning. The SSD stated that Resident 1 told him he felt nervous at that time, but he said that he feels fine now. On 11/9/2023 at 3:46 p.m. during an interview, the Director of Nursing (DON) stated that this was the first time that physical abuse happened between Resident 1 and Resident 2, and it should not have occurred according to the Abuse policy and regulations. A review of the facility ' s policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, undated, indicated the facility ' s policy, The facility shall establish a system to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property that lead to abuse when left unchecked. Residents shall not be subjected to abuse by anyone, including but not limited to, facility staff; other resident; consultants or volunteers, staff of other agencies serving the individual; family members or legal guardians, friends, or other individuals. The facility ' s policy indicated, the purpose is to uphold a resident's right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntarily seclusion. Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) when on 11/8/2023, at 6:45 p.m., Resident 2 hit Resident 1 on the face. Resident 1 was lying in bed and Resident 2, while standing at Resident 1's bedside punched Resident 1 several times on the face and body, causing pain and redness to the right eye area which needed ice pack application and pain medication. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility and caused Resident 1 to report pain and feelings of anxiety (feeling of worry, nervousness, or uneasiness) because of the altercation with Resident 2. Resident 1 was placed at high risk of increased feelings of depression (constant feeling of sadness and loss of interest, which stops a person from doing normal activities), with symptoms of sadness, irritability, frustration, because of his diagnoses of depression and anxiety. Findings: A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1 on 6/24/2021 with a readmitted on 1/26/2022. Resident 1's diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), dementia (is the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/21/2023, indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 1 required supervision or touching assistance for showering, dressing, transferring, walking, and rolling left to right in bed. A review of Resident 1's Change in Condition Evaluation (COC), dated 11/8/2023, timed at 6:45 p.m., indicated Resident 1 was seen getting hit in the face by Resident 2. The COC indicated Certified Nursing Assistant 1 (CNA 1) heard Resident 1 screaming at another resident (Resident 2) from Resident 1's room. Upon arrival CNA 1 found Resident 1 in his bed and Resident 2 was punching Resident 2. CNA 1 immediately separated the two residents, and more staff arrived on site at this time for further assistance and redirection. Licensed Vocational Nurse 1 (LVN 1) immediately checked Resident 1 noted the resident tense (manifestation of stress or anxiety), with redness at right eye, no other visible injuries noted. A review of Resident 1's Medication Administration Record (MAR - medications administered to the residents), indicated Tylenol (pain medication) 1,000 milligrams (mg - a unit of measurement) was given on 11/8/2023 at 6:51 p.m. A review of Resident 1's Social Services Note, dated 11/9/2023, at 1:07 p.m., indicated Resident 1 talked with the Social Services Designee (SSD). The Social Services note indicated Resident 1 stated that the other resident (Resident 2) had come into his room and started punching him. The note indicated Resident 1 stated he felt nervous during the time of the incident, but now he was doing fine and felt better. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 10/4/2023 with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), major depressive disorder, psychosis, and dementia. A review of Resident 2's MDS, dated [DATE], indicated the resident had severely impaired cognition, and required moderate assistance with showering, dressing, transferring, walking, and personal hygiene. A review of Resident 2's Change in Condition Evaluation, dated on 11/8/2023 and timed at 11:03 p.m. indicated Resident 2 was standing over another resident (Resident 1) punching him. Resident 2 was confused and aggressive. The COC indicated Resident 2 did not remember the physical assault. On 11/9/2023 at 12:15 p.m. during an interview, Resident 1 stated yesterday (11/8/2023) Resident 2 went into his room and sat on his bed. Resident 1 stated that he told Resident 2 to go back to his room and not to come back and Resident 2 started hitting him on the face and did not give him a chance to stand or defend himself. When asked how the incident made him feel, Resident 1 did not want to elaborate. On 11/9/2023 at 1:05 p.m. during an interview, CNA 1 stated on 11/8/2023 at around 6:45 p.m. she heard yelling coming from Resident 1's room and she immediately went to the room. CNA 1 stated that she saw Resident 1 lying in his bed with his legs cramped up defending himself against Resident 2 who was punching him in his face and body. CNA 1 stated that Resident 1 was trying to block Resident 2. She stated that she immediately separated the residents and took Resident 2 outside the room. CNA 1 stated LVN 1 came into the room and assessed Resident 1. CNA 1 stated that she later saw Resident 1's right eye and it was red. CNA 1 stated that Resident 1 had complained of pain to his right eye and LVN 1 gave him medication and an ice pack. CNA 1 stated that no resident should ever get hit by another resident in facility. On 11/9/2023 at 1:18 p.m., during an interview, Social Services Designee (SSD) stated he talked to Resident 1 in the morning. Resident 1 told him (SSD) that Resident 2 went inside his room and sat beside him on the bed. The SSD stated that Resident 1 told Resident 2 to leave, Resident 2 became mad and started punching him. The SSD stated that Resident 1 had some redness around his right eye this morning. The SSD stated that Resident 1 told him he felt nervous at that time, but he said that he feels fine now. On 11/9/2023 at 3:46 p.m. during an interview, the Director of Nursing (DON) stated that this was the first time that physical abuse happened between Resident 1 and Resident 2, and it should not have occurred according to the Abuse policy and regulations. A review of the facility's policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, undated, indicated the facility's policy, The facility shall establish a system to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property that lead to abuse when left unchecked. Residents shall not be subjected to abuse by anyone, including but not limited to, facility staff; other resident; consultants or volunteers, staff of other agencies serving the individual; family members or legal guardians, friends, or other individuals. The facility's policy indicated, the purpose is to uphold a resident's right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntarily seclusion.

Based on interview and record review, the facility failed to provide the necessary behavioral health care that was person-centered to maximize dignity and safety for one of three sampled residents (Resident 1). On 4/12/2023 at 1:15 a.m., Resident 1 fell in her room due to restlessness and was then sat in her wheelchair with a Quick Release Soft Belt (QRSB- a type of restraint) restraint. At 1:36 a.m. Registered Nurse 1 (RN 1) wheeled Resident 1 to an empty and dark resident room and moved a linen cart to partially block the door. Resident 1 did not receive any behavioral interventions, was not monitored for safety, and was not provided with any nursing care during the time the resident remained in the room until 5:58 a.m. (4 hours and 22 minutes). As a result, Resident 1 was left unsupervised with no behavioral interventions. Based on the reasonable person concept, due to Resident 1's impaired cognition (involving conscious intellectual activity such as thinking, reasoning, or remembering) and mental health problems, leaving Resident 1 alone in the dark while agitated and in distress subjected the resident to negative psychological effects including feelings of hopelessness, helplessness, and humiliation, increased anxiety, and depression. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 1/27/2022 with diagnoses including Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), schizoaffective disorder (a mental health problem where the person experience psychosis [a mental illness characterized by disconnection from reality] as well as mood symptoms), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and delusional disorder (a type of mental health condition in which a person cannot tell what was real from what was imagined). A review of Resident 1's History and Physical exam, dated 3/14/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/2/2023, indicated the resident had cognitive impairment and was unable to make her needs known. The MDS Behavior section indicated Resident 1 had delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary) as a potential indicator of psychosis. Resident 1 required limited assistance with one person assist with bed mobility, transfer, walk in room and corridor, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor on same floor and from off-unit locations), and toilet use. Resident 1 was incontinent (unable to control) of bladder and bowel functions. Resident 1 used antipsychotic (a type of drug used to treat symptoms of psychosis) medication daily, used a walker as a mobility device, and did not use restraints or alarms. A review of Resident 1's Fall Risk Assessment, dated 2/17/2023, indicated the resident had a total score of 24. A total score above 18 represented high fall risk. A review of the Physician's Order for Resident 1, dated 4/21/2022, indicated to give Risperidone (antipsychotic medications to treat psychosis) 0.5 milligrams (mg-unit of measure) twice a day for psychosis manifested by inability to process internal stimuli causing anger or stress affecting activities of daily living. A review of the Physician's Order for Resident 1, dated 2/17/2023, indicated to give Oxcarbazepine a (mood stabilizer) 300 mg two times a day for schizoaffective disorder manifested by uncontrollable mood swings causing anger interfering with daily living activities. A review of the Physician's Order for Resident 1, dated 3/17/2023, indicated to increase the Risperidone 0.5 mg to three times a day for psychosis manifested by inability to control extreme mood swings causing anger outburst leading to possibility of harming self or others. A review of Resident 1's Psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) Summary Sheet for Risperidone indicated the resident had episodes of behaviors of inability to control extreme mood swings seven times during the month of 2/2023, 46 times during 3/2023, and 90 times from 4/1 to 4/12/2023 A review of Resident 1's Psychotropic Summary Sheet for Oxabenzapine indicated the resident had episodes of behaviors of inability to control extreme mood swings five times during the month of 2/2023, and 24 times during 3/2023. A review of Resident 1's Change of Condition (COC) Forms, indicated that on 12/29/2022 at 4:10 p.m., 2/17/2023 at 11:12 a.m., 3/8/2023 at 5:26 p.m., 3/14/2023 at 1:00 p.m., and 3/31/2023 at 5:14 a.m., the resident had a fall, and the physician and responsible party were notified. A review of Resident 1's Physician's Order, dated 3/31/2023, indicated the use of a Quick Release Soft Belt when out of bed for resident's continuous attempts to get up and out of wheelchair for positioning and safety. A review of Resident 1's Care Plan dated 3/31/2023, for the resident's physical restraint use, indicated the resident had a physical restraint in use, the QRSB. The goal was to employ least restrictive measures daily. The interventions did not include the kind of less restrictive measures to be provided before using a physical restraint. A review of Resident 1's Care Plan, developed on 2/17/2023, for the resident's inability to control extreme mood swings causing outburst leading to possibility to harming self or others indicated that one of the goals was to minimize episodes through appropriate interventions daily. The interventions included approaching Resident 1 calmly, ask to take a deep breath, room visit for support, encouragement and monitor needs, and assess for pain and discomfort. A review of Resident 1's Care Plan, dated 3/1/2023, for the resident's cognitive and communication deficit, indicated the resident had cognitive and communication deficit manifested by impaired decision making, aging process, hearing deficit, and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The goal was to maximize cognitive skills and decision-making capabilities daily. One of the interventions was to avoid unfamiliar situations when possible. A review of Resident 1's Care Plan, developed on 3/1/2023, for the resident's self-care deficit for bed mobility and transfer indicated the intervention of assisting Resident 1 with activities of daily living (ADLs, such as personal hygiene, toilet use, dressing, transfers, and eating) and provide incontinent care as needed. It also indicated an intervention to provide Resident 1 with adequate hydration and nutrition and providing safe environment. A review of Resident 1's COC Form, a late entry dated 4/12/2023 timed at 3:42 p.m. by the Director of Staff Development (DSD), the DSD documented based on a report received, that on 4/12/2023 at 1:15 a.m., Resident 1 was found on the floor by the bed in the resident's room. RN 1 assessed Resident 1 and there were no visible injuries. Resident 1 was then sat in a wheelchair. The DSD notified Resident 1's physician about the resident's fall incident on 4/12/2023 at 8 a.m. and the responsible party was notified on 4/12/2023 at 9 a.m. On 4/12/2023 at 2:47 p.m., during a concurrent telephone interview and record review, Certified Nurse Assistant 1 (CNA 1) stated Resident 1 was found sitting on the floor beside the resident's bed on 4/12/2023 at 1:15 a.m. and she informed RN 1. RN 1 and CNA 1 placed Resident 1 in a wheelchair and RN 1 wheeled the resident inside an empty room and kept the lights off. RN 1 placed the linen cart in front of the room where the resident was placed covering half of the entrance to the room. Resident 1 was awake, constantly moved around, and very agitated while in the wheelchair. CNA 1 stated she informed RN 1 on 4/12/2023 at 2:50 a.m. that placing Resident 1 in an empty and dark room was an abusive act and RN 1 instructed CNA 1 to watch the resident. CNA 1 took pictures of the area where the Resident 1 was placed and a review of the pictures sent by CNA 1 indicated the resident was in a wheelchair without a footrest, with a QRSB around the resident's waist, and the resident facing the hallway with a linen cart blocking half of the entrance to the room. On 4/13/2023 at 11:11 a.m., during a review of the surveillance video with the Administrator (ADM), on 4/12/2023 at 1:36 a.m., RN 1 was observed wheeling Resident 1 into an empty room and at 1:39 a.m. RN 1 moved the linen cart in front of the door of the room where Resident 1 was placed blocking the entrance to the room. On 4/12/2023 at 2:04 a.m., CNA 1 left the Nursing Station and at 2:38 a.m., CNA 1 walked down the hallway and went inside the opposite room where Resident 1 was placed. On 4/12/2023 at 5:58 a.m. Resident 1 wheeled self out of the room. On 4/12/2023 at 6:07 a.m., Resident 1 was observed wheeling herself out of the room reaching out to grab a staff. While reviewing the surveillance video, the ADM stated that on 4/12/2023 at 7:30 p.m., during an interview, RN 1 explained that Resident 1 was agitated and had the behavior of reaching out and scratching other residents and staff. The ADM stated that during the time the resident was inside the dark room, no nursing staff went to monitor Resident 1's behavior, check on the resident for repositioning, incontinent care, or toilet use. On 4/13/2023 at 2:01 p.m., during a telephone interview, RN 1 stated that Resident 1 was disoriented, irritable, grabbed people, tried to walk all the time, and slid down the bed to sit on the floor mat. RN 1 stated that on 4/12/2023 after Resident 1 fell ,1 she placed Resident 1 in an empty room facing the hallway with the linen cart placed by the door to prevent the resident from grabbing other residents. On 4/17/2023 at 6:45 a.m., during a telephone interview, Licensed Vocational Nurse 2 (LVN 2) stated that Resident 1 was combative, not able to communicate and understand well, disoriented and with behaviors of grabbing other residents and staff. On 4/17/2023 at 2:13 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 was resistant to care, grabbed other residents and intentionally throwing self on the floor. Resident 1 was removed from the room where the resident fell and placed in a quiet environment which was an empty room. The DON further acknowledged placing a resident in an empty room can potentially cause an increase in anxiety, aggressiveness, and harm to self. The DON was unable to provide evidence Resident 1 was provided with individual behavioral health care and service to improve her behavior. A review of the facility's in-services titled, Dementia and Its Environment, conducted on 3/10/2023, for the nursing staff, indicated care to residents with Alzheimer's disease with dementia included providing a consistent routine and avoid moving the resident. It indicated that residents with dementia that were moved to another part of the facility causes anxiety, increased agitation, and behavioral outbursts. A review of the facility's policy and procedure titled, Residents' Rights: Purpose and Policies, revised on 7/13/2023, indicated the purpose to ensure each resident was able to fully exercise the rights as a resident and to ensure residents were afforded these rights that contribute to their quality of life and to the overall quality of care provided in the facility. The facility shall provide service to each resident with respect, courtesy, and consideration of resident's needs and feelings. All residents are to be free from mental and physical abuse and free from restraints.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had the right to be free from involuntary seclusion (separation of a resident from other residents or from her/his room) imposed for staff convenience. On 4/12/2023 at 1:15 a.m., Resident 1 fell in her room due to restlessness and was sat in her wheelchair. At 1:36 a.m., Registered Nurse 1 (RN 1) wheeled Resident 1 to an empty and dark resident's room, moved a linen cart to partially block the door, left the room without turning on the lights, isolating Resident 1 from a familiar environment. Resident 1 remained in the room until 5:58 a.m. when she wheeled herself out of the room. As a result, Resident 1 was subjected to involuntary seclusion on 4/12/2023 at 1:15 a.m. to 5:58 a.m. (4 hours and 22 minutes). Based on the reasonable person concept, due to Resident 1's impaired cognition (involving conscious intellectual activity such as thinking, reasoning, or remembering) and medical condition, an individual subjected to involuntary seclusion has increased anxiety (a mental health disorder characterized by feelings of worry, nervousness, or fear that are strong enough to interfere with one's daily activities), depression (a mood disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), emotional distress such as becoming fearful from being in the dark in an unfamiliar place, feeling punished, tired of sitting in the wheelchair, and not receiving nursing care. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 1/27/2022 with diagnoses including Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), anxiety disorder, schizoaffective disorder (a mental health problem where the person experience psychosis [a mental illness characterized by disconnection from reality] as well as mood symptoms), major depressive disorder, and delusional disorders (a type of mental health condition in which a person cannot tell what was real from what was imagined). A review of the Physician's Order for Resident 1, dated 4/21/2022, indicated to give Risperidone (antipsychotic medications) 0.5 milligrams (mg) twice a day for psychosis manifested by inability to process internal stimuli causing anger or stress affecting activities of daily living. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/2/2023, indicated the resident had cognitive impairment and was unable to make her needs known. The MDS Behavior section indicated Resident 1 had delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary) as a potential indicator of psychosis. Resident 1 required limited assistance with one person assist with bed mobility, transfer, walk in room and corridor, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor on same floor and from off-unit locations), and toilet use. Resident 1 was incontinent (unable to control) bladder and bowel functions. Resident 1 used antipsychotic (to treat psychosis) medication daily, used a walker as a mobility device, and did not use restraints or alarms. A review of Resident 1's Fall Risk Assessment, dated 2/17/2023, indicated the resident had a total score of 24. A total score above 18 represented high fall risk. A review of Resident 1's Care Plan, developed on 2/17/2023, for the resident's inability to control extreme mood swings causing outburst leading to possibility to harming self or others indicated that one of the goals was to minimize episodes through appropriate interventions daily. The interventions included approaching Resident 1calmly, ask to take a deep breath, room visit for support, encouragement and monitor needs, and assess for pain and discomfort. A review of Resident 1's Care Plan, developed on 2/17/2023, for the resident's risk of developing pressure (or bedsores, damage to an area of the skin caused by constant pressure on the area for a long time) and other types of skin breakdown related to incontinence of bowel and bladder, had a goal to minimize the risk of skin breakdown. The interventions included turn and position as needed in bed and wheelchair, maintain adequate hydration and nutrition, clean after each episode of incontinence, and encourage maximum mobility as tolerated. A review of Resident 1's Care Plan, developed on 3/1/2023, for the resident's cognitive and communication deficit and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), had a goal for Resident 1 to maximize cognitive skills and decision-making capabilities daily. One of the interventions was to avoid unfamiliar situations when possible. A review of Resident 1's Care Plan, developed on 3/1/2023, for the resident's self-care deficit for bed mobility and transfer included in the intervention assisting Resident 1 with activities of daily living (ADLs, such as personal hygiene, toilet use, dressing, transfers, and eating) as needed, providing incontinent care as needed and a safe environment. A review of Resident 1's Care Plan, developed on 3/1/2023, for the resident's cognitive impairment and communication deficit indicated the intervention to avoid unfamiliar situations when possible. A review of Resident 1's History and Physical exam, dated 3/14/2023, indicated the resident did not have the capacity to understand and make decisions. A review of the Physician's Order for Resident 1, dated 3/17/2023, indicated to increase the Risperidone 0.5 mg to three times a day for psychosis manifested by inability to control extreme mood swings causing anger outburst leading to possibility of harming self or others. A review of Resident 1's Psychotropic (medications that affect a person's mental state) Summary Sheet for Risperidone indicated the resident had episodes of behaviors of inability to control extreme mood swings seven times during the month of 2/2023, 46 times during 3/2023, and 90 times from 4/1 to 4/12/2023. A review of Resident 1's Physician's Order, dated 3/31/2023, indicated the use of a Quick Release Soft Belt (QRSB - a type of restraint) when out of bed for resident's continuous attempts to get up and out of wheelchair for positioning and safety. A review of Resident 1's Care Plan dated 3/31/2023, indicated the resident had a physical restraint in use, the QRSB. The goal was to employ least restrictive measures daily. The interventions did not include the kind of less restrictive measures to be provided before using physical restraint. A review of Resident 1's Change of Condition (COC) Form, a late entry dated 4/12/2023 timed at 3:42 p.m. by the Director of Staff Development (DSD) indicated the DSD documented, that on 4/12/2023 at 1:15 a.m., Resident 1 was found on the floor by the bed in the resident's room. RN 1 assessed Resident 1 and there were no visible injuries. Resident 1 was then sat in a wheelchair. LVN 2 notified Resident 1's physician about the resident's fall incident at 8 a.m. and the responsible party was notified at 9 a.m. On 4/12/2023 at 2:47 p.m., during a telephone interview, Certified Nurse Assistant 1 (CNA 1) stated Resident 1 was found sitting on the floor beside the resident's bed on 4/12/2023 at 1:15 a.m. and she informed RN 1. RN 1 and CNA 1 placed Resident 1 in a wheelchair and RN 1 wheeled the resident inside an empty room and kept the lights off. RN 1 placed the linen cart in front of the room where the resident was placed covering half of the entrance to the room. Resident 1 was awake, constantly moved around, and very agitated while in the wheelchair. CNA 1 stated she informed RN 1 on 4/12/2023 at 2:50 a.m. that placing Resident 1 in an empty and dark room was an abusive act and RN 1 instructed CNA 1 to watch the resident. On 4/13/2023 at 11:11 a.m., during an observation of the surveillance video and concurrent interview with the Administrator (ADM), on 4/12/2023 at 1:36 a.m., RN 1 was observed wheeling Resident 1 into an empty and dark room and at 1:39 a.m. RN 1 moved the linen cart in front of the door of the room where Resident 1 was placed blocking the entrance to the room. On 4/12/2023 at 2:04 a.m., CNA 1 left the Nursing Station and at 2:38 a.m., CNA 1 walked down the hallway and went inside the opposite room where Resident 1 was placed. On 4/12/2023 at 5:58 a.m. Resident 1 wheeled self out of the room. On 4/12/2023 at 6:07 a.m., Resident 1 was observed wheeling herself out of the room reaching out to grab a staff. During the time Resident 1 was in the room, no nursing staff was observed going into the room to monitor Resident 1 for behavior manifestation, provide interventions, repositioning, incontinent care, or toilet use. The ADM stated that on 4/12/2023 at 7:30 p.m., during an interview, RN 1 explained that Resident 1 was agitated and had the behavior of reaching out and scratching other residents and staff. On 4/13/2023 at 2:01 p.m., during a telephone interview, RN 1 stated Resident 1 was disoriented, irritable, grabbed people, tried to walk all the time, and slid down the bed to sit on the floor mat. RN 1 stated that on 4/12/2023 after Resident 1 fell , she placed Resident 1 in an empty room facing the hallway with the linen cart placed by the door to prevent the resident from grabbing other residents. RN 1 stated she did not document the fall, did not call the physician or Resident 1's responsible party. On 4/17/2023 at 2:13 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 was resistant to care, grabbed other residents and intentionally throwing self on the floor. Resident 1 was removed from the room where the resident fell and placed in a quiet environment which was an empty room. The DON further acknowledged placing a resident in an empty room can potentially cause an increase in anxiety, aggressiveness, and harm to self. A review of the facility's policy and procedure titled, Abuse and Mistreatment of Residents, revised on 7/13/2023, indicated the purpose to uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The policy defined involuntary seclusion as separation of a resident from other residents, or from their room, or confinement to their room (with or without roommates) against a resident's will, or the will of the resident's legal representative. The policy also indicated that the DON, DSD, nursing supervisors, and /or designee shall monitor resident-staff interaction to ensure that residents are treated in an environment that promotes respect, privacy dignity, and discourages abuse. A review of the facility's in-services titled, Dementia and Its Environment, conducted on 3/10/2023, for the nursing staff, indicated residents with Alzheimer's disease have dementia. The instructions provided in caring for residents with dementia included providing a consistent routine and avoid moving the resident. It indicated that residents with dementia that were moved to another part of the facility causes anxiety, increase agitation and behavioral outbursts. A review of the facility's policy and procedure titled, Residents' Rights: Purpose and Policies, reviewed on 7/13/2023, indicated the purpose to ensure each resident was able to fully exercise the rights as a resident and to ensure residents were afforded these rights that contribute to their quality of life and to the overall quality of care provided in the facility. The facility shall provide service to each resident with respect, courtesy, and consideration of resident's needs and feelings. All residents are to be free from mental and physical abuse and free from restraints.

Based on observation, interview and record review, the facility failed to provide supervision to prevent accidents and injury for one of three sampled residents (Resident 1), who had wandering behavior (roaming around with no purpose; aimless, slow, or pointless movements, meandering, or repetitive locomotion that exposes the individual to harm; it is frequently incongruent with boundaries, limits, or obstacles) as per plan of care and policies. On 10/5/2022, at 11:15 a.m. after Resident 1 wheeled himself in the hallway, he then placed his hand on the exit door frame, the door then closed after having been opened by the Maintenance Supervisor (MS), jamming Resident 1's fingers of his right hand between the door and the frame. Resident 1 then began yelling in his wheelchair. The MS had unlocked the exit door to the patio, which was a self-closing door, to push a maintenance cart to the patio, without looking at his left or right side for a resident in the proximity. Once the MS and his cart passed through the door the MS did not look back to the self-closing door to ensure a resident was not hurt with the closing door. As a result, Resident 1's right hand middle finger was caught in between the closing door and its frame. Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1) where he was diagnosed with an open fracture (break of a bone) of the right middle finger requiring five sutures (stiches to close the open wound) and a soft cast (a protective covering to prevent movement to aid in healing a broken bone). Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident, on 1/1/2022 with diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 1's Care Plan, developed on 1/3/2022, for the resident's risk of purposeless wandering and potential for self-injury and placement in a secured unit (locked facility) secondary to dementia, had a goal for the resident to have directed activities. The interventions included managing Resident 1's behavioral and psychological symptoms of dementia (BPSD). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 9/29/2022 indicated the resident's cognition for daily decision making was severely impaired (problems with a person's ability to think, learn, remember, use judgement, and make decisions), and needed extensive assistance with activities of daily living (ADL, such as bathing, toilet use, dressing, transfers, and eating). Resident 1 used a wheelchair as mobility device. A review of Resident 1's Care Plan, developed on 9/30/2022, for the resident's self-care deficit for locomotion (moving from place to place) needed total assist to extensive assistance. The interventions included assisting Resident 1 with ADLs as needed and providing a safe environment. A review of Resident 1's Changes of Condition form, dated 10/5/2022, indicated at 10:30 a.m. the resident was noted in his wheelchair propelling himself throughout the hallways. At 11:15 a.m., after having wheeled himself in the hallway and grabbing the exit door frame, Resident 1 was yelling in his wheelchair at the side entrance (and exit) door with the right third middle finger lodged in the right side of the door jamb. Registered Nurse 1 (RN 1) and Certified Nursing Assistant 1 (CNA 1) released the finger immediately. Resident 1's physician was notified and ordered to transfer the resident by paramedics (medical professionals specialized in emergency treatment) to GACH 1 Emergency Department (ED) for further evaluation. A review of GACH 1 ED Summary of Visit dated 10/5/2022, indicated Resident 1's right middle finger had an open fracture (break of a bone) which required five sutures and the application of a soft cast. Resident 1 returned to the facility on the same day, 10/5/2022. On 10/12/2022, at 2:27 p.m., during an interview, CNA 1 stated that on the date of the incident(10/5/2022), she heard the door close and then heard Resident 1 screaming. CNA 1 stated she saw Resident 1 in the hallway and the resident's right hand fingers were jammed between the door and the door frame . CNA 1 stated she called for help and opened the door with a key and RN 1 released the resident's fingers. During an interview, on 10/12/2022, at 2:35 p.m., RN 1 stated she responded immediately upon hearing CNA 1's call for help and went to the hallway between the shower room and Room 11. RN 1 saw the resident sitting in the wheelchair and his fingers in the door hinge. RN 1 stated all staff should make sure of the residents' safety especially while opening and closing doors. During a concurrent record review and interview on 10/13/2022, at 2:35 p.m., with MS, the facilities film footage of the incident from the surveillance security video recording CAM 6 2022-10-05 11 14 dated 10/5/2022 at 11:14 a.m. was reviewed. On the footage it was observed the MS did not look to either side in the process of unlocking the door to notice Resident 1 was approaching from the right side. After the MS walked through the door, he did not look back to check if any residents were following behind him. The MS stated he assumed no residents were behind him and he should have checked to ensure that there were indeed no residents around. The film footage then showed that the door closed on Resident 1's right hand fingers, jamming it between the door and the door frame. On 10/13/2022, at 2:40 p.m. during an interview, the Director of Nursing (DON) stated that upon opening and closing the exit door in the hallway, MS should have checked both sides of the door to ensure there were no residents nearby. A review of the facility's undated policy and procedures titled, Secured Unit Policy indicated, The Secured Unit will offer placement for Resident who wander and are not otherwise a danger to themselves or others Placement in the Secured Unit will be for the resident's safety and for closer observation by facility staff. A review of the facility's undated policy and procedures titled, Wandering indicated, The patient/resident has the right to personal freedom and dignity. Personal freedom is exercised in a manner commensurate (capable of being measured by a common standard) with the patient's/resident's ability and his/her safety. A review of the facility's undated policy and procedures titled, Patient Safety Plan indicated, patient safety events are defined as, but not limited to, adverse events or potential adverse events that are determined to be preventable, as well as health-care-associated infections.

Based on interview and record review, the facility failed to ensure one of nine sampled residents (Resident 1), who was nonverbal, had severely impaired cognition (mental process of thinking and understanding), and totally dependent on staff for care was kept free from sexual abuse. Facility staff found Certified Nursing Assistant 1 (CNA 1) behind closed curtains with Resident 1. CNA 1 had his pants and underwear down to his ankles while standing in between Resident 1 ' s legs and holding her legs up with his hands. Resident 1 was observed lying across the bed, with her head against the wall, her waist at the edge of the bed and her legs spread open and being held up by CNA 1. This deficient practice resulted to Resident 1 being subjected to a nonconsensual sexual assault (attack) by CNA 1 while under the care of the facility. Based on the reasonable person concept, due to Resident 1 ' s severely impaired cognition and medical condition, an individual subjected to rape (unlawful sexual intercourse or any other sexual penetration, without consent) has lifetime physical pain and psychological effects including feelings of hopelessness, helplessness and humiliation. On 3/14/2022 at 5:42 p.m., the State Agency (the Department) called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to prevent the sexual abuse. On 3/17/2022 at 1:14 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: 1. CNA 1 no longer works for the facility. CNA 1 is under police custody as of 3/13/22. 2. Resident 1 was evaluated by the psychologist on 3/14/22. 3. Resident 1 was provided with 1:1 (one staff to care for one resident) female sitter to provide comfort, safety, and re-assurance for 30 days and will be re-evaluated after 30 days. 4. Only female Certified Nursing Assistants (CNAs) will be assigned to Resident 1 and provide activities of daily living (ADL-tasks of everyday life) care indefinitely. 5. A female licensed nurse will be assigned to Resident 1, in the absence of a female licensed nurse, a female staff will accompany the male licensed staff to provide medications and/or treatments indefinitely. 6. The outside lock of the gates to the facility were changed on 3/13/22. 7. The facility reception area is physically monitored by staff for 18 out of 24 hours a day. The front door is locked after the change of shift at 11:00 p.m. 8. The Director of Staff Development (DSD) started conducting in-services on 3/15/22 with all staff regarding Administrator or her designee ' s approval in allowing prior employees or off duty employees into the facility. 9. The Social Service Designees started conducting interviews of all residents using the Trauma Care Evaluation on 3/13/22 to identify residents with new signs of trauma related to abuse with an emphasis on sexual abuse. This will be conducted for the next three months. 10. Body checks were conducted on 3/15/22, on all residents. No new skin changes of unknown origin were identified during body checks. 11. The nursing staff is reviewing all Change of Conditions (COC) forms from December 2018 to March 2022 (the timeframe CNA 1 was employed at the facility) pertaining to any new altered skin integrity issues in suspicious locations of the body (bruising on inner thighs, vaginal bleeding/discharge). 12. The DSD conducting in-services on 3/13/22 with all staff regarding facility policy and procedure on Abuse Prevention with emphasis on sexual abuse. The DSD will conduct scheduled bi-annual in-services regarding facility Abuse Prevention Policy and Procedure. The DSD will assess the facility staffs ' knowledge and competency on abuse utilizing a competency skills test. A one-on-one follow up will be provided as needed. 13. The DSD conducts background checks prior to orientation and the corresponding Department Manager will conduct reference checks prior to hiring new employees. 14. The CNAs conducts body checks focusing on suspicious locations of the body (bruising on inner thighs, vaginal bleeding/discharge) every shift and will report to licensed nurses if any changes in skin condition is observed. 15. Body checks to all residents will be conducted weekly by the Treatment Nurse to identify any issues with resident ' s skin condition that are of unknown origin. 16. The facility conducts monthly Resident Council Meeting to solicit any issues/concerns/complaints made by residents. On 3/17/2022 at 3:49 p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the Department accepted the IJ Removal Plan and removed the Immediate Jeopardy in the presence of the ADM and the DON. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 7/19/17, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s History and Physical dated 11/27/21 indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/11/22 indicated Resident 1 had no speech, is rarely/never understood and rarely/never understands others. The MDS further indicated Resident 1 had severely impaired cognitive skills for daily decision making and was dependent on staff for activities of daily living. A review of Resident 1 ' s Change of Condition (COC)/Interact Assessment Form dated 3/12/22 indicated that Resident 1 was involved in an alleged sexual abuse incident involving a facility staff. The form indicated that Resident 1 was found lying down across her bed, naked from the waist down, with her legs up and bended to her chest. The form further indicated that CNA 1 was noted by Resident 1 ' s bed with his pants down. The form indicated that Local Law Enforcement arrived to investigate the allegation and informed staff that the Sexual Assault Response Team (SART) was called to collect specimens (a sample for medical testing). During a review of the facility ' s video camera footage of Camera 1 (video camera that faces Nurses Station A) taken on 3/12/22 in the presence of the ADM and DON, the following can be seen: 1. 8:36 p.m. – CNA 1 enters Resident 1 ' s room. 2. 8:38 p.m. – Certified Nursing Assistant 2 (CNA 2) enters Resident 1 ' s room. 3. 8:39 p.m. – Certified Nursing Assistant 3 (CNA 3) approaches Resident 1 ' s room and is at the doorway when CNA 1 is seen running out of Resident 1 ' s room with his hands at the waists of his pants pulling them up. CNA 2 and CNA 3 are seen running after CNA 1. During a review of the facility ' s video camera footage of Camera 2 (the facility ' s video camera that faces the side exit) taken on 3/12/22 in the presence of the ADM and DON, the following can be seen: 1. 8:41 p.m. – CNA 1 is running down the hallway, his hands pulling up his pants at the waist. CNA 1 is able to use his key to exit out the side door of the facility. CNA 2 and CNA 3 are seen following behind CNA 1. During a review of the facility ' s video camera footage of Camera 3 (the facility ' s outdoor video camera that faces the side exit) taken on 3/12/22 in the presence of the ADM and DON, the following can be seen: 1. 8:42 p.m. – CNA 1 is seen running towards the gate holding his pants up with his hands and exiting the gate that leads out to the parking lot. A review of the facility ' s Licensed Nurse Record, dated 3/13/22 at 10:17 a.m., indicated that Resident 1 was on monitoring for emotional distress status post [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the ADM on 3/14/22 at 1:15 p.m., ADM stated that based on the investigation of the facility, CNA 1 was caught by CNA 2 inside Resident 1 ' s room, standing above Resident 1 with his pants down while touching the resident inappropriately. ADM stated the police were able to apprehend CNA 1 on 3/13/22 and that CNA 1 is currently under the custody of Local Law Enforcement. During an interview with Registered Nurse 1 (RN 1) on 3/14/22 at 4:00 p.m., RN 1 stated that on 3/12/22 at around 8:00 p.m., she was called to go to Resident 1 ' s room by CNA 2. When she arrived in Resident 1 ' s room, she saw Resident 1, lying perpendicular (across) on her bed with her head against the wall; Resident 1 ' s knees were up to her chest, and the bed was in the high position (around waist level when standing next to it). RN 1 further stated Resident 1 had clothes covering her upper body, but her lower body was naked, without any incontinence brief (adult diapers) or pants. During an interview with CNA 2 on 3/15/22 at 11:00 a.m., CNA 2 stated that on 3/12/22 she was the assigned CNA for Resident 1. CNA 2 stated that on 3/12/22 she was frequently checking on Resident 1 because she was a high fall risk. CNA 2 stated during her 8:30 p.m. rounds, she entered Resident 1 ' s room and noticed that the lights were off, and the privacy curtains were closed. CNA 2 stated that she also noticed that the bed was in the high position (the mattress is elevated high off the floor), which was not the position she last left the bed in. CNA 2 stated that when she opened the privacy curtain, she found Resident 1 positioned across the bed, her waist at the edge of the bed, and her head against the wall. CNA 2 stated she saw CNA 1 facing the resident with his pants and boxers down to his ankles, standing in between Resident 1 ' s legs and carrying Resident 1 ' s legs up with his hands. CNA 2 stated when CNA 1 saw her, he pulled his pants up and tried to fix Resident 1 ' s positioning. CNA 2 stated she started to scream for help. CNA 2 stated CNA 3 went to the room to help. CNA 2 stated that CNA 1 then pushed her out of the way and ran past her towards the side exit. CNA 2 stated she was with CNA 3 trying to stop CNA 1 from leaving, but he was able to exit and get into his car and leave. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 3/17/22 at 3:05 p.m., LVN 1 stated that during her shift (3:00 p.m. to 11:00 p.m.) on 3/12/2022, she was helping to pass out nourishments to the residents when she heard CNA 2 screaming. LVN 1 stated CNA 2 was screaming abuse. LVN 1 stated that when she entered Resident 1 ' s room, she saw Resident 1 laying across the bed with her head against the wall and buttocks area at the edge of the bed with her knees pulled up to the chest, laying to the right side. LVN 1 stated Resident 1 had a patient gown on, but one of her breasts and perineal area (area between the thighs) were exposed. LVN 1 further stated that Resident 1 usually wears an incontinence brief, but at that time there was none observed. LVN 1 stated she was in shock and immediately proceeded to do a stat (immediate) call to Resident 1 ' s room to alert all facility personnel that there is an emergency situation and help is needed. LVN 1 was observed with tears in her eyes and stated that she feels so sad about the incident and so sad for Resident 1. During an interview with Registered Nurse 2 (RN 2) on 3/17/22 at 3:30 p.m., RN 2 stated at around 8:35 p.m. on 3/12/22, he was in the process of giving report to incoming Registered Nurse 1 (RN 1) when there was a stat call to Resident 1 ' s room indicating that there is an emergency situation that needs everyone ' s attention. RN 2 stated that he went to Resident 1 ' s room. RN 2 stated he saw Resident 1 in a hospital gown with no diaper. RN 2 stated Resident 1 ' s perineal area was completely exposed. RN 2 stated Resident 1 looked flushed (a reddening of the face, especially in the cheeks). RN 2 stated he immediately called the local law enforcement; the DON and the ADM. RN 2 stated the local law enforcement came about one hour after they were called. RN 2 stated the local law enforcement told him to secure the area around Resident 1 since it was considered a crime scene. RN 2 stated the facility staff was instructed to try not to touch Resident 1 ' s vaginal area as much as possible because SART was coming to conduct an assessment and collect samples. During an interview with the DON on 3/29/22 at 9:32 a.m., the DON stated on the evening of 3/12/22, CNA 1 was found by facility staff having sex with Resident 1. The DON stated that she immediately filed reports with the resident ' s family, Local Law Enforcement, and State Agencies informing them that Resident 1 had been raped by CNA 1. A review of the facility ' s policy and procedure titled, Abuse & Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards and did not implement and modify care plan interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as high risk for falls due to cognitive impairment/poor safety awareness, the facility failed to ensure the resident was provided physical assistance during transfers, ambulation, and failed to re-evaluate the care plan to address the resident's continued episodes of independent transfers and walking unsupervised. This deficient practice resulted in Resident 1 suffering a fall in his room, on [DATE], when he sustained a head injury, developed a subdural hematoma (a pool of blood between the brain and its outermost covering), and subsequently died on [DATE]. Findings: A review of the closed clinical record indicated Resident 1 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. with reality). A review of the Minimum Data Set (MDS - standardized assessment and care planning tool), dated [DATE], indicated Resident 1 had severely impaired cognitive skills for daily decision-making, required one-person physical assistance with transfers, and required supervision when walking in his room and in the hallway. A review of the fall risk assessments, dated [DATE], [DATE], [DATE], [DATE], and [DATE], indicated Resident 1 was a high risk for falls. A review of the fall reduction care plan, dated [DATE], indicated Resident 1 had a fall on the same date related to decreased strength/endurance, poor safety awareness/judgement, unsteady gait, non-use of call light, history of falls, balance deficit, and cognitive impairment. The care plan interventions included frequent visual monitoring, room close to the nurse's station for close monitoring, call light in reach, PT/OT (physical / occupational therapy) assessment and training, non-skid shoes, interdisciplinary team meeting for falls, restraint assessment, night light, and Falling Star Program. A review of the investigative report indicated Resident 1 had fallen in the hallway, on [DATE], at 7:45 p.m.(approximately one month after admission). The investigative report indicated measures to prevent recurrence included continued monitoring of the resident, assisting to activities under supervision, and continued PT/OT treatment. The post fall assessment indicated Resident 1 had impaired strength, balance, and safety awareness. A review of the nursing Post-Fall Assessment and Follow-Up, dated [DATE], indicated Resident 1 did not know how to use the call light, no restraints were in use at the time of the fall, and a restraint reassessment was not required. During an interview with the Physical Therapist (PT), on [DATE], at 3 p.m., she stated Resident 1 was really confused, and even though she spoke Persian to him, he could not follow instructions. The PT stated she tried to instruct the resident on using a walker, but he could not follow cues and did not know what to do with the walker. The PT stated, When we provided treatment, he could not follow commands to stand, walk, etc. So we used a gait belt, and guided him to move his leg, to sit we had to physically put him in the chair. He was so confused, he could not follow instructions. This indicated the fall reduction care plan interventions, call light within reach, PT/ OT training, and restraint assessment were not applicable for Resident 1 and the care plan was not revised / modified to reflect appropriate fall interventions for Resident 1. A review of Resident 1's Super Star Program care plan, initiated [DATE], indicated the interventions were identical to the Fall Reduction care plan, however there was no assessed need of restraint/safety device to minimize recurrence of fall such as alarms, per facility policy, despite Resident 1's non use of the call light and severe cognitive impairment. A review of a Multidisciplinary Progress Note, dated [DATE], indicated Resident 1 was noted with dark purplish skin discoloration to L posterior mid leg (behind knee), skin intact, no swelling on site, physician notified with no new orders, and message left for daughter. During an interview and record review with Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 3 (LVN 3), on [DATE], at 12:15 p.m., they could not provide an explanation of the cause of the bruises on Resident 1, nor could they locate any further documentation in the record regarding the bruises. A review of the fall reduction care plan, dated [DATE], indicated Resident 1 had a fall (second fall) related to decreased strength/endurance, poor safety awareness/judgement, unsteady gait, non-use of call light, history of falls, balance deficit, and cognitive impairment (the same conditions as the previous fall). The care plan interventions indicated there were no revisions from the previous care plan, dated [DATE], to help prevent further falls/injuries, despite the interventions of call light within reach, PT/ OT training, and restraint assessment were not applicable for Resident 1. A review of the investigative report indicated on [DATE], Resident 1 was found lying on the floor in the hallway outside his room at 11:50 p.m., with a laceration (a deep cut or tear in skin) on his left third finger which required 6 sutures to close. The investigative report indicated measures to prevent recurrence included continued monitoring of Resident 1 and assist to activities with supervision (same as previous investigative report dated [DATE]). A review of the interdisciplinary team notes (IDT), dated [DATE], indicated Resident 1 required minimal assist for transfers and ambulation, no(assistive device) was needed. The IDT recommendations included to respect the right of the resident to be independent and remind resident to request assistance/use call light. The post fall assessment, dated [DATE], indicated Resident 1 had impaired strength, balance, and safety awareness (the same as previous fall), and there were no restraints in place at the time of the fall. The post fall assessment indicated a restraint reassessment was not required and that Resident 1 knew how to use the call light. This contradicted the previous post fall assessment ([DATE]) and the most recent post fall assessment ([DATE]). A review of a staff interview record, dated [DATE], at 11:55 p.m., indicated Certified Nurse Aide 1 (CNA 1) stated she had changed Resident 1 in his bed, at 11:10 p.m., and he was awake when she left him in his bed shortly afterwards. A review of another staff interview record, dated [DATE], at 11:55 p.m., indicated LVN 1 stated at 11:50 p.m. that night, she was checking the hallways and noted Resident 1 lying on the floor outside Room 3. LVN 1 stated she called for assistance and went to check on the resident. Resident 1 was transported to the acute care hospital where Resident 1 received 6 sutures to his left 3rd finger. The staff interview record indicated Resident 1 returned to the facility in the early morning of [DATE]. A review of the clinical record indicated Resident 1 did not receive a tab alarm or new care plan interventions, per facility policy. A review of the fall reduction care plan, dated [DATE], indicated Resident 1 had a fall (the third fall) related to the same conditions as the two previous falls. A review of the nursing Post-Fall Assessment and Follow-Up, dated [DATE], indicated Resident 1 did not know how to use the call light, no restraints were in place at the time of the fall, and no restraint reassessment was required. A review of the investigative report, dated [DATE], indicated Resident 1 was found lying on the floor by the footboard and window in his room. The resident was unresponsive, bleeding from a laceration on the left side of his head, eyes closed, respirations rapid and heavy. The investigative report indicated first aid was administered, 911 was called, and Resident 1 was transported to the acute hospital. A review of a staff interview record, dated [DATE], indicated CNA 2 stated at 7:35 p.m. that night, she toileted and changed Resident 1 and put him in the bed. CNA 2 stated she made several rounds and the resident was still in bed. CNA 2 stated at 8:30 p.m., while passing nourishments, she heard a sound, checked all the rooms until she found Resident 1 lying face down on the floor between his bed and the bathroom in front of the window. A review of a Multidisciplinary Progress Note, dated [DATE], at 8:30 p.m., indicated Resident 1 was found lying on the floor by the footboard of his bed by the window of his bedside. The resident was found in prone (face down) position with skin laceration 4 x 0.5 centimeters (cm) on left side of his head above the ear, with moderate bleeding. Upon assessment the resident was noted unresponsive to external stimuli, with eyes tightly closed, with heavy, fast breathing. The progress note indicated pressure was applied with sterile gauze to the left side of head laceration. Neuro check done, resident was noted unresponsive, not able to assess pupils due to tightly closed eyes. The resident was not able to perform hand grasps and 911 was called immediately. During an interview with LVN 2, on [DATE], at 3 p.m., she stated on the evening of Resident 1's last fall, at 8:30 p.m., she was passing medications in Room 13 when CNA 2 called her and said to hurry to Resident 1's room. Upon arrival, LVN 2 found Resident 1 lying on the floor at the foot of his bed, with his head closest to the window. LVN 2 stated the left side of his head was on the floor, with a small amount of blood. Resident 1 was given oxygen and 911 was called and transported the resident to the acute care emergency room . During an interview with Resident 1's roommate (Resident 2), on [DATE], at 2:30 p.m., he stated the night of Resident 1's last fall, Resident 1 was in bed, then he got out of bed and came over to Resident 2's bedside. Resident 2 told Resident 1 to go away, he did not want to talk to him. Resident 2 stated Resident 1 then slowly walked back toward his bed by placing hand over hand on the footboard of Resident 2's bed. When Resident 1 reached the end of the footboard and had nothing to hold onto, he fell and struck his head. A review of the acute care hospital admitting history and physical, dated [DATE], indicated Resident 1 received a CT scan (X-ray using a computer to show cross-sectional views) which revealed a subdural hematoma (a pool of blood between the brain and its outermost covering). Resident 1 was transferred to another acute care hospital for further intervention and the plan was for a craniotomy (surgical removal of part of the skull to expose the brain) and evacuation of the bleed. The hospital history and physical indicated Resident 1's prognosis was poor. A review of the Discharge Summary Notes, dated [DATE], indicated the hospital course included craniotomy, Resident 1 failed to improve postoperatively, developed seizures, and remained lethargic. It was decided to proceed with do not resuscitate (DNR) status and comfort care only. The discharge summary notes indicated Resident 1 was transferred to the medical floor, where he expired. The death pronouncement indicated the cause of death was cardiopulmonary arrest (a sudden stop in effective blood circulation due to the failure of the heart to contract) due to acute subdural hematoma. The facility's policy and procedure titled, Fall Reduction (General), undated, indicated it was the policy of the facility to reassess all residents with falls every time they occur. A comprehensive care plan shall be developed to prevent any recurrence and to meet resident's specific needs. The policy indicated the resident would be assessed for need of restraint/safety device to minimize recurrence of fall such as alarms, and floor mats. Residents with repeated falls must have restraint assessment, new care plan entry to reduce fall risk, and IDT meeting to discuss measures to reduce fall risk with family notification. The facility's policy and procedure titled, Fall Reduction (Ambulatory), undated, indicated a comprehensive care plan would be developed to meet resident's specific needs. Once fall risk had been established, IDT shall discuss the resident's status and implement a fall risk program which included alarms, non-skid floor strips, floor mats, etc.