Every finding on record at Intercommunity Care Center

Based on observation, interview, and record review, the facility failed to ensure the physician was notified when one of three sampled residents (Resident 1), who was diagnosed with type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), did not receive prescribed Tradjenta (linagliptin, a medication used to help control blood sugar in people with type 2 diabetes) from 8/21/2026 through 8/27/2026 due to medication unavailability. This deficient practice resulted in Resident 1's physician being unaware of the repeated missed doses of Tradjenta and unable to provide further instructions regarding the missed medication. This deficient practice placed Resident 1 at risk for unmanaged blood sugar levels. Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication.During a review of Resident 1's History and Physical (H&P), dated 8/21/2026, the H&P indicated Resident 1 had an altered mental status (a change in awareness, thinking, or behavior) and was non-verbal.During a review of Resident 1's Physician and Telephone Order Form (Physician's Order), dated 8/21/2026 at 2:30 p.m., the Physician's Order indicated Resident 1's attending physician discontinued Lantus (insulin glargine, a long-acting insulin used to control blood sugar) and prescribed Tradjenta 5 milligrams ([mg], metric unit of measurement used for medication dosage and/or amount) via gastrostomy tube ([GT], a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) daily and to continue accu-checks (blood sugar checks used to measure the amount of sugar in the blood) every morning at breakfast with the same sliding scale (insulin dose based on blood sugar levels).During a review of Resident 1's Medication Administration Record (MAR) for August 2026, the MAR indicated Tradjenta 5 mg was ordered on 8/21/2026. A handwritten line with an arrow extended through the administration spaces from 8/21/2026 through 8/24/2026, with no documentation that Tradjenta was administered on those dates. The MAR documented Tradjenta as administered on 8/25/2026. The MAR indicated the medication was not available on 8/26/2026 and 8/27/2026.During a review of Resident 1's blood sugar records from 8/22/2026 through 8/27/2026, the records indicated Resident 1's blood sugar levels were 269 mg/dL on 8/22/2026, 212 mg/dL on 8/23/2026, 148 mg/dL on 8/24/2026, 216 mg/dL on 8/25/2026, 142 mg/dL on 8/26/2026, and 181 mg/dL on 8/27/2026. (standard blood sugar range - 80 to 100 mg/dl)During a concurrent observation and interview on 8/27/2026 at 1:46 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 1's Tradjenta 5 mg was noted as unavailable in Medication Cart 2. LVN 3 stated she contacted the pharmacy regarding the unavailable medication but the medication did not arrive. LVN 3 stated she did not notify the physician. LVN 3 stated the physician should have been notified of the missed medication to determine whether an alternative should have been given and a Change in Condition (CIC) should have been implemented.During a concurrent interview and record review on 8/27/2026 at 2:24 p.m., LVN 2 reviewed Resident 1's MAR and stated she documented Tradjenta 5 mg as administered on 8/25/2026; however, she stated she did not administer the medication because it was not available. LVN 2 stated Resident 1 was missing six days of Tradjenta because the order date on the MAR was 8/21/2026. LVN 2 stated she should have contacted the physician and pharmacy regarding the missed medication but became distracted and forgot. LVN 2 stated not receiving the medication could affect Resident 1's blood sugar. LVN 2 stated she should have notified the physician to determine what the physician wanted staff to do and whether an alternative medication should have been given. LVN 2 further stated she should have notified the DON and supervisor of the missing medication.During an interview on 8/27/2026 at 3:59 p.m. with the Director of Nursing (DON), the DON stated LVN 3 was assigned to Resident 1 on 8/21/2026, 8/22/2026, 8/23/2026, and 8/24/2026. The DON stated if a medication was not available, the charge nurse administering medications should contact the pharmacy to determine the status of the medication. The DON stated the pharmacy was available 24 hours a day and there was no reason the nurses did not follow up when the medication was not available. The DON stated Resident 1 should not have gone for several days without the medication and without follow-up because the resident could become sick and there could be harm to the resident. The DON stated a CoC should have been completed after Resident 1 went several days without the medication. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, revised February 2021, the P&P indicated the facility would promptly notify the attending physician of changes in a resident's medical condition or status. The P&P indicated the nurse would notify the resident's attending physician or physician on call when there was a need to significantly alter the resident's medical treatment. The P&P further indicated prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider. The P&P indicated the nurse would record information related to changes in the resident's medical condition or status in the medical record.

Based on observation, interview, and record review, the facility failed to ensure a prescribed medication was available and administered as ordered for one of three sampled residents (Resident 1) when the facility failed to obtain Tradjenta (linagliptin, a medication used to lower blood sugar), failed to follow up when the medication remained unavailable, and documented the medication as administered when it was not given. This failure resulted in Resident 1 not receiving Tradjenta as ordered from 8/22/2026 through 8/27/2026 and increased the resident's risk of experiencing inadequate blood sugar control and adverse effects related to acute (sudden onset) hyperglycemia (a sudden rise in blood sugar levels).Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication. During a review of Resident 1's History and Physical (H&P), dated 8/21/2026, the H&P indicated Resident 1 had an altered mental status (a change in awareness, thinking, or behavior) and was non-verbal. During a review of Resident 1's Physician and Telephone Order Form (Physician's Order), dated 8/21/2026 at 2:30 p.m., the Physician's Order indicated Resident 1's attending physician prescribed Tradjenta 5 milligrams ([mg], metric unit of measurement used for medication dosage and/or amount) via gastrostomy tube ([GT], a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) daily and to continue accu-checks (blood sugar checks used to measure the amount of sugar in the blood) every morning at breakfast. During a review of Resident 1's Medication Administration Record (MAR) for August 2026, the MAR indicated Tradjenta 5 mg was ordered on 8/21/2026. A handwritten line with an arrow extended through the administration spaces from 8/21/2026 through 8/24/2026, with no documentation that Tradjenta was administered on those dates. The MAR documentation indicated Tradjenta as administered on 8/25/2026. The MAR further indicated the medication was not administered on 8/26/2026 and 8/27/2026.During a review of Resident 1's Nurse's Medication Notes for August 2026, the Nurse's Medication Notes contained no documentation regarding the status or availability of Tradjenta from 8/21/2026 through 8/25/2026. The notes indicated Tradjenta was not available on 8/26/2026. The notes indicated on 8/27/2026 Tradjenta was not available, the pharmacy was contacted, and the medication would be delivered that day. During a concurrent observation, interview, and record review on 8/27/2026 at 1:46 p.m. with Licensed Vocational Nurse (LVN) 3, Medication Cart 2 was observed and Resident 1's prescribed Tradjenta 5 mg was not available in the medication cart. Resident 1's August 2026 MAR was reviewed and indicated Tradjenta was ordered on 8/21/2026. LVN 3 stated she contacted the pharmacy on 8/26/2026 regarding the unavailable medication and was waiting for the medication to be delivered; however, the medication was not delivered. LVN 3 stated she should have followed up with the pharmacy when the medication was not delivered. LVN 3 stated she contacted the pharmacy again on 8/27/2026 and was informed that the pharmacy had missed the order. LVN 3 acknowledged the MAR indicated Tradjenta was ordered on 8/21/2026 and stated the medication had not been given from 8/22/2026 through 8/27/2026. During a concurrent interview and record review on 8/27/2026 at 2:24 p.m. with LVN 2, Resident 1's MAR was reviewed. LVN 2 acknowledged Tradjenta 5 mg was not available in Medication Cart 2. LVN 2 stated she documented Tradjenta as administered on 8/25/2026; however, she did not administer the medication because it was not available. LVN 2 stated she should not sign a medication as administered when the medication was not given and stated she should have circled the MAR to indicate the medication was not administered. LVN 2 stated she should have contacted the pharmacy regarding the unavailable medication but became distracted and forgot. LVN 2 stated Resident 1 had missed six days of Tradjenta and stated missing the medication for six days could affect the resident's blood sugar. During an interview on 8/27/2026 at 3:59 p.m. with the Director of Nursing (DON), the DON stated LVN 3 was assigned to Resident 1 on 8/21/2026, 8/22/2026, 8/23/2026, and 8/24/2026. The DON stated if a medication was not available for the next day, the charge nurse administering medications should contact the pharmacy to determine the status of the medication. The DON stated the pharmacy was available 24 hours a day and there was no reason the nurse did not follow up when the medication was not available. The DON stated Resident 1 should not have gone for several days without the medication and without follow-up because the resident could become sick and there could be harm to the resident. During a review of the facility's policy and procedure (P&P) titled Pharmacy Services - Role of the Provider Pharmacy, revised 4/2010, the P&P indicated the provider pharmacy was to provide routine pharmacy service seven days a week and emergency pharmacy service 24 hours per day, seven days a week. The P&P further indicated the provider pharmacy was to deliver medications to the facility and help the facility ensure that all deliveries were correct and proper documentation related to delivery was provided. During a review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated medications were to be administered in a safe and timely manner and as prescribed. The P&P indicated medications were to be administered in accordance with prescriber orders. The P&P further indicated when a medication was withheld, the nurse was to initial and circle the MAR space provided for the medication and dose, and the nurse was to initial the resident's MAR after giving each medication. During a review of the facility's P&P titled Documentation of Medication Administration, revised 11/2022, the P&P indicated medication administration was to be documented immediately after the medication was given. The P&P further indicated documentation was to include the reason a medication was withheld or not administered. During a review of the facility's policy P&P titled Adverse Consequences and Medication Errors, revised 6/2025, the P&P indicated a medication error was defined as the preparation or administration of drugs or biological which was not in accordance with provider's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. The P&P indicated examples of medication errors included omission - a drug is ordered but not administered.

Based on observations (video surveillance), interviews and record review, the facility failed to protect the residents' right to be free from physical abuse by for one of eight sampled residents (Resident 1) when Resident 1 physically attacked and strangled Resident 2 leading to Resident 2's death. Also, the facility failed to take additional steps to prevent further potential abuse from occurring when staff allowed Resident 1 to leave the room and encounter other residents (Residents 3, 4, 5, 6, 7, and 8) without providing supervision and monitoring of Resident 1. These deficient practices resulted in the death of Resident 2 by Resident 1 on 8/1/2026 at approximately 7:15 p.m., when staff found Resident 1 strangling Resident 2. Resident 1 was allowed to move about the facility freely and entered the facility's activity/dining room (Winter Room) where she remained for 21 minutes following the assault on Resident 2 and had access to six other residents (Residents 3, 4, 5, 6, 7, and 8) who were present in the Winter Room, placing those residents at risk for harm, serious injury, or death. On 8/6/2026 at 5:41 p.m., while onsite at the facility, an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and called in the presence of the facility's Administrator (ADM), the Assistant Administrator (AADM) and the Director of Nursing (DON), due to the facility's failure to supervise and monitor Resident 1 following an assault on Resident 2 and Resident 2's subsequent death. An IJ Removal Plan ([IJRP] a plan to immediately correct the deficient practices) was immediately requested. On 8/11/2026 the facility submitted an acceptable IJRP. After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed and no longer present on 8/12/2026 at 2:30 p.m., in the presence of the ADM and the AADM. Non-compliance of F600 remained at the scope and severity of G with actual harm occurring that is not immediate Jeopardy. The IJRP included the following: On 8/7/2026 the DON and Director of Staff Development (DSD) gave training to the Licensed Nurses and Certified Nursing Assistants (CNAs) who were involved in the incident. It was emphasized that during a serious behavioral event wherein a resident assaults another resident, staff were to make sure that the resident who committed the assault was not left unattended and remained under direct supervision until law enforcement, emergency medical services, or another qualified professional assumed responsibility for the resident. It was explained that not doing so placed all other residents at risk for potential harm. On 8/7/2026 the facility updated its Abuse Prevention Policy with an addendum: Resident to Resident Assault Response and Post Incident Resident Safety to include response to resident assaultive behavior. The updated policy outlined staff responsibilities during a serious behavioral event, including responsibility to ensure the resident who committed the assault was not left unattended and remained under direct supervision until law enforcement, emergency medical services, or another qualified professional assumed responsibility for the resident. The policy identified the need to protect other residents who might be exposed to the incident by promptly assessing the immediate area for additional safety risks. The staff were to separate the residents involved, increase supervision of the affected area as indicated, and assign any available staff to maintain the safety of the residents. When continued proximity presents a risk for additional harm, the resident(s) would be temporarily relocated to a safe area or other appropriate location based on the assessed risk and the residents' needs. On 8/7/2026, the DON and Department supervisors gave an in-service to facility staff, including Licensed Nurses, CNAs, and other direct care personnel, regarding the updated Resident Assault Response Procedure. The in-service included the immediate steps required following resident assault, the importance of protecting all residents from potential harm, and the responsibility to maintain continuous supervision of the resident who engaged in the assaultive behavior. Staff were instructed that a resident who has assaulted another resident must never be left unattended following the incident. A designated staff member must remain with the resident until law enforcement arrived and assumed custody. On 8/7/2026 the DON met separately with the Registered Nurse Supervisor (RNS) and Licensed Nurses to discuss the procedures and their responsibilities during a serious incident. Licensed Personnel were instructed on the importance of immediate delegation, maintaining resident supervision, communication with leadership, and timely intervention. The RNS will make rounds at least hourly on each shift to evaluate resident safety, identify potential behavior concerns manifested by severe angry outbursts and/or striking out, provide direction to staff, and ensure residents exhibiting aggressive or assaultive behavior were placed on one-to-one supervision (a dedicated staff member who is assigned to continuously watch and assist a single resident at all times).Findings: a. During a review of Resident 1's undated admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis of paranoid schizophrenia (a chronic brain disorder marked by false beliefs of persecution or conspiracy known as delusions [having false or unrealistic beliefs], and auditory hallucinations [hearing sounds or voices that are not real]). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 1 had moderate cognitive impairment (clear problems with memory, thinking, and reasoning, that disrupts regular daily activities). The MDS indicated Resident 1 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, showering/bathing, dressing upper body, and partial/moderate assistance (helper does less than half the effort) for dressing the lower body, putting on or taking off footwear, and personal hygiene. Resident 1 was ambulatory with supervision or touch assistance. During a review of Resident 2's admission Record (Face Sheet), undated, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (major mood episodes like mania [a state of abnormally elevated, expansive, or irritable mood paired with high energy, hyperactivity, and reduced need for sleep] and sometimes depression), tardive dyskinesia ([TD] a movement disorder that causes uncontrolled, repetitive body movements, usually in the face, tongue, lips, fingers, or toes. It happens as a side effect of taking certain medicines), and extrapyramidal and movement disorder (drug-induced movement disorders caused by medications that block dopamine receptors [specialized protein structures on cell surfaces that bind to the chemical messenger dopamine to regulate movement emotions, and reward] in the brain). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive status could not be assessed. The MDS indicated Resident 2 required supervision or touch assistance with oral hygiene, toileting hygiene, lower body dressing, and walking up to 50 feet. Resident 2 required partial/moderate assistance with eating, dressing the upper body, and putting on or taking off footwear, bathing/showering, and personal hygiene required substantial/moderate assistance (helper does more than half the effort). During a review of the facility's Summary of Incident, dated 8/4/2026, the Summary of Incident indicated on 8/1/2026 at approximately 7:15 p.m., CNA 1 entered Resident 1 and Resident 2's shared room and observed Resident 2 lying on her bed on her right side facing the window while Resident 1sat on Resident 2's bed and leaned forward toward Resident 2. Resident 1 had a string or shoelace on Resident 2's face, CNA 1 attempted to move Resident 1 away from Resident 2 but Resident 1 resisted. CNA 1 called for help, CNA 2 responded immediately and assisted CNA 1 to separate Resident 1 and Resident 2 then CNA 2 yelled for help. The Summary of Incident indicated licensed nursing staff responded immediately and determined Resident 2 was unresponsive (when a person does not react or show signs of life, movement, or awareness when stimulated by sound, touch or pain), cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure performed when someone has stopped breathing or their heart has stopped) was initiated, and paramedics were called. During a review of the Paramedic Run Sheet (an official legal and medical document that paramedics and emergency medical technicians [EMTs] a trained health care provider who gives basic emergency care] use to record every detail of an emergency medical response, from initial dispatch and patient assessment to treatments given and final transfer of care at a hospital), dated 8/1/2026, the Paramedic Run Sheet indicated paramedics were called at 7:24 p.m., and arrived at the facility and to Resident 2 at 7:35 p.m. Resident 2 was found on the bed in full arrest (heart was not beating) after strangulation by another resident (Resident 1) and was found with a pulse but apneic (when a person has temporarily stopped breathing), ligatures (a cord, thread, or wire to tie off a blood flow) [marks], and tracheal deviation (when the windpipe shifts to one side of the neck instead of staying in the middle) to the left. CPR was initiated but the initial rhythm (heartbeat) was PEA (pulseless electrical activity [a serious type of cardiac arrest when the heart shows normal or organized electrical signals on a monitor, but the heart muscle does not pump). There was no change to rhythm throughout the resuscitation. During an interview on 8/4/2026 at 3:35 p.m. with CNA 1 , CNA 1 stated on 8/1/2026 around 7:15 p.m., while he was passing nourishment snacks (food and/or beverages provided between regularly scheduled meals to supplement a resident's nutritional and hydration intake) to residents, he went inside Residents 1 and 2's room and noticed she (Resident 1) was sitting on Resident 2's bed and leaning forward, Resident 2 was on her right side facing the window. He (CNA 1) asked Resident 1 what she was doing but she did not respond, as he got closer, he saw Resident 1 holding a shoelace in both of her hands, her fist was clenched tightly with the palms side of her hands facing up. The shoelace was wrapped around Resident 2's mouth and neck, and Resident 1 was pulling the shoelace tightly with both of her hands. He tried to pull Resident 1 off Resident 2, but she was very strong, she turned her head to look at him with a blank stare, but she would not let go of the shoelace. CNA 1 stated he saw there was blood on Resident 2's bed, he left the room, stood outside in the hallway, right outside of Residents 1 and 2's bedroom and called CNA 2 to help him. When they (CNA 1 and CNA 2) returned to the room, Resident 1 was still pulling the shoelace around Resident 2's neck and mouth, and they (CNA 1 and CNA 2) separated the residents by pulling Resident 1 off Resident 2. During an interview on 8/5/2026 at 1:31 p.m. with CNA 2, CNA 2 stated on 8/1/2026 around 7:15 p.m., CNA 1 asked for help in Resident 1 and Resident 2's shared room. When she walked into the room Resident 1 was on Resident 2's bed, she could only see the back of Resident 1, and Resident 2 was facing the window away from the doorway entrance. When she got closer, she saw Resident 1 was strangling Resident 2 with a shoelace, the shoelace was cutting into the corners of Resident 2's mouth. CNA 2 stated she screamed what are you doing? and tried to move Resident 1 from Resident 2 by hitting Resident 1's shoulder. Eventually Resident 1 got up without saying anything, walked away and left the room. CNA 2 stated she took Resident 2's pulse but could not find one, and by that time CNA 3 came into the room and began CPR. During an interview on 8/6/2026 at 4:18 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 8/1/2026 around 7:15 p.m., while she was at Nursing Station B she heard a scream from CNA 2, coming from Resident 1 and Resident 2's shared room, what did you do? Oh my God! She (LVN 1) went to the Resident's room and saw that Resident 2 was not moving and asked CNA 2 what happened? CNA 2 told her (LVN 1) that Resident 1 choked Resident 2. She (LVN 1) checked Resident 2's pulse and found none, she (LVN 1) ran to Nursing Station B and called a code blue (an emergency announcement used in hospitals and medical centers to signal that a person is having a life-threatening medical crisis, such as cardiac arrest) and CPR was initiated until the paramedics arrived. b. During a concurrent observation of the facility's video surveillance and interview with the ADM on 8/4/2026 at 3 p.m., the video surveillance time stamped 8/1/2026 indicated Resident 1 was observed walking alone without staff knowledge, intervention or monitoring, down the hallway (passing the facility's Wardrobe room and the DON's office) between 7:17:37 and 7:18:37 (1 minute and 35 seconds). Resident 1 was observed walking into the facility's activity/dining room (the Winter Room) at 7:18 p.m. where staff and police found Resident 1 sitting in the Winter Room at 7:38 p.m., unsupervised next to and amongst six other residents (Residents 3, 4, 5, 6, 7, 8). After reviewing the video surveillance, the ADM stated there were no staff present in the Winter Room with Resident 1 and six other residents until police arrested Resident 1 at 7:38 p.m. During an interview on 8/4/2026 at 3:35 p.m. with CNA 1, CNA 1 stated on 8/1/2026 around 7:15 p.m., following the incident when Resident 1 attacked Resident 2, and after Resident 1 was pulled off Resident 2, Resident 1 walked away laughing, like nothing happened. After Resident 1 strangled Resident 2, he (CNA 1) left the room to get help for Resident 2 which was why he did not stop Resident 1 from leaving the room. CNA 1 stated he (CNA 1) should have stopped Resident 1 because Resident 1 could have hurt another resident. During an interview on 8/5/2026 at 1:31 p.m., with CNA 2, CNA 2 stated on 8/1/2026 after the incident when Resident 1 strangled Resident 2, the police arrived, the police asked where the suspect (Resident 1) was, she (CNA 2) and other staff began looking for Resident 1 and found Resident 1 in the Winter Room, Resident 1 was smiling when the police arrested her. During an interview on 8/6/2026 at 4:18 p.m., with LVN 1, LVN 1 stated on 8/1/2026 after Resident 1 strangled Resident 2, Resident 1 walked past her (LVN 1) and left the room like nothing happened. She (LVN 1) did not think to contain Resident 1 and stop Resident 1from leaving the room because her (LVN 1) priority was to start CPR on Resident 2. During an interview on 8/7/2026 at 2:17 p.m., the DON stated on 8/1/2026 at 7:17 p.m., when Resident 1 left her bedroom after harming Resident 2, staff should have stayed with Resident 1 to monitor her and prevent Resident 1 from harming any other residents. During a review of Resident 3's undated admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 had diagnoses that included schizophrenia (a chronic brain disorder marked by auditory hallucination) and an anxiety disorder (a mental health condition involving intense, excessive, and ongoing fear or worry about everyday situations). During a review of Resident 4's undated admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4 had diagnoses including schizoaffective disorder and extrapyramidal movement disorder. During a review of Resident 5's undated admission Record (Face Sheet), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5 had diagnoses including schizophrenia, extrapyramidal movement disorder, and schizoaffective disorder. During a review of Resident 6's undated admission Record (Face Sheet), undated, the Face Sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6 had diagnoses including schizoaffective, dementia (a progressive state of decline in mental abilities), generalized anxiety disorder, extrapyramidal movement disorder, and schizoaffective disorder. During a review of Resident 7's undated admission Record (Face Sheet), undated, the Face Sheet indicated Resident 7 was admitted to the facility on [DATE]. Resident 7 had a diagnosis of paranoid schizophrenia. During a review of Resident 8's undated admission Record (Face Sheet), undated, the Face Sheet indicated Resident 8 was admitted to the facility on [DATE]. Resident 8 had diagnoses including paranoid schizophrenia, extrapyramidal movement disorder, schizoaffective disorder, and anxiety disorder. During a review of facility's Policy and Procedure (P/P), titled Unmanageable Residents dated 4/2010, the P/P indicated should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the nurse supervisor/charge nurse must immediately provide for the safety of all concerned. The director of nursing services has the authority to order emergency restraint use in accordance with the facility's established restraint policy. During a review of facility's undated P/P titled Abuse Prevention and Investigation the P/P indicated the facility will not condone resident abuse by anyone including. other residents. As part of prevention of abuse, the facility will identify, correct, and intervene in situations in which abuse is more likely to occur. Employees will receive training during orientation to the facility and as part of our ongoing in-service training program on issues related to abuse. The training program will at least include the following: Appropriate interventions to deal with aggressive and/or catastrophic reactions [an extreme, intense, and disproportionate emotional or behavioral outburst triggered by a minor stressor or everyday demand] of residents. How to recognize signs of burnout, frustration and stress that may lead to abuse

Based on observation, interview, and record review, the facility failed to immediately notify the physician and Responsible Party (RP) for one sampled resident (Resident 1) when Resident 1 repeatedly refused to take her prescribed medications. This failure resulted in Resident 1's physician not and RP being unaware that Resident 1 was refusing medications and placed Resident 1 at risk of unmanaged heart disease and diabetes, cognitive decline, higher chance of hospitalization, and further noncompliance with medical care.Findings: During a review of Resident 1's undated admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis of paranoid schizophrenia (a chronic brain disorder marked by false beliefs of persecution or conspiracy known as delusions [having false or unrealistic beliefs], and auditory hallucinations [hearing sounds or voices that are not real]). During a review of Resident 1's History and Physical (H&P) dated 5/28/2026, the H&P indicated Resident 40 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 1 had moderate cognitive impairment (clear problems with memory, thinking, and reasoning, that disrupts regular daily activities). The MDS indicated Resident 1 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, showering/bathing, dressing upper body, and partial/moderate assistance (helper does less than half the effort) for dressing the lower body, putting on or taking off footwear, and personal hygiene. Resident 1 was ambulatory with supervision or touch assistance. During a review of Resident 1's Physician Order Report signed 7/22/2026, the Physician's Order Report indicated physician's orders for: 1. Depakote Delayed Release 250 mg, give one tablet by mouth twice a day; 9 a.m., and 5 p.m., for mood swings, order date 9/4/2025 2. Mood Stabilizer (for Depakote Use), observe resident closely for significant side effects; Lethargy (lack of energy or tiredness) 3. Benicar 20 mg, give one tablet by mouth one time a day, 9:00 AM, for hypertension. Hold for SBP less than 110 mmhg, Diastolic ([DBP] - the pressure in the arteries when the heart is at rest between beats) of less than 60 mmhg, less than 60 bpm, order date 9/4/2025 4. Amlodipine 5 mg, give one tablet by mouth one time a day at bedtime, 9:00 PM, for hypertension (high blood pressure). Hold for Systolic ([SBP] the pressure caused by heart while contracting) of less than 110 millimeters mercury (mmhg a unit of measure of pressure) or heart rate (HR, reference range for a normal adult heart rate is typically 60-100 bpm, with values below 60 bpm considered bradycardia [slow heart rate]) less than 60 bpm, order dated 9/4/2025. 5. Metformin 1000 mg, give one tablet by mouth twice a day, 9 a.m. and 5 p.m., for Type 2 Diabetes Mellitus, give with meals, order date 9/4/2025 During a review of Resident 1's Care Plan dated 9/4/2025, the Care Plan indicated Resident 1 was on multiple medications. The Care Plan's interventions indicated to call Resident 1's physician for appropriateness and need of all ordered medications. Report to MD, family members, and significant others for any change in condition. During a review of Resident 1's Care Plan dated 9/4/2025, the Care Plan indicated Resident 1 had a potential for irregular pulse and chest pains secondary to coronary artery disease (blocked or narrowed arteries that reduce blood flow to the heart). The Care Plan's interventions indicated to monitor for chest pain or abnormal pulses; Report to the MD for unusual occurrences promptly; Monitor vital signs; and to administer medications as ordered During a review of Resident 1's Care Plan dated 9/4/2025, the Care Plan indicated Resident 1 had a potential for exacerbation (increase) of blood pressure and its acute and chronic complications, hypertension ([HTN] high blood pressure). The Care Plan's intervention indicated to monitor the effectiveness or adverse effects; Assess, document and notify the MD/family of findings; and to administer medications (Amlodipine and Benicar) as ordered. During a review of Resident 1's Care Plan dated 9/4/2025, the Care Plan indicated Resident 1 was at risk for hyperglycemia (high blood sugar) related to DM. The Care Plan's intervention indicated. to administer medications as ordered. During a review of Resident 1's Care Plan dated 9/10/2025, the Care Plan indicated Resident 1 had altered thought processes due to her diagnosis of paranoid schizophrenia.periods of confusion, disorientation, unawareness of time and place and inability to recognize staff names and faces and others.The Care Plan indicated Resident 1 was at risk for decline in cognitive abilities. The Care Plan's interventions indicated.to observe for any change in mental status/cognitive skills; Redirect resident attention as appropriate; Psych consult treatment, and follow-up as appropriate; Learn patients (resident's) needs and pay attention to non-verbal cues; Use resident names During a review of Resident 1's Care Plan, dated 12/12/2025, the Care Plan indicated Resident 1 was noncompliant (non-adherence) with labs, dental, ophthalmology and podiatry care, as evidenced by Resident 1's verbal refusal of recommended labs and consults. Resident 1's Care Plan interventions indicated to assess resident's refusal (time, financial concerns, lack of understanding), provide clear and simple education about the purpose of labs and specialty consults; collaborate with the Interdisciplinary Team ([IDT] a coordinated group of health professionals and staff members who work together to plan, deliver, and evaluate a resident's care) to address barrier; document and report refusal of care to the MD (physician) and the Responsible Party (RP) During a review of Resident 1's Medication Administration Record ([MAR] a permanent record that shows which medicine was given, how much, when, and by whom) for the months of 4/2026 through 7/2026, documentation by licensed nurses initial and circled on the MAR, indicated Resident 1 refused the following medications: 1. Depakote 250 mg order to be administered twice a day at 9 a.m. and 5 p.m. was documented not administered or refused a total of 56 times: Resident 1 was documented to have refused Depakote in 4/2026 12 times, in 5/2026 15 times, in 6/2026 16 times, and in 7/2026 13 times. 2. Between 5/2026 through 7/2026, Resident 1's Benicar 20 mg order to be administered once a day at 9 a.m., was documented not administered or refused a total of 27 times: Resident 1 refused Benicar five consecutive days, and no blood pressure level was documented on: 5/26/2026 at 9 a.m., 5/27/2026 at 9 a.m., 5/28/2026 at 9 a.m., 5/29/2026 at 9 a.m., and 5/30/2026 at 9 a.m. 3. Between 5/2026 through 7/2026, Resident 1's Amlodipine 5 mg order to be administered once a day at 9 a.m., was documented not administered or refused a total of 16 times. Resident 1 refused Amlodipine two consecutive days, on 5/30/2026 at 9 a.m., 5/31/2026 at 9 a.m., in 6/2026 six times, and in 7/2026 eight times. 4. Resident 1's Metformin 1000 mg order to be administered twice a day at 9 a.m., and 5 p.m. was documented not administered or refused a total of 10 times. Resident 1 refused Metformin between 6/2026 through 7/2026 on 6/1/2026 at 9 a.m., 6/5/2026 at 9 a.m., 6/6/2026 at 9 a.m., 6/8/2026 at 9 a.m., 6/22/2026 at 9 a.m.,6/23/2026 at 9 a.m., and 5 p.m., 7/13/2026 at 9 a.m., 7/29/2026 at 9 a.m., and 7/30/2026 at 9 a.m. During an on 8/6/2026 at 2:34 p.m., the Director of Staff Development (DSD) stated on the third refusal of medication the licensed nurses should notify the resident's physician and document the refusal in the nursing notes and the interventions tried. During an interview on 8/6/2026 at 5:30 p.m., the Director of Nursing (DON) stated there was no documentation that Resident 1's physician was notified that Resident 1 was refusing medications. During a telephone interview on 8/10/2026 at 2:33 p.m., Resident 1's physician in the presence of the DON stated she did not recall being notified that Resident 1 was refusing medications including Benicar, Amlodipine, and Metformin. Resident 1's physician stated Resident 1's psychiatrist (MD 2) should have been called regarding Resident 1 refusal to take Depakote, which was prescribed for mood swings. During an interview on 8/10/2026 at 3 p.m., p.m., with LVN 5 and LVN 6, LVN 6 stated she offered Resident 1 her medication three times and she should have documented Resident 1's refusal on the resident's MAR. LVN 5 and LVN 6 stated they did not notify Resident 1's physician when she repeatedly refused to take her medications. During a review of the facility's Policy and Procedures (P&P) titled, Change in a Resident's Condition or Status, dated 3/2022, 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.The nurse will notify the resident's attending physician or physician on call when there has been a (an). refusal of treatment or medication two (2) or more consecutive times .requires interdisciplinary review and/ or revision to the care plan.Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 2/2021, indicated, If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, and explanation is documented in the resident's medical records. The explanation should include what steps were taken to include the resident or representative in the process.

Based on interview, and record review, the facility failed to ensure one sampled resident's (Resident 1) behavior monitoring was specific to the behavior being monitored or the effectiveness of the interventions, and medication refusals of Depakote (for mood stabilization), Benicar (for high blood pressure), Amlodipine (for high blood pressure), and Metformin (used to treat diabetes and help lower high blood sugar levels) were assessed. The facility's failure to assess and address Resident 1's refusal to take medications and related care interventions had the potential of Resident 1not receiving timely interventions, leading to serious negative outcomes such as worsening mental health symptoms, uncontrolled diabetes ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), increased blood pressure, and risk of hospitalization.Findings: During a review of Resident 1's undated admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis of paranoid schizophrenia (a chronic brain disorder marked by false beliefs of persecution or conspiracy known as delusions [having false or unrealistic beliefs], and auditory hallucinations [hearing sounds or voices that are not real]). During a review of Resident 1's History and Physical (H&P) dated 5/28/2026, the H&P indicated Resident 40 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 1 had moderate cognitive impairment (clear problems with memory, thinking, and reasoning, that disrupts regular daily activities). The MDS indicated Resident 1 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, showering/bathing, dressing upper body, and partial/moderate assistance (helper does less than half the effort) for dressing the lower body, putting on or taking off footwear, and personal hygiene. Resident 1 was ambulatory with supervision or touch assistance. During a review of Resident 1's Physician Order Report signed 7/22/2026, the physician order report indicated physician's orders for: 1. Depakote Delayed Release 250 mg, give one tablet by mouth twice a day; 9 a.m., and 5 p.m., for mood swings, order date 9/4/2025 2. Mood Stabilizer (for Depakote Use), observe resident closely for significant side effects; Lethargy (lack of energy or tiredness) 3. Target Behavior: (mood swings), at the end of each shift, mark frequency- how often behavior occurred and intensity - how resident responded to redirection. Intensity Code: 0= Did not occurred; 1 = Easily Altered; 2 = Difficult to Redirect. Special Instructions: Staff Note: Add Frequency and Intensity med notes to order for tracking. Every shift: Night, Day, Evening, order date 9/4/2025 4. Target Behavior: (Delusional thinking). At the end of each shift mark, Frequency-how often behavior occurred & Intensity-how resident responded to redirection. Intensity Code: 0=Did Not Occur; 1 = Easily Altered; 2=Difficult to Redirect. Special Instructions: Staff Note: Add Frequency & Intensity med notes to order for tracking. Every Shift; Night, Day, Evening, order date 9/4/2025 5. Invega Hafyera (every six months) Syringe, 1,560 mg/ 5ml, inject intramuscularly, every six (6) months for psychosis related to paranoid schizophrenia, on the 5th of March and September, during the 7 a.m., to 3 p.m., shift, order date 2/15/2026 6. Amlodipine 5 mg, give one tablet by mouth one time a day at bedtime, 9 p.m., for hypertension ([HTN] high blood pressure). Hold for Systolic ([SBP] - the pressure caused by heart while contracting) of less than 110 millimeters mercury (mmhg a unit of measure of pressure) or heart rate (HR, reference range for a normal adult heart rate is typically 60-100 bpm, with values below 60 bpm considered bradycardia [slow heart rate]) less than 60 bpm, order dated 9/4/2025. 7. Benicar 20 mg, give one tablet by mouth one time a day, 9 a.m., for HTN. Hold for SBP less than 110 mmhg, Diastolic ([DBP] - the pressure in the arteries when the heart is at rest between beats) of less than 60 mmhg, less than 60 bpm, order date 9/4/2025 8. Metformin 1000 mg, give one tablet by mouth twice a day, 9 a.m., and 5 p.m., for Type 2 Diabetes Mellitus, give with meals, order date 9/4/2025 During a review of Resident 1's Care Plan dated 9/4/2025, the Care Plan indicated Resident 1 had a potential for irregular pulse and chest pains secondary to coronary artery disease (blocked or narrowed arteries that reduce blood flow to the heart). The Care Plan's interventions indicated to monitor for chest pain or abnormal pulses; Report to the MD for unusual occurrences promptly; Monitor vital signs; and to administer medications as ordered During a review of Resident 1's Care Plan dated 9/4/2025, the Care Plan indicated Resident 1 had a potential for exacerbation (increase) of blood pressure and its acute and chronic complications, hypertension ([HTN] high blood pressure). The Care Plan's intervention indicated to monitor the effectiveness or adverse effects; Assess, document and notify the MD/family of findings; and to administer medications (Amlodipine and Benicar) as ordered. During a review of Resident 1's Care Plan dated 9/4/2025, the Care Plan indicated Resident 1 was at risk for hyperglycemia (high blood sugar) related to DM. The Care Plan's intervention indicated. to administer medications as ordered. During a review of Resident 1's Care Plan dated 9/10/2025, the Care Plan indicated Resident 1 had altered thought processes due to her diagnosis of paranoid schizophrenia.periods of confusion, disorientation, unawareness of time and place and inability to recognize staff names and faces and others.The Care Plan indicated Resident 1 was at risk for decline in cognitive abilities. The Care Plan's interventions indicated.to observe for any change in mental status/cognitive skills; Redirect resident attention as appropriate; Psych consult treatment, and follow-up as appropriate; Learn patients (resident's) needs and pay attention to non-verbal cues; Use resident names During a review of Resident 1's Care Plan, dated 12/12/2025, the Care Plan indicated Resident 1 was noncompliant (non-adherence) with labs, dental, ophthalmology and podiatry care, as evidenced by Resident 1's verbal refusal of recommended labs and consults. Resident 1's Care Plan interventions indicated to assess resident's refusal (time, financial concerns, lack of understanding), provide clear and simple education about the purpose of labs and specialty consults; collaborate with the Interdisciplinary Team ([IDT] a coordinated group of health professionals and staff members who work together to plan, deliver, and evaluate a resident's care) to address barrier; document and report refusal of care to the MD (physician) and the Responsible Party (RP) During a review of Resident 1's Medication Administration Record ([MAR] a permanent record that shows which medicine was given, how much, when, and by whom) for the months of 4/2026 through 7/2026, documentation by licensed nurses initial and circled on the MAR, indicated Resident 1 refused the following medications: 1. Depakote 250 mg order to be administered twice a day at 9 a.m. and 5 p.m. was documented not administered or refused a total of 56 times: Resident 1 refused Depakote on: 4/7/2026 at 9 a.m. 5 p.m., 4/8/2026 at 5 p.m., 4/9/2026 at 9 a.m., 4/10/2026 at 9 a.m., 4/11/2026 at 5 p.m., 4/12/2026 at 9 a.m., 4/16/2026 at 9 a.m., 5 p.m., 4/17/2026 at 5 p.m., 4/18/2026 at 5 p.m., and 4/27/2026 at 9 a.m. Resident 1's refused Depakote on: 5/1/2026 at 9 a.m., 5/11/2026 at 9 a.m., 5/12/2026 at 9 a.m., 5/13/2026 at 9 a.m., 5/14/2026 at 9 a.m., 5/15/2026 at 9 a.m., 5/21/2026 at 9 a.m., 5/26/2026 at 9 a.m., 5/27/2026 at 9 a.m., 5/28/2026 at 9 a.m., and 5 p.m., 5/29/2026 at 9 a.m., 5 p.m.,5/30/2026 at 5 p.m., and 5/31/2026 at 5 p.m. Resident 1's refused Depakote on: 6/1/2026 at 9 a.m., 6/4/2026 at 5 p.m., 6/5/2026 at 9 a.m., 6/6/2026 at 9 a.m., 6/7/2026 at 5 p.m., 6/8/2026 at 9 a.m., 5 p.m., 6/13/2026 at 5 p.m., 6/15/2026 at 5 p.m., 6/16/2026 at 9 a.m., 6/22/2026 at 9 a.m., 6/23/2026 at 9 a.m., and 5 p.m., 6/27/2026 at 9 a.m., 6/28/2026 at 9 a.m., and 6/30/2026 at 9 a.m. Resident 1's refused Depakote on: 7/7/2026 at 9 a.m., 7/11/2026 at 5 p.m., 7/12/2026 at 9 a.m., 7/13/2026 at 9 a.m., 7/14/2026 at 9 a.m., 7/18/2026 at 5 p.m., 7/19/2026 at 9 a.m., and 5 p.m., 7/20/2026 at 5 p.m., 7/29/2026 at 9 a.m., and 5 p.m.,7/30/2026 at 9 a.m., and 7/31/2026 at 9 a.m. 2. Between 5/2026 through 7/2026, Resident 1's Benicar 20 mg order to be administered once a day at 9 a.m., was documented not administered or refused a total of 27 times: Resident 1 refused Benicar five consecutive days, and no blood pressure level was documented on: 5/26/2026 at 9 a.m., 5/27/2026 at 9 a.m., 5/28/2026 at 9 a.m., 5/29/2026 at 9 a.m., and 5/30/2026 at 9 a.m. Resident 1's refused Benicar nine times, and no blood pressure level was documented seven out of nine times on: 6/1/2026 at 9 a.m., 6/6/2026 at 9 a.m., 6/16/2026 at 9 a.m., 6/23/2026 at 9 a.m., 6/27/2026 at 9 a.m., 6/28/2026 at 9 a.m., and 6/30/2026 at 9 a.m. Two out of nine times Resident 1's blood pressure was documented, and medication was not administered/refused on 6/5/2026 at 9 a.m. and 6/22/2026 at 9 a.m. Resident 1refused Benicar 13 times, and no blood pressure level was documented 11 out of 13 times on: 7/6/2026 at 9 a.m., 7/7/2026 at 9 a.m., 7/12/2026 at 9 a.m., 7/13/2026 at 9 a.m., 7/14/2026 at 9 a.m., 7/20/2026 at 9 a.m., 7/25/2026 at 9 a.m., 7/28/2026 at 9 a.m., 7/29/2026 at 9 a.m., 7/30/2026 at 9 a.m., and 7/31/2026 at 9 a.m., For Resident 1, two out of 13 times her blood pressure level was documented, and medication was not administered/refused on 7/19/2026 at 9 a.m., and 7/24/2026 at 9 a.m. 3. Between May - July 2026, Resident 1's Amlodipine 5 mg order to be administered once a day at 9 a.m., was documented not administered or refused a total of 16 times: Resident 1 refused Amlodipine two consecutive days, and no blood pressure level was documented on 5/30/2026 at 9 a.m., 5/31/2026 at 9 a.m. Resident 1 refused Amlodipine six times, and no blood pressure level was documented on: 6/4/2026 at 9 a.m., 6/7/2026 at 9 a.m., 6/13/2026 at 9 a.m., 6/15/2026 at 9 a.m., 6/27/2026 at 9 a.m., and 6/28/2026 at 9 a.m. Resident 1 refused Amlodipine eight times on: 7/6/2026 at 9 a.m., 7/7/2026 at 9 a.m., 7/14/2026 at 9 a.m., 7/19/2026 at 9 a.m., 7/20/2026 at 9 a.m., (no blood pressure was documented), 7/26/2026 at 9 a.m., (no blood pressure was documented), 7/28/2026 at 9 a.m., and 7/29/2026 at 9 a.m. 4. Between 6/2026 through 7/2026 Resident 1's Metformin 1000 mg order to be administered twice a day at 9 a.m., and 5 p.m., was documented not administered or refused on: 6/1/2026 at 9 a.m., 6/5/2026 at 9 a.m., 6/6/2026 at 9 a.m., 6/8/2026 at 9 a.m., 6/22/2026 at 9 a.m.,6/23/2026 at 9 a.m., and 5 p.m., 7/13/2026 at 9 a.m., 7/29/2026 at 9 a.m., and 7/30/2026 at 9 a.m. During a concurrent interview and record review on 8/6/2026 at 2:34 p.m., with the Director of Staff Development (DSD) Resident 1's MARs for 4/2026 through 7/2026 were reviewed for behavior and medication administration. The DSD stated, Resident 1 was pleasant and soft spoken, very smart and knew she could refuse all medications (meds) except psychiatric (psych) medications. The DSD stated on the third refusal of medication the licensed nurses should notify the resident's physician and document the refusal in the nursing notes and alone with interventions tried. The DSD stated licensed nurses documented on Resident 1's MARs between 4/2026 through 7/2026 the number of episodes by hashmarks (tally marks, used to count the frequency of recurring events) for mood swing behavior. The DSD stated that mood swings could include a variety of behaviors, but there was no documentation describing the behaviors observed, their triggers, what interventions were attempted to relieve or reduce the behavior, or if those interventions were effective. The DSD stated hashmarks indicate Resident 1 displayed mood swings but was not specific. Resident 1 getting angry, for example, could be a mood swing behavior and it would be helpful to document what the mood swing was, under what circumstances or trigger it occurred, as that information could help the next staff member caring for Resident 1 to know what might trigger or worsen the resident's behavior. During a concurrent interview and record review on 8/6/2026 at 3:02 p.m., with the DSD, Resident 1's Nursing Progress notes and MARs for the Months of 4/2026 through 7/2026 were reviewed. The DSD stated the 4/2026 MAR, showed Resident 1 had 15 documented episodes of delusional thinking and 29 episodes of mood swings. The 6/2026 MAR indicated Resident 1 experienced 101 episodes of delusional thinking and 64 episodes of mood swings. The DSD stated the Nursing Progress notes did not include any descriptions of Resident 1's behavioral symptoms, such as delusional thinking or mood swings. During an interview and record review on 8/6/2026 at 4:49 p.m., the Medical Records Director (MRD) reviewed Resident 1's Nursing Weekly Summary Report for the period from 5/7/2026 to 7/30/2026. The MRD stated there was no documentation showing the charge nurses (Licensed Vocational Nurse [LVN]) reported to the Registered Nurse Supervisor (RNS) that Resident 1 was refusing medications, including Depakote for mood swings. The MRD stated Resident 1 missing multiple doses of medications, including Depakote, could cause the resident to become irritable, experience changes in behavior, become sad, or show worsening behavior. The MRD stated Resident 1 needed to take Depakote to help keep the resident's behavior stable. During a telephone interview on 8/10/2026 at 4:30 PM, the facility's Consultant Pharmacist (Pharm) 1, in the presence of the Director of Nursing (DON), Pharm 1 stated licensed nurses should record any signs indicating that Resident 1's behavior or condition was different from the previous day. Pharm 1 stated that it was the licensed nurses' responsibility to observe and assess Resident 1 to determine if there were any changes in her behavior from one day to the next. Pharm 1 stated licensed nurses should document a description of the behavior they observe to help the physician review the resident's behaviors and make informed decisions about adjustments to the resident's care. During an interview on 8/10/2026 at 5:25 p.m., the Administrator (ADM) acknowledged Resident 1 refused additional medications that included DM medication, Metformin and blood pressure medications, Benicar and Amlodipine. The ADM stated Resident 1's refused blood pressure medications three consecutive days which could have resulted in HTN and the physician should have been notified. During a review of the facility's Policy and Procedures (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated 2/2025, the P&P indicated, The care plan includes, as a minimum: a description of the behavioral symptoms, including. precipitating factors or situations. Targeted and individualized interventions for the behavioral and/ or psychosocial symptoms.specific and measurable goals for targeted behaviors; and how the staff will monitor the effectiveness of the interventions. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 3/2022, the P&P indicated, If psychotropic medications are prescribed for behavioral symptoms, documentation includes: potential underlying causes of the behavior; specific, target behaviors and expected outcomes; monitoring for efficacy and adverse consequences. The P&P indicated under, Monitoring: The IDT monitors for and documents any new, worsening, or improved symptoms in the resident's behavior, mood, and function.Interventions are adjusted based on the impact on behavior and other symptoms.When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. During a review of the facility's P&P titled, Charting and Documentation, dated 7/2017, the P&P indicated: Documentation in the medical record may be electronic, manual or a combination.The following information is to be documented in the resident medical record: Objective observations; Medication administered; Treatments or services performed: Changes in the resident's condition.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.Documentation of procedures and treatments will include care-specific details, including:the date and time the procedure/treatment was provided;the name and title of the individual(s) who provided the care;the assessment data and/or any unusual findings obtained during the procedure/ treatmenthow the resident tolerated the procedure/treatment;whether the resident refused the procedure/ treatment;notification of family, physician or other staff, if indicated;and the signature and title of the individual documenting.

Based on interview, and record review, the facility failed to ensure behaviors for three of three sampled residents (Residents 1, 2 and 3) were documented in a narrative form in the resident's clinical records when the behaviors were identified and documented by numbers on 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). As a result, Resident's 1, 2 and 3's specific behaviors remained unknown and had the potential to place all residents at risk for harm by not identifying potentially dangerous behaviors.Findings: a. During a review of Resident 1's undated admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis of paranoid schizophrenia (a chronic brain disorder marked by false beliefs of persecution or conspiracy known as delusions [having false or unrealistic beliefs], and auditory hallucinations [hearing sounds or voices that are not real]). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 1 had moderate cognitive impairment (clear problems with memory, thinking, and reasoning, that disrupts regular daily activities). The MDS indicated Resident 1 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, showering/bathing, dressing upper body, and partial/moderate assistance (helper does less than half the effort) for dressing the lower body, putting on or taking off footwear, and personal hygiene. Resident 1 was ambulatory with supervision or touch assistance. During a review of Resident 1's Physician Order , the Physician Order indicated the following: 1. 9/4/2025 - Depakote (a mood-stabilizing medication used to treat bipolar disorder) 250 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), twice a day for mood swings. Staff should monitor the resident for any mood swings and 12/18/2025 - delusional thinking (a false belief), at the end of every shift (day, evening, and night) document how many times the mood swings occurred and how strongly the resident reacted when staff tried to redirect them. Staff should use the following scale when recording intensity: 0 if no mood swings happened, 1 if the resident was easily redirected, and 2 if the resident was difficult to redirect. All frequency and intensity information must also be added to the medication notes so the behavior can be tracked over time. 2. 2/15/2026 - Invega Hafyera (an antipsychotic medication used to treat Schizophrenia) 1560 mg intramuscular (an injection given in the muscle tissue) injection, every six months for psychosis (seeing or hearing things that are not there or believing things that are not true) related to paranoid schizophrenia. During a review of Resident 1's MAR, dated 7/2026, the MAR indicated on 7/5/2026 Resident 1 had two episodes of delusional thinking and was difficult to redirect, on 7/10/2026 Resident 1 had 1 episode of delusional thinking and was easily redirected, and on 7/12/2026 Resident 1 had two episodes of delusional thinking and was difficult to redirect. The MAR indicated Resident 1 had 22 episodes of mood swings 22 days in a row between 7/10/2026 and 7/31/2026 and was easily redirected. The MAR did not indicate under the notes section details regarding Resident 1's delusional thoughts or mood swings. b. During a review of Resident 2's admission Record (Face Sheet), undated, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (major mood episodes like mania [a state of abnormally elevated, expansive, or irritable mood paired with high energy, hyperactivity, and reduced need for sleep] and sometimes depression), tardive dyskinesia ([TD] a movement disorder that causes uncontrolled, repetitive body movements, usually in the face, tongue, lips, fingers, or toes. It happens as a side effect of taking certain medicines), and extrapyramidal and movement disorder (drug-induced movement disorders caused by medications that block dopamine receptors in the brain). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive status could not be assessed. The MDS indicated Resident 2 required supervision or touch assistance with oral hygiene, toileting hygiene, lower body dressing, and walking up to 50 feet. Resident 2 required partial/moderate assistance with eating, dressing the upper body, and putting on or taking off footwear, bathing/showering, and personal hygiene required substantial/moderate assistance (helper does more than half the effort). During a review of Resident 2's Physician Order, the Physician's Order indicated the following: 1. 7/16/2012 - Monitor Resident 2 for any loud disruptive outbursts related to her diagnosis of schizoaffective disorder, bipolar type, at the end of every shift (day, evening, and night) document how many times the mood swings occurred and how strongly the resident reacted when staff tried to redirect them. Staff should use the following scale when recording intensity: 0 if no mood swings happened, 1 if the resident was easily redirected, and 2 if the resident was difficult to redirect. All frequency and intensity information must also be added to the medication notes so the behavior can be tracked over time. 2. 7/16/2014 - Monitor Resident 2 for anxiety; intrusive repetitive thoughts, and restlessness, at the end of every shift (day, evening, and night) document how many times the mood swings occurred and how strongly the resident reacted when staff tried to redirect them. Staff should use the following scale when recording intensity: 0 if no mood swings happened, 1 if the resident was easily redirected, and 2 if the resident was difficult to redirect. All frequency and intensity information must also be added to the medication notes so the behavior can be tracked over time. 3. 6/15/2016 - Monitor Resident 2 for refusal of ADLs, meals, and meals, related to schizoaffective disorder, bipolar type, at the end of every shift (day, evening, and night) document how many times the mood swings occurred and how strongly the resident reacted when staff tried to redirect them. Staff should use the following scale when recording intensity: 0 if no mood swings happened, 1 if the resident was easily redirected, and 2 if the resident was difficult to redirect. All frequency and intensity information must also be added to the medication notes so the behavior can be tracked over time. 4. 10/6/2023 - Invega Hafyera 1560 mg intramuscular injection, every six months for bipolar schizoaffective disorder manifested by refusing ADLs, meals, and medications. During a review of Resident 2's MAR, dated 7/2026, the MAR indicated on 7/18/2026 Resident 2 had two episodes of intrusive repetitive thought, and restless anxiety that was difficult to redirect, and 13 episodes (13 days in a row) between 7/19/2026 and 7/31/2026 that were easily to redirected. The MAR indicated on 7/18/2026, Resident 2 had two episodes of loud disruptive outbursts that were easy to redirect. The MAR indicated Resident 2 had six episode of loud disruptive outburst that were easy to redirect (five days in a row) between 7/21/2026 through 7/25/2026 , and between 7/27/2026 through 7/31/2026 (five days in a row) Resident 2 had five episodes of loud disruptive outburst that were easy to redirect. The MAR did not indicate under the notes section details of Resident 2's anxiety or loud disruptive outburst. During a review of Resident 2's Medication Administration Record (MAR), dated 7/2026, the MAR indicated 7/18/2026 through 7/31/2026 (14 days in a row) Resident 2 had 14 episodes of refusal of ADLs, meds, and meals, that were easy to redirect. The MAR did not indicate under the notes section any details regarding monitored behaviors. c. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 had diagnoses including schizophrenia (a chronic brain disorder marked by auditory hallucination) and an anxiety disorder (a mental health condition involving intense, excessive, and ongoing fear or worry about everyday situations). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was moderately impaired. The MDS indicated Resident 3 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, showering/bathing, dressing, and required partial/moderate assistance for personal hygiene. During a review of Resident 3's Physician's Order , dated 8/28/2024, the Physician's Order indicated the following: a. Clozapine (an antipsychotic used to treat Schizophrenia) 400 mg tablet at bedtime for psychosis related to schizophrenia. b. Depakote ER (extended release) 1000 mg tablet at bedtime for mood swings related to schizophrenia. c. Depakote ER 500 mg tablet in the morning for mood swings related to schizophrenia. d. Monitor Resident 3 for agitation, angry outbursts, hallucinations, and paranoia at the end of every shift (day, evening, and night) document how many times the mood swings occurred and how strongly the resident reacted when staff tried to redirect them. Staff should use the following scale when recording intensity: 0 if no mood swings happened, 1 if the resident was easily redirected, and 2 if the resident was difficult to redirect. All frequency and intensity information must also be added to the medication notes so the behavior can be tracked over time. During a review of Resident 3's MAR, dated 7/2026, the MAR indicated on 7/12/2026 through 7/26/2026 (15 days in a row) Resident 3 had 15 episodes of agitation/angry outbursts that were easily redirected. The MAR indicated on 7/5/2026 through 7/26/2026 (22 days in a row) Resident 3 had 26 episodes of hallucinations that were easily redirected. The MAR indicated on 7/8/2026 through 7/31/2026 (24 days in a row) Resident 3 had 41 episodes of paranoia. The MAR did not indicate under the notes section details or Resident 3's behavior of agitation/angry outburst, hallucinations, or paranoia. During an interview on 8/5/2026 at 10:33 a.m., the Medical Records Director (MRD) stated nurses only tally resident behaviors, and do not document the actual behavior specifically unless it is a change of condition which means there is a new or worsening behavior.During an interview on 8/5/2026 at 2:48 P.M., Licensed Vocational Nurse (LVN) 3 stated they licensed nurses do not document the details of residents' behaviors. LVN 3 stated she did not remember the exact date that ) Resident 1 was standing in the hallway outside the dining room talking to someone who was not there and appeared to be upset. She redirected her (Resident 1) to her room, and she went to her room without any problems. LVN 3 stated she did not document in Resident 1's medical record what she (Resident 1) was doing when she observed her behavior and acknowledged that it was important to chart the specific behaviors of Resident 1 to know how coordinate a plan of treatment as a team. During an interview on 8/6/2026 at 2:14 p.m., the Director of Staff Development (DSD) stated with their current system of documenting Residents' behaviors, she would have to speculate what the specific behaviors was because there was no narrative or description of residents' behaviors that were observed by staff and given a number of times they occurred on the MAR. During an interview on 8/7/2026 at 12:13 p.m., The Assistant Administrator (AADM) stated charting behaviors of residents was not specific enough. If Resident 1 was hearing voices, the voices could have told her to harm someone, which was unsafe and dangerous for other residents. The AADM stated based on Resident 1's chart, there was no way to tell what Resident 1's specific behaviors were. She did not know what Resident 1 was paranoid about, what types of hallucinations she had, or what agitated her. During an interview on 8/7/2026 at 2:17 p.m., the Director of Nursing (DON) stated licensed nurses should be more specific when they documented residents' behaviors to determine if the resident needed additional evaluation and treatment. During a review of facility's Policy and Procedure (P/P) titled Behavior Assessment, Intervention, and Monitoring dated 2/2025, the P/P indicated nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, cognition, including any recent precipitating or relevant factors or environmental triggers, and that new onset or changes of behavior are evaluated and documented, regardless of the degree of risk to the resident or others. The IDT thoroughly evaluates new or changing behavioral symptoms to identify underlying causes and addresses any modifiable factors that may have contributed to the resident's change in condition.

Based on observation, interview, and record review, the facility failed to ensure Resident to Resident abuse between one of three sampled residents (Resident 1 and Resident 2) was reported to the California Department of Public Health (CDPH) within two hours. As a result, the CDPH was not notified timely of the alleged abuse, and this had the potential to delay CDPH's investigation and place residents at risk for further abuse.Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis of paranoid schizophrenia (a chronic brain disorder marked by false beliefs of persecution or conspiracy known as delusions [having false or unrealistic beliefs], and auditory hallucinations [hearing sounds or voices that are not real]). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated [DATE], the MDS indicated Resident 1 had moderate cognitive impairment (clear problems with memory, thinking, and reasoning, that disrupts regular daily activities). The MDS indicated Resident 1 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, showering/bathing, dressing upper body, and partial/moderate assistance (helper does less than half the effort) for dressing the lower body, putting on or taking off footwear, and personal hygiene. Resident 1 was ambulatory with supervision or touch assistance. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (major mood episodes like mania [a state of abnormally elevated, expansive, or irritable mood paired with high energy, hyperactivity, and reduced need for sleep] and sometimes depression), tardive dyskinesia ([TD] a movement disorder that causes uncontrolled, repetitive body movements, usually in the face, tongue, lips, fingers, or toes. It happens as a side effect of taking certain medicines), and extrapyramidal and movement disorder (drug-induced movement disorders caused by medications that block dopamine receptors in the brain). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive status could not be assessed. The MDS indicated Resident 2 required supervision or touch assistance with oral hygiene, toileting hygiene, lower body dressing, and walking up to 50 feet. Resident 2 required partial/moderate assistance with eating, dressing the upper body, and putting on or taking off footwear, bathing/showering, and personal hygiene required substantial/moderate assistance (helper does more than half the effort). During a review of the facility's Facsimile (Fax) Confirmation to the CDPH, dated [DATE], the Fax Confirmation indicated the fax was sent to the CDPH at 2:24 a.m., on [DATE] (seven hours and nine minutes after the resident to resident abuse occurred). During a review of the facility's Summary of Incident, dated [DATE], the Summary of Incident indicated on [DATE] at approximately 7:15 p.m., CNA 1 entered Resident 1 and Resident 2's shared room and observed Resident 2 lying on her bed on her right side facing the window while Resident 1 sat on Resident 2's bed and leaned forward toward Resident 2. Resident 1 had a string or shoelace on Resident 2's face, CNA 1 attempted to move Resident 1 away from Resident 2 but Resident 1 resisted. CNA 1 called for help, CNA 2 responded immediately and assisted CNA 1 to separate Resident 1 and Resident 2 then CNA 2 yelled for help. The Summary of Incident indicated licensed nursing staff responded immediately and determined Resident 2 was unresponsive (when a person does not react or show signs of life, movement, or awareness when stimulated by sound, touch or pain), cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure performed when someone has stopped breathing or their heart has stopped) was initiated, and paramedics were called. During an interview on [DATE] at 10:58 a.m., the Administrator (ADM) stated on [DATE], at approximately 9 p.m., he was notified that there was an incident between Resident 1 and Resident 2, resulting in Resident 2's death. The ADM stated he should have reported the physical abuse that occurred between Resident 1 and Resident 2 to the CDPH within two hours, but he was concerned with making sure the other residents at the facility were safe and did not submit the fax report to CDPH until [DATE] at 2:24 a.m. During a review of facility's undated Policy and Procedure (P/P) titled Abuse Prevention and Investigation the P/P indicated any incident of substantiated abuse will be reported to the local Department of Health Services and Licensing and Certification Office by telephone immediately.

Based on interview and record review, for one of six sampled residents (Resident 130), the facility failed to: provide non-pharmacologic interventions prior to administering psychotropic medications: Zyprexa [medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) or bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] and Remeron (medication used to treat major depressive disorder) Monitor resident for the specific manifested behaviors for the use of Remeron. This deficient practice had the potential to place residents at risk for receiving unnecessary medication.Findings: During a review of Resident 130's admission Records, the admission Records indicated the facility admitted Resident 130 on 2/26/2021 and was readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and resting tremor (a rhythmic, involuntary shaking of a body part like a hand or leg that happens when those muscles are completely relaxed and resting) on the right upper extremity.During a review of Resident 130's history and physical (H&P) dated 3/14/2026, the H&P indicated Resident 130 had fluctuating (changing frequently) ability to understand and make decisions.During a review of Resident 130's Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 130 had severe impairment of the ability to think or make decisions. The MDS indicated Resident 130 had behaviors of delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 130 needed staff supervision with eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, and taking off or putting on footwear. The MDS indicated Resident 130 needed moderate staff assistance with personal hygiene. During a concurrent interview and record review on 6/11/2026 at 9:31 a.m., with Licensed Vocational Nurse (LVN) 7, Resident 130's orders and medication administration record MAR for May 2026 and June 2026 were reviewed. LVN 7 stated Resident 130 had an order for Zypreza 10 milligrams MG - unit of measurement) once a day for schizophrenia manifested by (M/B) complaining of people stealing from him and an order for Remeron 15 MG every night for right hand tremors. LVN 7 stated the Remeron order for hand tremors needs to be clarified. LVN 7 stated there is no documentation that indicated Resident 130's hand tremors were being monitored. During an interview on 6/12/2026 at 2:08 p.m., with the Facility Pharmacy Consultant (FPC), the FPC stated if the resident was receiving Remeron for hand tremors, then the facility should monitor and document the episodes of hand tremors so the physician can determine if the prescribed treatment is working and should be continued.During a concurrent interview and record review on 6/12/2026 at 2:55 p.m., with LVN 6, Resident 130's MAR for May 2026 and June 2026 were reviewed. LVN 6 stated there was no indication that nonpharmacological interventions were provided prior to administration of Zyprexa and/or Remeron. During an interview on 6/12/2026 at 3:18 p.m., with the Director of Nursing (DON), the DON stated it was important to provide non-pharmacological interventions to decrease the usage of psychotropic medications. The DON stated non-pharmacological interventions should be documented in the MAR with the behavior management tasks. The DON stated it was important to monitor and document the medication's indicated manifested behavior so the psychiatrist can review the behaviors and decide to decrease or continue the medications. During a review of the facility's policy and procedure (P&P), titled Psychotropic Medication Use, revised February 2025, the P&P indicated prior to initiate the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives; the indications and rationale for the recommendation; the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and the resident's/representative's right to accept or decline the treatment. During a review of the facility's P&P, titled Tapering Medications and Gradual Drug Dose Reduction, revised February 2025, the P&P indicated behavioral interventions are used to support the resident and refer to individualized, nonpharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical, or psychosocial wellbeing. During a review of the facility's P&P, titled Behavioral Assessment, Intervention and Monitoring, revised February 2025, the P&P indicated non-pharmacologic approaches are used to the extent possible to avoid or reduce use of psychotropic medications to manage behavioral symptoms.

Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS- a resident assessment tool) were completed within the required time frame for five of five sampled residents (Residents 21, 34, 123, 12, and 88) as evidenced by:A. Failing to assess and transmit the required quarterly MDS for Residents 21,34, and 123 within the mandated OBRA assessment (a federally mandated evaluation required for every resident in a Medicare or Medicaid-certified nursing facility, regardless of how they pay for their care) schedule (every 92 days).B. Failing to complete quarterly MDS for Residents 12 and 88 timely. This failure had the potential to negatively affect the provision of necessary care and services, including delayed care planning, failure to identify emerging or ongoing medical issues, and a decreased quality of life for Residents' 21, 34, 123, 12, and 88, as the MDS is a federally mandated assessment tool essential for ensuring timely care planning and accurate identification of resident needs. Findings: A. During a review of Resident 21's admission record, the admission record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a chronic mental health disorder characterized by intense, irrational suspicions, false beliefs, and auditory hallucinations [hearing, seeing, smelling things that are not based on reality]), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and extrapyramidal disorder (involuntary muscle movements and defects in muscle tone). During a review of Resident 21's History and Physical (H&P), dated 10/22/2025, the H&P indicated, Resident 21 did not have the capacity (ability) to understand and make decisions. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21's cognitive skills for daily decision making were severely impaired (never or rarely able to make decisions). The MDS indicated Resident 21 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating, hygiene, shower, dressing, bed mobility, and transfer. During a concurrent interview and record review on 6/12/2026 at 11:37 a.m., with the Minimum Data Set Nurse (MDSN), Resident 21's MDS, dated [DATE], was reviewed. The MDS indicated it was completed and transmitted on 2/12/2026. The MDSN stated, there was no MDS completed for Resident 21 after this. The MDSN stated the quarterly assessment was due to be completed on 5/4/2026 and it was not completed. During a review of Resident 34's admission record, the admission record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), and blindness of left eye. During a review of Resident 34's H&P, dated 10/22/2025, the H&P indicated, Resident 34 did not have the capacity to understand and make decisions. During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34's cognitive skills for daily decision making were moderately impaired (poor decision making, supervision required). The MDS indicated Resident 34 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating, hygiene, dressing, shower, bed mobility, and transfer. During a concurrent interview and record review on 6/12/2026 at 11:41 a.m., with the MDSN, Resident 34's MDS, dated [DATE], was reviewed. The MDS indicated it was completed and transmitted on 2/10/2026. The MDSN stated, there was no MDS completed after this. The MDSN stated the quarterly assessment was due to be completed on 4/30/2026 and it was not completed. During a review of Resident 123's admission record, the admission record indicated Resident 123 was admitted initially to the facility on 5/2/2013 and last readmission was on 7/11/2025 with diagnoses of dementia (a progressive state of decline in mental abilities), DM , and schizophrenia. During a review of Resident 123's H&P , dated 5/9/2026, the H&P indicated, Resident 123 could make needs known but could not make medical decision. During a review of Resident 123's MDS, dated [DATE], the MDS indicated Resident 123's cognitive skills for daily decision making were severely impaired (never or rarely able to make decisions). The MDS indicated Resident 123 required moderate assistance (Helper does less than half the effort) from one staff for shower, personal hygiene, and Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating, oral hygiene, toileting hygiene, dressing, bed mobility, transfer. During a concurrent interview and record review on 6/12/2026 at 11:47 a.m., with the MDSN, Resident 123's MDS, dated [DATE], was reviewed. The MDS indicated it was completed and transmitted on 2/12/2026. The MDSN stated, there was no MDS completed after this. The MDSN stated the MDS assessments were required to be completed upon a resident's admission, quarterly, annually, and when there was a significant change in the resident's condition, consistent with the federally mandated OBRA assessment schedule. The MDSN stated the assessments must be completed in a timely manner to ensure the information accurately reflects the resident's current status. The MDSN stated the MDS was used to identify the residents' needs, and if the assessment did not reflect accurate and current information, necessary care and treatment may not be implemented. During an interview on 6/12/2026 at 3:12 p.m., with the Administrator (ADMIN), the ADMIN stated it was important to complete and transmit MDS assessments in a timely manner because resident care and treatment are based on the resident's current health status as reflected in the assessment. The ADMIN stated delays in completing MDS assessments could result in delays in care planning, failure to identify emerging or ongoing medical issues, and a decreased quality of life for residents. During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessment, revised 10/2023, the P&P indicated, Policy Statement: A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the Minimum Data Set (MDS) is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. Policy Interpretation and Implementation: 1. OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include a. admission Assessment; b. Quarterly Assessment; c. Annual Assessment; d. Significant Change in Status Assessment (SCSA); e. Significant Correction to Prior Comprehensive Assessment (SCPA); f. Significant Correction to Prior Quarterly Assessment (SCQA); and g. Discharge Assessment (return anticipated and return not anticipated) . 6. The resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments. During a review of the facility's P&P titled, Resident Assessment Instrument, revised 9/2010, the P&P indicated, Policy Interpretation and Implementation: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessment and reviews according to the following schedule: a. within 14 days of the resident's admission to the facility, b. When there has been a significant change in the resident's condition, c. at least quarterly, and d. once every 12 months . 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allow the resident to reach his/her highest practicable level of functioning. B. 1. During a review of Resident 12's admission Record, the admission Record indicated the facility initially admitted Resident 12 to the facility on [DATE] and readmitted on [DATE] with diagnoses including, metabolic encephalopathy (any damage or disease that affects the brain), muscle wasting and atrophy. During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 had severe cognitive impairments (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 12 required partial assistance from others with eating, sit to lying, substantial assistance with oral hygiene, bathing, upper body dressing, sit to stand, and bed to chair transfers and dependent assistance with lower body dressing. 2. During a review of Resident 88's admission Record, the admission Record indicated the facility initially admitted Resident 88 on 10/3/2003 and readmitted on [DATE] with diagnoses including, difficulty in walking and paranoid schizophrenia (a mental health disorder that is characterized by disturbances in thought). During a review of Resident 88's MDS dated [DATE], the MDS indicated Resident 88 was moderately impaired in cognitive skills for daily decision making. The MDS indicated Resident 88 required supervision assistance from others with eating, and substantial assistance with oral hygiene, dressing, sit to stand and bed to chair transfers. During an interview on 6/10/2026 at 8:57 a.m. with the MDSN, the MDSN stated the MDS was an assessment that reflected a resident's overall status and showed what treatments the resident was receiving from the facility. The MDSN stated MDS assessments were completed on admission and quarterly thereafter. MDSN stated a quarterly MDS assessment was done every three months, and the facility had 14 days to complete the assessment. The MDSN stated it was important to complete MDS assessments timely to provide a current reflection of the resident and for the facility to review the plan of care for each resident to see if there were any changes the facility needed to address. During a concurrent interview and record review on 6/11/2026 at 8:29 a.m., with the MDSN, Resident 12's MDS assessments were reviewed. The MDSN stated Resident 12's last MDS was completed on 2/2/2026. The MDSN stated Resident 12's next quarterly MDS assessment was due 5/2/2026 and the facility was still in the process of completing the MDS assessment. The MDSN stated Resident 12's quarterly MDS assessment due 5/2/2026 was late. During a concurrent interview and record review on 6/11/2026 at 8:29 a.m., with the MDSN, Resident 88's MDS assessments were reviewed. The MDSN stated Resident 88's last MDS was completed on 2/12/2026. The MDSN stated Resident 88's next quarterly MDS assessment was due 5/14/2026 and the facility was still in the process of completing the MDS assessment. The MDSN stated Resident 88's quarterly MDS assessment due 5/14/2026 was late. During an interview on 6/11/2026 at 10:32 a.m., with the DON, the DON stated MDS assessments should be completed quarterly and on time because the MDS was an assessment of the resident and assisted with care planning for each resident. The DON stated if the MDS assessments were late, something may happen with the resident, and the facility may not catch it. During a review of the facility's policies and procedures (P&P) titled, Resident Assessments, revised 10/2023, indicated quarterly assessments must be performed for all residents. The P&P indicated the resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person centered care plan for four of ten sampled residents (Resident 59, 115, 13, and 80) related to:A. Failing to reflect, develop, and implement a comprehensive, person centered care plan that addressed Resident 59's post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) triggers with specific, individualized interventions and Resident 115's skin excoriation (a scrape or scratch to the skin) from scratching with untrimmed fingernails.B. Complete a quarterly joint mobility assessment (JMA, assessment of joint range of motion [ROM, full movement potential in a joint] to monitor changes) since 7/4/2024 in accordance with Resident 80's care plan.C. Complete a quarterly JMA since 3/21/2025 in accordance with Resident 13's care plan.These deficient practices resulted in Resident 80 experiencing a decline in ROM without facility knowledge or identification and intervention and had the potential for Resident 13 to experience a decline in ROM. This failure had the potential to result in unmet needs for Residents 59, 115, 13 and 80, negatively affecting their well being and contributing to poor resident outcomes. Findings: A. During a review of Resident 59's admission record, the admission record indicated Resident 59 was admitted initially to the facility on 9/25/2023 and last readmission was on 1/27/2025 with diagnoses including PTSD, depression (a mental health condition marked by a prolonged low mood and a loss of interest or pleasure in everyday activities), insomnia (trouble falling asleep or staying asleep), and left eye blindness. During a review of Resident 59's History and Physical (H&P), dated 10/11/2025, the H&P indicated, Resident 59 had the capacity (ability) to understand and make decisions. During a review of Resident 59's Minimum Data Set (MDS-a resident assessment tool), dated 4/4/2026, the MDS indicated Resident 59 required moderate assistance (Helper does less than half the effort) from one staff for oral hygiene, shower, dressing, and Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for toileting hygiene, bed mobility, transfer, eating. During a concurrent observation and interview on 6/8/2026 at 2:43 p.m., with Resident 59 in his room, Resident 59's door was closed and all lights were off. Resident 59's room was dark because the curtains were drawn. Resident 59 stated he wanted the door closed and the lights off because he was sensitive to bright lights and loud noises. Resident 59 stated, when he was exposed to bright lights and loud noises, he experienced nightmares about the war. Resident 59 stated he was a veteran and suffered from traumatic war experiences. Resident 59 stated he was taking a sleeping pill due to insomnia. During a concurrent interview and record review on 6/11/2026 at 3:32 p.m., with the Minimum Data Set Nurse (MDSN), Resident 59's Care Plan (CP) titled, Risk for ineffective coping due to diagnosis of PTSD, dated 5/23/2025 was reviewed. The CP Goal indicated Resident 59 would remain free of PTSD symptoms by 2/2026. The CP Approach Plan indicated staff should monitor early signs of PTSD symptoms during each interaction and encourage Resident 59 to identify and avoid known triggers. The MDSN stated the CP did not identify Resident 59's specific triggers, and the interventions were not resident specific. The MDSN stated not identifying specific triggers to treat placed Resident 59 at risk of re traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again). The MDSN stated the lack of individualized interventions and failure to identify resident specific triggers could compromise Resident 59's emotional safety and well being. During a review of Resident 115's admission record, the admission record indicated Resident 115 was admitted initially to the facility on 7/1/2024 and last readmission was on 5/27/2025 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), skin-picking disorder(a mental health condition characterized by the repeated, compulsive picking of one's own skin) and dementia (a progressive state of decline in mental abilities). During a review of Resident 115's H&P, dated 7/12/2025, the H&P indicated, Resident 115 did not have the capacity (ability) to understand and make decisions. During a review of Resident 115's MDS, dated [DATE], the MDS indicated Resident 119's cognitive skills for daily decision making were severely impaired (never or rarely able to make decisions). The MDS indicated Resident 115 required maximal assistance (Helper does more than half the effort) from one staff for lower body dressing, personal hygiene, moderate assistance (Helper does less than half the effort) from one staff for shower, upper body dressing, and Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for toileting hygiene, oral hygiene, bed mobility, transfer, eating. During a concurrent observation and interview on 6/8/2026 at 3:34 p.m., with Resident 115 in Resident 115's room, Resident 115 was seated in a wheelchair and was observed scratching her head. Resident 115 had bright red liquid substance appearing to be fresh blood was noted on the top of Resident 115's head, forehead, and left ear. Restorative Nursing Assistant (RNA) 1 intervened to stop Resident 115 from scratching. Resident 115's fingernails were observed to be long, sharp, unmanicured, jagged, and unclean. Resident 115's fingernails and fingers were covered dark red dried substance that appeared to be dried blood mixed with bright red liquid substance that appeared to be fresh blood. Resident 115 stated that her head, forehead, and ears were extremely itchy, and she could not stop herself from scratching constantly. During a concurrent interview and record review on 6/11/2026 at 3:43 p.m., with the MDSN, Resident 115's Care Plan (CP) titled, Potential for further infection related to Resident 115 exhibits a pattern of picking at skin, scalp, and ears revised 4/2026 was reviewed. The CP Goal indicated that Resident 115 would be free of signs and symptoms of infection by 7/2026. The CP Approach Plan indicated keeping fingernails trimmed short to reduce the risk of injury. The MDSN stated staff failed to implement the care plan intervention to keep Resident 115's fingernails trimmed short, which was necessary to prevent further injury and infection. The MDSN stated that failure to implement the fingernail trimming intervention could compromise Resident 115's skin integrity and increase the risk of infection on the resident's skin. During an interview on 6/12/2026, at 4:04 p.m., with the Director of Nursing (DON), the DON stated the care plan should be resident centered and corresponding interventions must be implemented to provide proper care to residents. The DON stated the resident's care plan is the resident's specific plan of care and should be implemented as written. The DON stated care plan interventions should be implemented and routinely reevaluated. The DON stated the care plan should be implemented to prevent recurrent events or complications. During a review of facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated, Policy Statement: 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. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 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 . 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are a. provided by qualified people b. culturally competent; and c. trauma informed. 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. B. During a review of Resident 80's admission Record, the admission Record indicated Resident 80 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, schizophrenia (a mental health disorder that is characterized by disturbances in thought) and unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 80's Minimum Data Set (MDS, resident assessment tool) dated 3/6/2026, the MDS indicated Resident 80 was severely impaired in cognitive skills for daily decision making (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, and problem-solving). The MDS indicated Resident 80 did not have any functional limitations in ROM in the upper extremity (UE, shoulder, elbow, wrist/hand) and had limitations in functional ROM on both sides of the lower extremities (LE, hip, knee, ankle/foot). The MDS indicated Resident 80 used a wheelchair. The MDS indicated Resident 80 required supervision for eating and substantial assistance for oral hygiene, toileting, sit to lying, sit to stand, and required dependent assistance for bed to chair transfers. During a review of Resident 80's Physician Order Report, the Physician Order Report indicated an order dated 2/6/2025 for Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) program for passive ROM (PROM, movement at a given joint with full assistance from another person) exercises on both lower extremities once a day seven times a week as tolerated. The Physician Order Report indicated an order dated 2/6/2025 for RNA to apply splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) on left knee once a day seven times a week up to five hours as tolerated. The Physician Order Report indicated an order dated 2/6/2025 for RNA to apply both ankle splints once a day seven times a week for five hours or as tolerated. During a review of Resident 80's CP dated 12/6/2024, the CP indicated Resident 80 was at risk for new and or development of joint limitations contracture (loss of motion of a joint) secondary to decreased mobility. The CP goal indicated Resident 80 will have no further increase in ROM limitations/contracture daily in three months. The CP approach plan indicated to provide JMA quarterly and as needed. During a review of Resident 80's CP dated 1/11/2025, the CP indicated Resident 80 had potential for decreased mobility related to use of splint. The CP approach plan indicated to reassess joint mobility quarterly or as needed. During a review of Resident 80's JMA dated 7/4/2024, the JMA indicated Resident 80 shoulders, elbows, wrists, and hand/fingers were within functional limits (variance due to normal aging process allowed). The JMA indicated Resident 80's minimal (75 – 100% available ROM) limitation in left hip, moderate (50-75% available ROM) limitation in right hip, both knees and both ankles. There were no other JMAs completed in Resident 80's medical records. During a review of Resident 80's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Evaluation dated 6/10/2026, the PT Evaluation indicated an increase in contracture in both ankles compared to the last PT evaluation on 12/18/2024 and Resident 80 developed a new contracture on the right knee. During an observation on 6/8/2026 at 9:52 a.m., Resident 80 was lying in bed towards the right side. Resident 80's knees were bent and Resident 80 was wearing a splint on the left knee and splint on the left ankle/foot. Resident 80 was not wearing a splint on the right ankle/foot. Resident 80's left and right ankle/foot were pointed down away from the body. During a concurrent interview and record review on 6/10/2026 at 9:55 a.m., with Registered Nurse Supervisor (RNS 1), Resident 80's JMA dated 7/4/2024 and care plans were reviewed. RNS 1 reviewed Resident 80's CP and stated the CPs indicated a JMA should be completed quarterly, but no JMAs were completed since 7/4/2024. RNS 1 stated it was important to monitor Resident 80's joint mobility to prevent any declines or changes. RNS 1 stated it was also important to monitor Resident 80's joint mobility to see if the RNA program was working so that staff could communicate with the physician if a change in the RNA program was needed. RNS 1 stated if a resident had a decline in joint mobility, it could affect their safety because their functional mobility would decline. RNS 1 stated she had not completed any JMA for any resident since she started working at the facility about a month and a half ago. During an interview on 6/10/2026 at 11:28 a.m., with the Physical Therapist (PT 1), PT 1 stated it was important to monitor ROM because ROM could suddenly change and if a resident did not receive intervention right away, the ROM could get worse. PT 1 stated if a resident's ROM worsened, it could cause skin issues, pressure sores and limit a resident's mobility. During an observation and interview on 6/10/2026 at 1:10 p.m., in Resident 80's room, PT 1 evaluated Resident 80's ROM in the legs. PT 1 stated Resident 80's ankles were almost fixed now (could no longer move). PT 1 asked Resident 80 if he had pain when moving the ankle and Resident 80 said yes. PT 1 reviewed Resident 80's PT Evaluation dated 12/18/2024 and compared Resident 80's evaluation today and PT 1 stated Resident 80's ankle ROM worsened from the last time Resident 80 was evaluated. PT 1 assessed Resident 80's right knee and stated there was a new contracture now in Resident 80's right knee when there was no contracture last time on 12/18/2024. PT 1 stated Resident 80 would need a splint for the right knee. PT 1 stated the ankle splints Resident 80 currently had could no longer fit because Resident 80's left ankle was inverted and pointed further down and fixed. PT 1 stated the ankle splints would not help Resident 80 anymore because the ankle could no longer get better. PT 1 stated both ankles were contracted at 35 degrees (pointed fully down away from the body) and that was the worst the ankle could get and the most severe impairment. PT 1 stated if therapy was notified earlier, then there definitely could have been interventions PT could have done such as get new splints and try to stretch the leg. PT 1 stated if therapy intervened earlier, therapy could have prevented the ankles from getting worse to this point. During an interview on 6/11/2026 at 10:32 AM with the DON, the DON stated JMAs should be completed upon admission and quarterly. The DON stated the therapy staff should complete JMAs instead of nurses, especially for residents with contractures. The DON stated if residents had ROM impairments, then the facility needed therapy staff to monitor the ROM, because therapy staff were more knowledgeable regarding ROM and contractures. The DON stated it was important to monitor a resident's joint mobility, because staff needed to catch any declines right away so that the facility could intervene and provide interventions like a therapy evaluation. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the interdisciplinary team develops and implements a comprehensive, person-centered care plan for each resident. CROSS-REFERENCE TO F580 AND F688 C. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including, unsteadiness on feet, and left hand contracture (loss of motion of a joint). During a review of Resident 13's Physician Order Report, Physician Order Report indicated an order dated 3/12/2025 for RNA to provide BUE active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) and left/finger PROM seven times a week or as tolerated. The POR indicated an order dated 6/19/2025 for RNA to apply left hand splint for four to six hours after ROM exercises to maintain joint integrity pre/post skin check once a day seven days a week as tolerated. During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had moderate cognitive impairments. The MDS indicated Resident 13 had functional limitations in ROM on one side of the upper extremity and no limitations on the lower extremities. The MDS indicated Resident 13 required supervision for eating, oral hygiene, upper body dressing, sit to lying, sit to stand, and bed to chair transfers. The MDS indicated Resident 13 required partial assistance with bathing and lower body dressing. During a review of Resident 13's CP dated 3/21/2025, the CP indicated Resident 13 needed an RNA program related to left hand contracted. The CP goal indicated Resident 13 would have no further loss with joint mobility in the next three months. The CP approach plan indicated to assess joint mobility assessment upon admission, as needed and quarterly. During a review of Resident 13's JMA dated 3/21/2025, the JMA indicated Resident 13's both shoulders, both elbows, both wrists, right hand/fingers, both hips, both knees, and both ankles were within functional limits (variance due to normal aging process allowed) and Resident 13 had severe (0 – 25% available ROM) limitations in left hand/fingers. There were no other JMAs completed. During an observation and interview on 6/8/2026 at 10:22 a.m., in Resident 13's room, Resident 13 was lying in bed and able to sit up at edge of bed. Resident 13 was wearing a left wrist/hand splint, and the left fingers were bent on top of the splint. During an interview on 6/10/2026 at 9:55 a.m., with the Registered Nurse Supervisor (RNS 1), RNS 1 stated the Registered Nurse supervisor was supposed to complete JMAs on admission, annual, and quarterly. RNS 1 stated it was important to monitor joint mobility to prevent any declines or changes. RNS 1 stated it was important to monitor joint mobility to see of the RNA program was working so that staff could communicate with the physician if a change in the program was needed. RNS 1 stated if a resident had a decline in joint mobility, it could affect their safety because their functional mobility would decline. During an interview on 6/10/2026 at 11:28 a.m., with the Physical Therapist (PT 1), PT 1 stated it was important to monitor ROM because ROM could suddenly change and if a resident did not receive intervention right away, the ROM could get worse. PT 1 stated if a resident's ROM worsens, it could cause skin issues, pressure sores and limit a resident's mobility. During an concurrent interview and record review on 6/10/2026 at 1:50 p.m., with RNS 1, Resident 13's JMA dated 3/21/2025 and care plans were reviewed. RNS 1 stated the last JMA was completed on 3/21/2025 and the JMA indicated Resident 13 had severe ROM limitations in the left hand/fingers. RNS 1 reviewed Resident 13's CP and stated the CP indicated JMAs should be completed upon admission, annually, and quarterly. RNS 1 stated JMAs were not completed quarterly for Resident 13 since 3/21/2025. RNS 1 stated it was important to assess Resident 13's joint mobility quarterly and not annually because annually was too long. RNS 1 stated quarterly was a good time frame to assess if a resident was improving or declining for joint mobility and catch any changes quicker. During an interview on 6/11/2026 at 10:32 a.m., with the DON, the DON stated JMAs should be completed upon admission and quarterly. The DON stated the rehab department should be staff to complete JMAs, especially for residents with contractures. The DON stated if residents had ROM impairments, then the facility needed therapy to monitor the ROM, because therapy staff were more knowledgeable. The DON stated it was important to monitor joint mobility, because staff needed to catch any declines right away so that the facility could intervene and provide interventions like a therapy evaluation. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the interdisciplinary team develops and implements a comprehensive, person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to ensure residents were free from potential accidents when:1. The facility did not ensure Resident 122 was reevaluated by physical therapy when Resident 122 started to pull their front wheel walker (FWW - type of mobility aid with wide base of support) behind them when walking instead of pushing the FWW in front of their body.2. The facility failed to ensure an electrical panel (the central hub that distributes electricity from the grid into the facility) was secured and not easily accessible to ambulatory residents affecting 78 out 141 residents. 3. One out of one sampled residents (Resident 112) was observed being pushed in the hallway while sitting on a rollator walker (a wheeled mobility aid). 4. The facility failed to identify the potential for Resident safety when one out of two sampled residents (Resident 144) was observed wandering into other resident's room. These deficient practices placed residents in the facility at risk for accidents to occur. Findings: 1. During a review of Resident 122's admission Records undated, the admission Records indicated the facility admitted Resident 122 on 2/13/2020 and was readmitted on [DATE] with diagnoses including history of falling, abnormalities of gait (walking) and mobility (movement), and hemiplegia (complete loss of the ability to move one side of the body) on the left side of the body. During a review of Resident 122's history and physical (H&P) dated 2/14/2026, the H&P indicated Resident 122 did not have the ability to understand and make decisions. During a review of Resident 122's Minimum Data Set (MDS – a resident assessment tool) dated 2/20/2026, the MDS indicated Resident 122 had moderate impairment of the ability to think and make decisions. The MDS indicated Resident 122 used a walker as a mobility device. The MDS indicated Resident 122 needed staff supervision with eating, oral hygiene, toileting hygiene, upper body dressing and needed moderate staff assistance with showering, lower body dressing, putting on or taking off footwear, and personal hygiene. The MDS indicated Resident 122 had an active diagnosis of hemiplegia. During a review of Resident 122's care plan dated 2/21/25, the care plan indicated Resident 122 was at risk for falls or injuries related to abnormalities of gait and mobility and was using a front wheel walker improperly. The care plan indicated goals of decreased significant injury as a result from falls in the next three months. The care plan indicated approach plans of educating Resident 122 about the proper use of front wheel walker, supervising Resident 122 during ambulation (walking) with front wheel walker to prevent falls, and monitor every 1 hour to maintain safety and fall precautions. During an interview on 6/10/2026 at 1 p.m. with Physical Therapist (PT) 1, PT 1 stated they had seen Resident 122 in the hallway the day before pulling the FWW and told Resident 122 to use the FWW correctly and push the FWW in front. PT 1 stated Resident 122 would have benefitted from a physical therapy evaluation to address the FWW use. PT 1 stated continued incorrect use of the FWW placed resident at risk for a fall. During a concurrent observation and interview on 6/10/2026 at 2:53 p.m., with Certified Nurse Assistant (CNA) 1, Resident 122 walked in the hallway with the FWW behind them (Resident 122). CNA 1 stated Resident 122 always walked with the FWW walker behind them. CNA 1 stated when we try to instruct Resident 122 to properly use the FWW in the front or move the FWW to the front, Resident 122 will raise his fists or move it back. During a concurrent interview and record review on 6/11/2026 at 9:02 a.m., with Licensed Vocational Nurse (LVN) 7, Resident 122's care plan titled Resident at times is resistive to care, may clench fists when upset, refuses medications sometimes and uses FWW in reverse dated 11/21/2025 was reviewed. LVN 7 stated the approach or interventions of the care plan indicated to notify the physician if refusal increases or behavior worsens. LVN 7 stated Resident 122 started pulling the FWW on 11/21/2025. During a concurrent interview and record review on 6/11/2026 at 9:04 a.m., with Licensed Vocational Nurse 7, Resident 122's physical therapy notes dated 6/12/2022, nursing notes, and change of condition documentation were reviewed. LVN 7 stated there is no documentation that indicated Resident 122's physician was notified that Resident 122 was using the FWW improperly. LVN 7 stated the physician should have been notified. LVN 7 stated the physician could have ordered a physical therapy evaluation for Resident 122. During an interview on 6/12/2026 at 3:18 p.m., with the Director of Nursing (DON), the DON stated it was important to notify the physician of a change of condition to get the resident proper treatment such as a physical therapy evaluation if necessary. The DON stated improper use of the FWW placed Resident 122 at risk for falls. During a review of the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, revised February 2021, the P&P indicated the nurse will notify the resident's attending physician or [physician on call when there has been a significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times); and/or when there is specific instruction notify the physician of changes in the resident's condition. During a review of the facility's P&P titled Assistive Devices and Equipment, revised February 2021, the P&P indicated residents, family, and visitors are trained are trained as indicated, on the safe use of equipment and devices. The P&P indicated the following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment.appropriateness for resident condition-the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. During a review of the facility's P&P titled Safety and Supervision of Residents, revised July 2017, the P&P indicated implementing interventions to reduce accident risks an hazards shall include communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented, and documenting interventions. 2.During an observation on 3/9/2026 at 3:01 p.m., in the hallway across from the smoking patio, an electrical panel was on the wall without a lock and unsecured. The electrical panel was able to be opened and the circuit breakers (an electrical switch designed to protect an electrical circuit from damage caused by overcurrent/overload or short circuit) were accessible. During an interview on 6/10/2026 at 9:31 a.m., the maintenance supervisor (MS) stated the electrical panel did not have a lock and if a resident tried to open it, they could. The MS stated the electrical panel contained circuit breakers for lighting, air conditioner units, and water heaters. The MS stated there was a risk that residents could access the electrical panel, switch off the breaker and turn off the lights. During an interview on 6/12/2026 at 3:18 p.m., the Director of Nursing (DON) stated there was a safety risk to the residents in the facility if the lights abruptly shut off due to a resident tampering with the electrical panel. The DON stated the residents could fall if suddenly there was not good visibility. During a review of the facility's P&P titled Safety and Supervision of Residents dated 7/2017, the P&P indicated the facility was to make the environment as free from accident hazards as possible. 3. During a review of Resident 112's admission Record indicated the facility admitted Resident 112 on 3/26/2021 with diagnoses including schizophrenia (a chronic and severe brain disorder that affects how a person thinks, feels, and acts ), dementia (a decline in mental ability—such as memory, thinking, and reasoning—severe enough to interfere with daily life), and depression (a common but serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities ). During a review of Resident 112's MDS dated [DATE], the MDS indicated Resident 112 had severe cognitive impairment (a profound decline in mental abilities—such as memory, reasoning, and judgment—that prevents independent living) and used a walker for ambulation. During an observation on 6/9/2026 at 8:30 a.m., Resident 112 was observed being pushed by certified nursing assistant (CNA) 13 while Resident 112 was sitting on the seat of the red rollator walker. During an interview on 6/9/2026 at 8:34 a.m., CNA13 stated Resident 112 had just finished her shower so he pushed her back to her room while she was sitting on her rollator walker. During an observation on 6/10/2026 at 8:37 a.m., Resident 112's red rollator walker was sitting at her bedside, a sticker on the inside of the rollator frame stated Warning: Do Not Move Rollator While Seated. During an interview on 6/10/2026 at 11:20 a.m., Physical Therapist (PT) 1 stated Residents were not to be seated on a rollator walker while it was being pushed. PT 1 stated the seat was to be used for quick breaks when the resident got tired while ambulating. PT 1 stated residents were at risk for falls if the rollator walker was used to push the residents on. During an interview on 6/12/2026 at 3:18 p.m., the DON stated residents were at risk for falls if they were pushed while sitting on the rollator walker. During a review of the manufacturer's specifications for Resident 112's Rollator [NAME] revised 1/7/2016, the manufacturers specifications indicated in bolded all capital letters DO NOT MOVE ROLLATOR WHILE SEATED. During a review of the facility's P&P titled Assistive Devices and Equipment dated 2/2021, the P&P indicated staff were to demonstrate competency on the use of devices and equipment prior to assisting residents. 4. a. During a review of Resident 150's admission Record, the admission Record indicated the facility admitted Resident 150 on 10/12/2010 with diagnoses including chronic kidney disease (CKD, a long-term condition where the kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood), heart failure (a chronic condition where the heart muscle doesn't pump blood as efficiently as it should, preventing it from meeting the body's needs), and urinary retention (the inability to completely empty your bladder, or not being able to urinate at all). During a review of Resident 150's MDS dated [DATE], the MDS indicated Resident 150 rarely or never made decisions. b. During a review of Resident 160's admission Record, the admission Record indicated Resident 160 was admitted to the facility on [DATE] with diagnoses of depression (a common but serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities ) and schizophrenia (a chronic and severe brain disorder that affects how a person thinks, feels, and acts). During a review of Resident 160's MDS dated [DATE], the MDS indicated Resident 160 was unable to complete the interview and had memory problems. The MDS indicated Resident 160 rarely or never made decisions. c. During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was admitted to the facility 6/6/2024 with diagnoses of dementia (a decline in mental ability severe enough to interfere with daily life ), post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or deeply stressful event), and anxiety disorder (mental health conditions characterized by persistent, excessive, and disproportionate fear or worry in everyday situations). The Resident admission Record indicated family member (FM) 1 was Resident 61's responsible party (the party responsible to making health care decisions when the principal party is unable to make said health care decisions for him or herself). During a review of Resident 61's MDS dated [DATE], the MDS indicated Resident 61 was unable to complete the interview and had memory problems. The MDS indicated Resident 61 rarely or never made decisions. d. During a review of Resident 144's admission Record, the admission Record indicated Resident 144 was admitted to the facility on [DATE] with diagnoses of schizophrenia and constipation (having fewer than 3 bowel movements a week. During a review of Resident 144's MDS dated [DATE], the MDS indicated Resident 144 had moderate cognitive impairment (noticeable memory or thinking problems—such as losing focus, frequently misplacing items, or struggling with language—but they remain largely independent and can perform daily activities ) and was able to walk 150 feet with supervision or touching assistance (helper provides verbal cues and/ or touching/ steadying and/ or contact guard assistance as resident completes activity). e. During a review of Resident 170's Resident admission Record, the admission Record indicated Resident 170 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms ), diabetes mellitus (high blood sugar), and constipation (fewer than 3 bowel movements per week). During a review of Resident 170's MDS dated [DATE], the MDS indicated Resident 170 had severe cognitive impairment. During an observation on 6/8/2026 at 10:11 a.m., Resident 144 was seen entering a room that was not hers, the room was shared by Resident 150, Resident 160, and Resident 170. Resident 144 proceeded to enter the restroom and after finishing with the restroom she walked back through the resident's room and exited the room. During an interview on 6/12/2026 at 10:32 a.m., with Family Member (FM)1, FM 1 stated she comes to the facility twice a week to visit Resident 61 and while she is visiting, other residents (unknown) walk into Resident 61's room and use the restroom. FM1 stated other residents that do not belong in the room come in and out of Resident 61's room a lot. FM1 stated she was tempted to have Resident 61 moved for this reason, but the facility's location was convenient for her. During an interview on 6/12/2026 at 3:18 p.m., with the DON, the DON stated Residents were to be redirected and not allowed into other resident's rooms. The DON stated when residents enter another resident room, they were invading their privacy, and it should not happen. The DON stated it posed a safety risk if residents were wandering into other residents' rooms. During a review of the facility's P&P titled Safety and Supervision of Residents dated 7/2017, the P&P indicated the facility's priority was resident safety and supervision and assistance to prevent accidents.

Based on observation, interview, and record review, the facility failed to ensure [NAME] nursing staff was competent when:1.A new physician's order was not carried out for one of eight sampled residents (Resident 40) 2. Checking residents trays, when Licensed Vocational Nurse (LVN) 7 did not know how to identify residents' ordered diet texture using the facility's color coded diet system affecting 46 of 141 residents on a texture modified diet such as pureed (paste or thick liquid suspension made from finely ground cooked food) or mechanical soft diet (diet for residents who experience chewing or swallowing limitations, food texture is modified by chopping or grinding). These deficient practices had the potential for a delay in care for Resident 40 and facility residents to receive the wrong food texture resulting in malnutrition or choking. 3.CNA 4 spoke to Resident 119 in a disrespectful and stern manner.This deficient practice had the potential to negatively impact Resident 119 and other residents CNA 4 cared for sense of safety, dignity and well-being. Findings: 1. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including glaucoma (a group of eye diseases that damage the optic nerve caused by a buildup of fluid and elevated pressure inside the eye), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), and frontotemporal neurocognitive disorder (rare progressive brain disease caused by the damage and shrinking of the brain's frontal [behind the forehead drives movement and personality] and temporal [near ears that process memory, language, and auditory information] lobes. During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 2/7/2026, the MDS indicated Resident 40 was mildly cognitively impaired. The MDS indicated Resident 40 required partial assistance (Helper provides less than half the effort) for bathing and personal hygiene and required supervision for all other aspect of activities of daily living (ADLs, routine tasks/activities such as eating, oral hygiene, toileting, a person performs daily to care for themselves). During a review of Resident 40's history and physical (H&P) dated 4/23/2026, the H&P indicated Resident 40 did not have the capacity to understand and make decisions During a review of Resident 40's Licensed Personnel Weekly Progress Notes dated 5/15/2026, the Licensed Personnel Weekly Progress Notes indicated Resident 40 was seen and examined by the optometrist (physician specializing in treating vision issues)(MD 2) and new orders were obtained for: a Registered Nurse (RN) to monitor the right pupil (black center of eye) daily for the next week to check if the right pupil became fixed (pupils that so not react to light, a critical medical sign) and dilated (occur when the black center of the eye becomes larger than normal) and to call MD 2 if it did. The Licensed Personnel Weekly Progress did not indicate the monitoring was done. During a concurrent interview and record review on 6/11/2026 at 4:17 p.m., with Licensed Vocational Nurse (LVN) 7, LVN 7 stated she reviewed Resident 40's Medication Administration Report (MAR) for 5/2026, Treatment Administration Report (TAR) for 5/2026, Physician's Orders for 5/2026, Licensed Personnel Weekly Progress Notes for 5/2026 and could see MD2's order given on 5/15/2026 RN to monitor the right pupil daily for next a week to check if the right pupil becomes fixed and dilated and to call MD 2 if it did but after reviewing the documents the order was not carried out. LVN 7 stated the nurse that took the order (unknown) should have endorsed the order to an RN, completed a change of condition (COC) and started a monitoring task for Resident 40 but it was not done. During an interview on 6/11/2026 at 4:29 p.m., with the Director of Nursing (DON), the DON stated the Physician's Order dated 5/15/2026 to monitor Resident 40's right pupil was not carried out and it was important that nurses carried out Physician's Orders because it ensured the proper treatments for the resident were being done. During an interview on 6/12/2026 at 10:52 a.m., with MD2, MD2 stated he gave the order for monitoring for the right pupil because when he saw Resident 40 on 5/15/2026, Resident 40 was developing a cranial nerve 3 palsy (a condition where damage to the nerve paralyzes specific eye muscles ) and a rare but serious finding that can occur when cranial nerve 3 palsy is present is a ruptured aneurysm (a bulge or ballooning in the wall of an artery ). MD2 stated the monitoring was ordered for nurses to evaluate if a medical problem had occurred (ruptured aneurysm) and the risk of staff not carrying out the monitoring order was possible missing a fixed and dilated pupil signaling that a ruptured aneurysm had occurred. During a review of the facility's Licensed Vocational Nurse (LVN, Charge Nurse, Treatment Nurse, and Unit Manager) job description undated, the job description indicated the LVN was to report COCs to the RN, communicate pertinent data to the RN, participates in shift-to-shift communication between incoming and outgoing nursing staff, and the LVN was to complete all duties as assigned. 2. During an observation on 6/9/2026 at 12:02 p.m., in the kitchen during lunch service preparation, Dietary Aide (DA) 2 called out chopped, and DA 3 placed whole uncut parsley on the plate. During a concurrent observation and interview on 6/9/2026 at 12:18 p.m., with the Dietary Supervisor (DS), DA 2 called out chopped, and DA 3 placed whole uncut parsley on the plate for another resident. During an interview on 6/9/2026 at 12:17 p.m., with LVN 7 in the resident dining room, LVN 7 stated there was no way to know the physician ordered diet texture unless they look at the diet order in the chart. During a concurrent observation and interview on 6/9/2026 at 12:45 p.m., with the DS, the tray carts were observed with color-coded labels. The DS stated black labels received pureed food, orange labels received chopped foods, and blue labels received regular texture food. During an interview on 6/10/2026 at 2:53 p.m., with the Registered Dietician (RD), the RD stated the facility uses a color-coded system on the tray carts which indicates the residents' ordered diet. The RD stated nursing checks the trays before distribution and should be able to identify resident's ordered food texture based on the color-coded system. During a review of the In-service training attendance sheet titled Dining Room/Regular and Diabetic Residents/Diets Color Code provided on 6/3/2026 by the Director of Staff Development (DSD) and the DS, the In-service indicated only Certified Nurse Assistants (CNA)'s were in-serviced. The In-service did not indicate that the LVN's were in-serviced on the color-coded system. During an interview on 6/12/2026 at 3:18 p.m., with the Director of Nursing (DON), the DON stated it is important for nursing to be able to identify the residents' ordered diet when checking the trays, because the nurses are the last safety check before residents receive the tray. The DON stated if the tray is incorrect or does not match the order, the nurse can inform the kitchen. During a review of the facility's policy and procedure (P&P), titled Dining Services Department Inservice Training Meals Quality – Preparation & Evaluation page 109, undated, the P&P indicated during food preparation the facility should pay attention to therapeutic diets preparation and appropriate seasoning and garnishing. During a review of the facility's P&P, titled Competency of Nursing Staff, revised May 2019, the P&P indicated the staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. During a review of the facility's P&P, titled Food and Nutrition Services, revised October 2017, the P&P indicated if an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. 3. During a review of Resident 119's admission Record, the admission record indicated the facility admitted Resident 119 on 10/24/2024 with diagnoses including paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational suspicions, mistrust, and false beliefs that others are plotting to harm or harass the individual), anxiety disorder (constantly feeling worried and nervous), and insomnia (trouble falling asleep or staying asleep). During a review of Resident 119's H&P, dated 10/22/2025, the H&P indicated Resident 119 did not have the capacity (ability) to understand information and make decisions. During a review of Resident 119's MDS, dated [DATE], the MDS indicated Resident 119's cognitive skills for daily decision making were moderately impaired (poor decision making and supervision required). The MDS indicated Resident 119 required moderate assistance (helper performs less than half of the effort) from one staff for shower, putting on foot wear, personal hygiene, and required supervision or touching assistance (helper provides verbal cues and/or touching, steadying, or contact guard assistance while the resident completes the activity) from one staff for toilet hygiene, dressing, bed mobility , transfer, eating. During an observation on 6/8/2026 at 1:07 p.m., Resident 119 was seen gently stroking another resident's (unknown) hair and face while they sat in a chair in the hallway. Resident 119 then stood up suddenly and asked the other resident to shake their hand. At that time, Certified Nursing Assistant (CNA) 4 approached Resident 119 and sternly stated, Go to your room, now! When Resident 119 entered the room, CNA 4 sternly stated, Sit down, then walked away and told Resident 119 to stay in the room. During a concurrent observation and interview on 6/8/2026 at 1:11 p.m., with Resident 119 in his room, Resident 119 was observed pacing back and forth in his room. Resident 119 stated, CNA 4 did not like him, because of the way CNA 4 spoke to him, he thought he had done something wrong that made CNA 4 mad at him. During an interview on 6/8/2026 at 1:15 p.m., with CNA 4 in a hallway, CNA 4 stated, she was fairly new to the facility. CNA 4 stated, she should have used a respectful tone of voice when she told resident 19 to sit down, and told him to go to his room, to ensure Resident 119 felt safe and respected During a concurrent interview and record review on 6/12/2026 at 9:12 a.m., with the Director of Staff Development (DSD), CNA 4's General Employee Orientation, dated 6/3/2026 was reviewed. The General Employee Orientation indicated the DSD was required to initial each section after completion and demonstrated competency. The General Employee Orientation indicated, there was no initials next to the sections for Resident Rights and Handling Residents with Inappropriate Behavior. The General Employee Orientation indicated there was no trainer's signature and date of evaluation. The DSD stated she could not provide evidence that the orientation training courses for Resident Rights and Handling Residents with Inappropriate Behavior were completed due to the missing initials and trainer's signature. The DSD stated the orientation was not completed and stated that insufficient training could contribute to a lack of competency in interacting with residents respectfully. During a review of the facility's Policy and Procedure (P&P) titled, Orientation Program for Newly Hired Employees, Transfers, Volunteers, revised 5/2019, the P&P indicated, Policy Interpretation and Implementation: 1. All newly hired personnel must attend a 10-hour orientation program within their first five days of hire .3. Our orientation program includes d. (4) A review of Resident rights .5. Our orientation program is an in-depth review of our facility's policies and procedures. A checklist is used to record materials reviewed .7. Orientation records include the date reviewed, participant's initials, subject matter reviewed, and other information deemed necessary or appropriate.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Three medication errors of 31 total opportunities contributed to an overall medication error rate of 9.68 % affecting two of four residents observed for medication administration (Resident 81 and Resident 146). The medication errors noted were as follows:1. Resident 81's prescribed metformin hydrochloride (medication used to control the amount of sugar in the blood) was not administered as ordered at the scheduled time.2. Resident 146's midodrine (medication used to increase blood pressure [[force of blood pushing against the blood vessels walls in the heart]) and esomeprazole (medication used to prevent production of too much acid in the stomach) were not available for administration as ordered by the physician.This failure had the potential to result in ineffective management of Resident 81's diabetes and Resident 146's hypotension and gastrointestinal condition, placing the residents at risk for uncontrolled symptoms, weakness, deterioration in condition, and the need for additional medical interventions. Findings:A. During a review of Resident 81's admission Record, the admission Record indicated the facility admitted Resident 81 on 10/8/2024 with diagnoses including hypertension (high blood pressure), paranoid schizophrenia (a mental illness that affects how a person thinks and understands what is real), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 81's history and physical (H&P) dated 10/22/2025, the H&P indicated Resident 81 had the capacity to make needs known but couldnot make medical decisions due to diagnosis of metabolic encephalopathy (a condition where the brain does not work properly because of chemical imbalance or a problem elsewhere in the body).During a review of Resident 81's Minimum Data Set (MDS - a resident assessment tool) dated 1/17/2026, the MDS indicated Resident 81 had moderate impairment of the ability to think or make decisions. The MDS indicated Resident 81 needed staff supervision with eating, oral hygiene and upper body (above the waist) dressing. The MDS indicated Resident 81 needed moderate assistance from staff with toileting hygiene, lower body (below the waist) dressing, putting on or taking off footwear, and personal hygiene, and needed maximum assistance from staff with showering or bathing. The MDS indicated Resident 81 had an active diagnosis of diabetes mellitus.During a medication administration (pass) observation on 6/9/2026 at 8:36 a.m., with Licensed Vocational Nurse (LVN) 2 in Resident 81's room, LVN 2 prepared metformin and other medications. Resident 81 refused medications including metformin.During a review of Resident 81's Physician Order Report dated 6/1/2026 - 6/30/2026, the Physician Order Report indicated Resident 81 was prescribed metformin tablet 850 mg (milligram - a unit of measurement) 1 tablet oral with food for diabetes mellitus twice a day 7:00 a.m. and 5:00 p.m.During a concurrent interview and record review on 6/10/2026 8:05 a.m., with LVN 2, Resident 81's Medication Administration Record (dated 6/1/2026 - 6/30/2026 was reviewed. LVN 2 stated the MAR indicated metformin tablet 850 mg give 1 tablet orally twice a day with food for diabetes at 7:00 a.m. and 5:00 p.m. LVN 2 stated the importance of making sure metformin was given with food was to decrease possible side effects of upset stomach and should have been administered within the two hour window or timed the medication to be administered when Resident 81's breakfast tray was delivered. LVN 2 stated had Resident 81 not refused the metformin, there would be potential for Resident 81 to experience side effects of upset stomach. During an interview on 6/9/2026 at 12:56 p.m., with LVN 2, LVN 2 stated breakfast was served between 7:00 a.m. and 7:30 a.m. LVN 2 stated the importance of administering metformin with meals was to prevent stomach irritation. LVN 2 stated if metformin was not administered with meals, there would be potential for Resident 81's stomach to be irritated. B. During a review of Resident 146's admission Record, the admission Record indicated Resident 146 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and gastro-esophageal reflux disease (GERD - a condition where stomach acid frequently flows backward into the muscular tube connecting the stomach and throat causing a painful burning sensation called heartburn).During a review of Resident 146's H&P dated 6/9/2026, the H&P indicated Resident 146 was unable to make his needs known and was dependent on all activities of daily living (ADLs, routine tasks and activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 146's MDS, dated [DATE], the MDS indicated Resident 146 had moderate impairment of the ability to think or make decisions. The MDS indicated Resident 146 was dependent on staff with all aspects of performing ADLs. The MDS indicated Resident 146 had impairments on one side of both the upper (shoulder and arm) and lower (hip and leg) extremities.During a review of Resident 146's Medication and Treatment Orders dated 6/2/2026, the Medication and Treatment Orders indicated a physician's order for midodrine hydrochloride 5 milligrams (mg - unit of measurement) one tablet via gastrostomy tube every eight hours for hypotension (Blood pressure below the reference range 120/80 millimeters mercury [mm/hg a unit of measure of pressure] - 90/60 mm/hg) hold for Systolic ([SBP] - the pressure caused by heart while contracting) of greater than 130 mm/hg, magnesium 40 mg delayed release one tablet via gastrostomy tube daily for GERD.During a concurrent medication administration (pass) observation and interview on 6/9/2026 at 9:28 a.m., with Licensed Vocational Nurse (LVN) 3 in Resident 146's room, LVN 3 stated Resident 146's midodrine and esomeprazole were unavailable. LVN 3 stated, she would inform the hospice (end of life care focused on comfort and pain control) agency to obtain the medications. LVN 3 stated the importance of having the medication available was to ensure the resident received the medication and to maintain blood pressure and to prevent stomach acid going up to the throat. LVN 3 stated there was potential for Resident 146 to experience adverse effects of hypotension.During an interview on 6/12/2026 at 4:25 p.m. with the Director of Nursing (DON) the DON stated the importance of administering medications as prescribed by the physician was to ensure the resident would be treated for symptoms, illnesses, or disease that warrant medications. The DON stated if medications were not administered as prescribed by the physician, the resident will not be treated for symptoms and medical conditions.During a review of the facility's policy and procedure (P&P) titled Administering Medications revised 4/2019, the P&P indicated .4. Medications are administered in accordance with prescribers orders, including any required time frame.7. Medications are administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).During a review of the facility's P&P titled Medication and Treatment Orders revised 7/2011, the P&P indicated, .11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.During a review of the facility's P&P titled Pharmacy Services Overview revised 2007, the P&P indicated The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist.3. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: . f. Help the facility assure that medications are requested, received, and administered in a timely manner as ordered by authorized prescribers;

Based on observation, interview and record review, the facility failed to ensure:1. Resident 50's Humulin R (regular insulin - medication used to lower blood sugar levels) with open date labeled 4/30/2026 was discarded.2. Acidophilus (a supplement used to keep digestive system healthy) opened on 6/4/2026 was stored in the refrigerator according to manufacturer's guidelines.3. Resident 64's used Lantus Solostar (Insulin Glargine - a long-acting insulin used to control blood sugar levels throughout the day and night) was labeled with date opened.4. Resident 7's unused Lantus Solostar was refrigerated as indicated on the pharmacy label.These failures had the potential to compromise the integrity and effectiveness of the medications, placing residents at risk for adverse drug side effects and ineffective treatment.Findings:A. During a review of Resident 50's admission Record undated, the admission Record indicated the facility admitted Resident 50 on 10/24/2022 and was readmitted on [DATE] with diagnoses including diabetes mellitus (a condition where your body has trouble controlling blood sugar levels), dementia (a progressive state of decline in mental abilities), and bipolar disorder (mood swings that range from the emotional lows to elevated periods of emotional highs).During a review of Resident 50's History and Physical (H&P) dated 10/13/2025, the H&P indicated Resident 50 was unable to make healthcare decisions due to underlying psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and was able to make needs known.During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 had moderate impairment of the ability to think and make decisions. The MDS indicated Resident 50 needed staff supervision with eating and toileting hygiene, moderate staff assistance with oral hygiene, showering, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. The MDS indicated Resident 50 had an active diagnosis of diabetes mellitus and was receiving insulin.During a concurrent observation and interview on 6/9/2026 at 10:26 a.m., with Licensed Vocational Nurse (LVN) 2, medication cart 1 was observed and checked. LVN 2 stated Resident 50's insulin with opened date on 4/30/2026 should have been discarded on 5/28/2026, and should have been replaced with a new vial. LVN 2 stated the importance of making sure insulin was discarded after 28 days or 31 days after opened date was to ensure the medication was still effective. LVN 2 stated if Resident 50 received the expired insulin, there was potential for Resident 50's blood sugar levels to be uncontrolled and experience adverse effects of high blood sugar levels.B. During a concurrent observation and interview on 6/9/2026 at 10:26 a.m., with LVN 3, medication cart 2 was observed and checked. LVN 3 stated the acidophilus that was opened on 6/4/2026 and stored in the cart, should have been refrigerated in the fridge as indicated on the manufacturer's label. LVN 3 stated if the acidophilus was not refrigerated, the supplement would not work appropriately and would not be effective. C. During a review of Resident 64's admission Record undated, the admission Record indicated the facility admitted Resident 64 on 2/1/2007 and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), hypertension (HTN - high blood pressure), and diabetes mellitus.During a review of Resident 64's H&P dated 9/13/2025, the H&P indicated Resident 64 did not have the capacity to understand or make decisions.During a review of Resident 64's MDS dated [DATE], the MDS indicated Resident 64 had severe impairment of the ability to think and make decisions. The MDS indicated Resident 64 needed setup assistance with oral hygiene, staff supervision with eating, toileting hygiene, upper and lower body dressing, and putting on or taking off footwear, and moderate staff assistance with showering and personal hygiene. The MDS indicated Resident 64 had an active diagnosis of diabetes mellitus and was receiving insulin.During a concurrent observation and interview on 6/9/2026 at 10:26 a.m., with LVN 3, medication cart 2 was observed and checked. LVN 3 stated Resident 64's Lantus Solostar was opened and used and did not have a date written on the date opened label and the pharmacy label indicated to discard unused portion after 28 days. LVN 3 stated the importance of writing the date when the insulin was first opened and used was to ensure the insulin was only used within 28 days as indicated on the pharmacy label. LVN 3 stated if the open date was not written on the label, there would be potential for Resident 64 to receive insulin that was no longer effective and there would be increased risk for untreated and fluctuating blood sugar levels.D. During a review of Resident 7's admission Record undated, the admission Record indicated the facility admitted Resident 7 on 4/1/2025 with diagnoses including paranoid schizophrenia (a mental illness that affects how a person thinks and understands what is real), hypertension, and type 2 diabetes mellitus.During a review of Resident 7's H&P dated 4/23/2026, the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions due to paranoid schizophrenia.During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had moderate impairment of the ability to think and make decisions. The MDS indicated Resident 7 needed staff supervision with eating, oral hygiene, toileting hygiene, upper and lower body dressing, and putting on or taking off footwear and moderate staff assistance with showering and personal hygiene. The MDS indicated Resident 7 had an active diagnosis of diabetes mellitus and was receiving insulin.During a concurrent observation and interview on 6/9/2026 at 10:26 a.m., with LVN 3, medication cart 2 was observed and checked. LVN 3 stated Resident 7's Lantus Solostar was filled by the pharmacy on 6/6/2026. LVN 3 stated the insulin had not been opened and used. LVN 3 stated the insulin should have been stored in the refrigerator if not used. LVN 3 stated the importance of storing unused insulin in the refrigerator was to preserve the effectiveness and integrity of the medication. LVN 3 stated if the insulin was not refrigerated there would be potential for Resident 7 to receive insulin that had decreased effectiveness leading to fluctuating blood sugar levels.During an interview on 6/12/2026 at 4:30 p.m., with the Director of Nursing (DON), the DON stated the importance of storing medication according to manufacturer guidelines and pharmacy instructions was to ensure medications would remain effective. The DON stated the importance of writing the date when the insulin was first opened and used was to identify when the insulin needed to be discarded according to pharmacy instructions of 28 days or 31 days. The DON stated if medications were not properly stored and labeled, there would be increased potential for residents to receive medication that were no longer active or effective and would increase the risk of residents experiencing adverse effect low or high blood sugar levels and upset stomach.During a review of the facility's policy and procedure (P&P) titled Administering Medications revised 4/2019, the P&P indicated, .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date open is recorded on the container.During a review of the facility's P&P titled Medication Labeling and Storage revised 2/2023, the P&P indicated .6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.Medication Labeling.5. Multi-dose vials that have been unopened or accessed (e.g., needle punctured are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview and record review, the facility failed to follow the facility's diet menu instructions when preparing food for 31 of 141 residents on mechanical soft diet (diet for residents who experience chewing or swallowing limitations, food texture is modified by chopping or grinding).This deficient practice had the potential to increase the residents' risk for aspiration (inhalation of foreign materials) or choking.Findings: During an observation on 6/9/2026 at 12:02 p.m., in the kitchen during lunch service preparation, Dietary Aide (DA) 2 called out chopped, and DA 3 placed whole uncut parsley on the plate.During a concurrent observation and interview on 6/9/2026 at 12:18 p.m., with the Dietary Supervisor (DS), DA 2 called out chopped, and DA 3 placed whole uncut parsley on the plate for another resident. During a concurrent interview and record review on 6/9/2026 at 12:20 p.m., with the DS, the menu recipe dated 6/9/2026 was reviewed. The menu recipe indicated no parsley for the mechanical soft diet. The DS stated the staff should have followed the recipe as written. During an interview on 6/10/2026 at 9:51 a.m., with the Registered Dietician (RD), the RD stated a mechanical soft diet consisted of soft foods that are easy to chew and swallow. The RD stated residents on a mechanical soft diet should not receive uncut parsley because it placed the residents at an increased risk of aspiration. During an interview on 6/12/2026 at 3:18 p.m., with the Director of Nursing (DON), the DON stated not following the menu recipe can place residents at risk for aspiration. During a review of the facility's policy and procedure (P&P), titled Dining Services Department Inservice Training Meals Quality - Preparation & Evaluation page 109, undated, the P&P indicated during food preparation the facility should pay attention to therapeutic diets preparation and appropriate seasoning and garnishing.

Based on observation, interview and record review, the facility failed to ensure:One container of shredded coconut labeled 2/2/2025 was disposed ofThe ice machine was free of dirt.These deficient practices had the potential to place the residents at risk for food borne illness or cross-contamination (the unintentional transfer of harmful bacteria, viruses, or allergens from one surface, object, or food to another).Findings:During a concurrent observation and interview on 6/8/2026 at 8:09 a.m., with the Dietary Supervisor (DS), one container of shredded coconut labeled 2/2/2025 was observed in the kitchen dry storage. The DS stated the date should indicate the use by date.During a concurrent observation and interview on 6/9/2026 at 12:51 p.m., with Dietary Aid (DA) 1, black and gray colored matter was observed along the internal wall of the ice machine's ice chute.During an interview on 6/9/2026 at 12:55 p.m., with the DS, the DS stated the ice machine should not look like that. The DS stated when the ice machine is dirty, it increases the risk for contaminated ice and cross contamination.During an interview on 6/12/2026 at 3:18 p.m., with the Director of Nursing (DON), the DON stated when food is expired or used after the use by date, there is a risk for diarrhea or food poisoning. The DON stated that when the ice machine is dirty, it could increase the risk for infection for residents.During a review of the facility's policy and procedure (P&P), titled Food Receiving and Storage, dated July 2014, the P&P indicated foods shall be received and stored in a manner that complies with safe food handling practices.7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ( use by date).During a review of the facility's Ice Machine Maintenance Manual, titled Section 4 Maintenance, dated February 2020, the Manual indicated the facility was responsible for maintaining the ice machine in accordance with the instructions in this manual.an extremely dirty ice machine must be taken apart for descaling and sanitizing.

Based on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 4 spoke to one of seven sampled residents (Resident 119) in a respectful manner.This failure had the potential for Resident 119 to experience loss of dignity and decreased self esteem.Findings:During a review of Resident 119's admission Record, the admission record indicated the facility admitted Resident 119 on 10/24/2024 with diagnoses including paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational suspicions, mistrust, and false beliefs that others are plotting to harm or harass the individual), anxiety disorder (constantly feeling worried and nervous), and insomnia (trouble falling asleep or staying asleep).During a review of Resident 119's History and Physical (H&P), dated 10/22/2025, the H&P indicated Resident 119 did not have the capacity (ability) to understand information and make decisions.During a review of Resident 119's Minimum Data Set (MDS - a resident assessment tool), dated 2/2/2026, the MDS indicated Resident 119's cognitive skills for daily decision making were moderately impaired (poor decision making and supervision required). The MDS indicated Resident 119 required moderate assistance (helper performs less than half of the effort) from one staff for shower, putting on foot wear, personal hygiene, and required supervision or touching assistance (helper provides verbal cues and/or touching, steadying, or contact guard assistance while the resident completes the activity) from one staff for toilet hygiene, dressing, bed mobility , transfer, eating.During an observation on 6/8/2026 at 1:07 p.m., Resident 119 was seen gently stroking another resident's (unknown) hair and face while they sat in a chair in the hallway. Resident 119 then stood up suddenly and asked the other resident to shake their hand. At that time, CNA 4 approached Resident 119 and sternly stated, Go to your room, now! When Resident 119 entered the room, CNA 4 sternly stated, Sit down, then walked away and told Resident 119 to stay in the room.During a concurrent observation and interview on 6/8/2026 at 1:11 p.m., with Resident 119 in his room, Resident 119 was observed pacing back and forth in his room. Resident 119 stated, CNA 4 did not like him, because of the way CNA 4 spoke to him, he thought he had done something wrong that made CNA 4 mad at him.During an interview on 6/8/2026 at 1:15 p.m., with CNA 4 in a hallway, CNA 4 stated, she was fairly new to the facility. CNA 4 stated, she should have used a respectful tone of voice when she told resident 19 to sit down, and told him to go to his room, to ensure Resident 119 felt safe and respected. During an interview on 6/10/2026 at 10:32 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated staff should approach Resident 119 in a calm manner and speak to the resident nicely. RNS 1 stated, the staff should treat residents with respect and promote their dignity. During an interview on 6/12/2026 at 4:04 p.m., with the Director of Nursing (DON), the DON stated that all staff should be trained on how to care for residents with dignity and respect. The DON stated that every resident should be treated with dignity and respect because it is their right.During a review of Resident 119's Care Plan (CP) titled, At risk for decline in psychosocial well being related to anxiety, initiated on 10/24/2024, the CP Goal indicated Resident 119 will have social interaction with staff daily by 7/2026. The CP Approach Plan indicated to validate the resident's feelings, encourage social interaction with staff, and provide empathic listening (the practice of listening to understand another person's emotions and perspective without judgment or the urge to fix the problem) and reassurance (a subsequent action used to provide emotional support, validate the person's feelings, and offer a sense of safety and relief).During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life-Dignity, revised 8/2009, the P&P indicated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation: 1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . 7. Staff shall speak respectfully to residents at all times.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, revised 12/2016, the P&P indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; b. be treated with respect, kindness, and dignity.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 130)'s: informed consent for Zyprexa [medication used to treat schizophrenia (a mental illness that is characterized by disturbances in thought) or bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] included the manifested behavior for the medication indication useInformed consent for Remeron (medication used to treat major depressive disorder) was renewed every six months. This deficient practice had the potential to violate the residents' right to make an informed decision regarding the use of psychotropic medications. Findings: During a review of Resident 130's admission Records, the admission Records indicated the facility admitted Resident 130 on 2/26/2021 and was readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and resting tremor (a rhythmic, involuntary shaking of a body part like a hand or leg that happens when those muscles are completely relaxed and resting) on the right upper extremity.During a review of Resident 130's history and physical (H&P) dated 3/14/2026, the H&P indicated Resident 130 had fluctuating (changing frequently) ability to understand and make decisions.During a review of Resident 130's Minimum Data Set (MDS - a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 130 had severe impairment of the ability to think or make decisions. The MDS indicated Resident 130 had behaviors of delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 130 needed staff supervision with eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, and taking off or putting on footwear. The MDS indicated Resident 130 needed moderate staff assistance with personal hygiene. During a concurrent interview and record review on 6/11/2026 at 9:31 a.m. with Licensed Vocational Nurse (LVN) 7, Resident 130's informed consent dated 12/31/2025, was reviewed. LVN 7 stated the informed consent indicated Resident 130's legal empowered representative consented for the use of the Zyprexa to treat Resident 130's schizophrenia. The informed consent did not indicate the manifested behavior of schizophrenia. During a concurrent interview and record review on 6/11/2026 at 10:17 a.m. with the Social Services Director (SSD), Resident 130's informed consent dated 7/28/2024, was reviewed. The informed consent indicated Resident 130's legal empowered representative consented for the use of Remeron to treat Resident 130's right hand tremor on 7/28/2025. The SSD stated this is the most recent informed consent for Remeron. The SSD stated the facility has not gotten to this resident's station for consents yet. The SSD stated psychotropic informed consent should have been renewed every six months.During an interview on 6/12/2026 at 3:18 p.m. with the Director of Nursing (DON), the DON stated it is important to renew informed consents every six months to ensure the resident and/or representative is informed of the indications, risks, and benefits of the medication and have the opportunity to agree or refuse with the treatment. During a review of the facility's policy and procedure (P&P), titled Psychotropic Medication Use, revised February 2025, the P&P indicated prior to initiate the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives; the indications and rationale for the recommendation; the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and the resident's/representative's right to accept or decline the treatment.

Based on observation, interview, and record review, the facility failed to honor and accommodate the resident's food preferences in a timely manner for one of four sampled residents (Resident 106). This deficient practice had the potential to negatively impact the resident's nutritional status, appetite, autonomy, and overall well-being. Findings:During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was readmitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by intense irrational suspicions), Type II Diabetes Mellitus (DM, a chronic disease that affects how the body processes sugar), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 106's history and physical (H&P) dated 4/11/2026, the H&P indicated Resident 106 has fluctuating capacity to understand and make decisions. During a review of Resident 106's Minimum Data Set (MDS, a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 106 was moderately cognitively (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) impaired. The MDS indicated Resident 106 required partial assistance (Helper does less than half the effort) from staff for bathing, and required supervision for eating oral hygiene, toileting hygiene upper (above waist) and lower (below waist) dressing, personal hygiene, sit to lying, and chair/bed-to-chair transfer. During an interview on 6/8/2026 at 10:17 a.m., with Resident 106, Resident 106 stated the day before (6/7/2026) she had requested she no longer wanted to have fish every lunch and dinner and wants to eat fish only when everyone else is eating fish. During a concurrent observation and interview on 6/8/2026 at 12:36 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 106 usually ate fish for lunch and dinner but she no longer wants fish for every lunch and dinner, and wanted to have it changed. Resident 106's lunch plate had fried fish on it. Resident 106's label on the tray cart indicated Requests fish daily at lunch and dinner unless pizza, hot dogs or hamburgers. During an interview on 6/9/2026 at 12:37 p.m., with Resident 106, Resident 106 stated she got fish again and indicated she had told the staff that she did not want fish anymore. During an interview on 6/9/2026 at 1:56 p.m., with the Registered Dietician (RD), the RD stated Resident 106 informed her last week on 6/2/2026 she did not want to have fish daily. The RD stated she did not check on whether Resident 106's preferences were updated. The RD stated she was served fish for lunch and then the fish was replaced with chicken. The RD stated it was important to respect the residents' food preference's as they are people and reserve the right to eat what they want. The RD stated not respecting the resident's food preference may lead to the residents eating less, may experience weight loss and may not be happy. During a concurrent interview and record review on 6/11/2026 at 9:38 a.m., with the Dietary Supervisor (DS), the DS stated on 6/2/2026, the RD informed her Resident 106 did not want fish anymore for lunch and dinner. The Dietary Recommendations documentation presented by the DS signed by the RD indicated on 6/2/2026, Resident 106 wanted to change back to menu items instead of fish, and fish was okay if it was on the menu. The DS stated she was aware Resident 106 received fish on 6/8/2026 and 6/29/2026 for lunch. The DS stated it was important to respect residents' preferences and not respecting their preference could lead to the residents not wanting to eat, lose appetite, and lose weight. During a review of the facility's policy and procedures (P&P) titled, Resident Rights, revised date 12/2016, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to exercise his or her rights as a resident of the facility.During a review of the facility's P&P titled, Resident Food Preferences, revised date 7/2017, the P&P indicated individual food preferences will be assessed.modifications to diet will only be ordered with the resident's or representative's consent. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night.During a review of the facility's P&P titled, Food and Nutrition Services, revised date 10/2017, the P&P indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. Reasonable efforts will be made to accommodate resident choices and preferences. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident.

Based on observation, interview, and record review, the facility failed to complete a change of condition and notify the physician when:a. one of 28 sampled residents (Resident 80) had a significant change in physical status identified in 4/2026 when multiple Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) staff reported Resident 80's repeated refusals to wear splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and attempts to take off splints.b. Resident 122 started to pull their front wheel walker (FWW - type of mobility aid with wide base of support) behind them when walking instead of pushing the FWW in front of their body.These deficient practices resulted in Resident 80 experiencing a decline in range of motion (ROM, full movement potential of a joint) in the knees and ankles without facility physician's knowledge and providing alternative interventions and treatments and the potential to result in a delay of treatment or Resident 122 experiencing a fall. Findings: a. During a review of Resident 80's admission Record, the admission Record indicated the facility initially admitted Resident 80 on 4/19/2010 and readmitted on [DATE] with diagnoses including, schizophrenia (a mental health disorder that is characterized by disturbances in thought) and unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 80's Minimum Data Set (MDS, resident assessment tool) dated 3/6/2026, the MDS indicated Resident 80 was severely impaired in cognitive skills for daily decision making (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, and problem-solving). The MDS indicated Resident 80 did not have any functional limitations in ROM in the upper extremity (UE, shoulder, elbow, wrist/hand) and had limitations in functional ROM on both sides of the lower extremities (LE, hip, knee, ankle/foot). The MDS indicated Resident 80 used a wheelchair. The MDS indicated Resident 80 required supervision for eating and substantial assistance for oral hygiene, toileting, sit to lying, sit to stand, and required dependent assistance for bed to chair transfers. During a review of Resident 80's Joint Mobility Assessment (JMA) dated 7/4/2024, the JMA indicated Resident 80 shoulders, elbows, wrists, and hand/fingers were within functional limits (variance due to normal aging process allowed). The JMA indicated Resident 80's minimal (75 – 100% available ROM) limitation in left hip, moderate (50-75% available ROM) limitation in right hip, both knees and both ankles. There were no other JMAs completed in Resident 80's medical records. During a review of Resident 80's Care Plan (CP) dated 12/6/2024, the CP indicated Resident 80 was at risk for new and or development of joint limitations contracture (loss of motion of a joint) secondary to decreased mobility. The CP goal indicated Resident 80 will have no further increase in ROM limitations/contracture daily in three months. The CP approach plan indicated to provide joint mobility assessment quarterly and as needed, provide restorative activities and exercises per physician order, notify physician or any changes in mobility status or signs of new or further development of joint mobility. During a review of Resident 80's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Evaluation and Plan of Treatment dated 12/18/2024, the PT Evaluation indicated Resident 80 was referred to skilled PT due to development of contractures on left knee and both ankles. The PT Evaluation indicated Resident 80 needed splints for both ankles. The PT Evaluation indicated Resident 80 had impairment in ROM in the right ankle at -10 degrees dorsiflexion (mild foot drop and foot cannot move back to a neutral position). The PT Evaluation indicated Resident 80 had impairments in ROM in left knee at -90 degree extension (knee was in a bent position and cannot straighten knee) and the left ankle at -10 degree dorsiflexion. During a review of Resident 80's CP dated 1/11/2025, the CP indicated Resident 80 had potential for decreased mobility related to use of splint. The CP approach plan indicated to apply splint as ordered, reassess joint mobility quarterly or as needed, and to notify physician of any unusual changes. During a review of Resident 80's Physician Order Report, Physician Order Report indicated the following orders: -order dated 2/6/2025 for RNA program for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises on both lower extremities once a day seven times a week as tolerated. -order dated 2/6/2025 for RNA to apply splint on left knee once a day seven times a week up to five hours as tolerated. -order dated 2/6/2025 for RNA to apply both ankle splints once a day seven times a week for five hours or as tolerated. During a review of Resident 80's 2/2026 Restorative (RNA) Flowsheet, the RNA Flowsheet indicated Resident 80 wore the left knee splint for two hours (seven times), three hours (19 times), and four hours (two times). The RNA Flowsheet did not indicate how long Resident 80 wore both ankle splints. During a review of the Restorative Nursing Weekly Summary Splint dated 2/6/2026, 2/13/2026, 2/20/2026, and 2/27/2026, the RNA Splint Weekly Summaries indicated a NO to refuses to wear (splint) and blank to resident takes off (splint). During a review of Resident 80's 3/2026 Restorative Flowsheet, the RNA Flowsheet indicated Resident 80 wore left knee splint for one hour (five times), two hours (nine times), three hours (16 times). The RNA Flowsheet did not indicate how long Resident 80 wore both ankle splints. During a review of the Restorative Nursing Weekly Summary Splint dated 3/6/2026, the RNA Splint Weekly Summary indicated a YES to resident takes off (splint). During a review of Resident 80's 4/2026 Restorative Flowsheet, the RNA Flowsheet indicated Resident 80 wore left knee splint for one hour (one time), two hours (26 times), three hours (two times) or five hours (one time). The RNA Flowsheet did not indicate how long Resident 80 wore both ankle splints. During a review of the Restorative Nursing Weekly Summary Splint dated 4/3/2026, the RNA Splint Weekly Summary indicated a check mark to resident takes off (splint), and a check mark to refuses to wear. During a review of the Restorative Nursing Weekly Summary Splint dated 4/10/2026, the RNA Splint Weekly Summary indicated a check mark to resident takes off (splint). During a review of the Restorative Nursing Weekly Summary Splint dated 4/17/2026, the RNA Splint Weekly Summary indicated YES to refuses to wear, and YES to charge nurse notified. The RNA Splint Weekly Summary indicated resident removes his splints, charge nurse notified, ankle splints, and knee splints. During a review of the Restorative Nursing Weekly Summary Splint dated 4/24/2026, the RNA Splint Weekly Summary indicated a check mark to resident takes off (splint), and a check mark to refuses to wear. During a review of Resident 80's 5/2026 Restorative Flowsheet, the RNA Flowsheet indicated Resident 80 wore left knee splint for one hour (three times), two hours (22 times), or three hours (six times). The RNA Flowsheet did not indicate how long Resident 80 wore both ankle splints. During a review of the Restorative Nursing Weekly Summary Splint dated 5/8/2026, the RNA Splint Weekly Summary indicated Yes to resident takes off (splint), and Yes to charge nurse notified. During a review of the Restorative Nursing Weekly Summary Splint dated 5/22/2026, the RNA Splint Weekly Summary indicated a check mark to resident takes off (splint). During a review of the Restorative Nursing Weekly Summary Splint dated 5/29/2026, the RNA Splint Weekly Summary indicated Yes to resident takes off (splint), and Yes to charge nurse notified. During a review of Resident 80's 6/2026 Restorative Flowsheet, the RNA Flowsheet indicated Resident 80 wore left knee splint for one hour (two times), two hours (three times), three hours (four times), or four hours (one time). The RNA Flowsheet did not indicate how long Resident 80 wore both ankle splints. During a review of Resident 80's Physical Therapy Evaluation dated 6/10/2026, the PT Evaluation indicated an increase in contracture in both ankles compared to the last PT evaluation on 12/18/2024 and Resident 80 developed a new contracture on the right knee. During an observation and interview on 6/8/2026 at 9:27 a.m.,, Resident 80 was sitting in a wheelchair in the hallway. Resident 80's knees were bent and the left ankle was bent forward and sideways towards the middle of the body. Resident 80 was able to move the left arm up and down and comb his hair. During an observation on 6/8/2026 at 9:52 a.m., Resident 80 was lying in bed towards the right side. Resident 80's knees were bent and Resident 80 was wearing a splint on the left knee and splint on the left ankle/foot. Resident 80 was not wearing a splint on the right ankle/foot. Resident 80's left and right ankle/foot were pointed down away from the body. During an observation and interview on 6/9/2026 at 10:22 a.m., in Resident 80's room, Resident 80 was lying on the back in bed. Restorative Nursing Assistant (RNA 1) and Restorative Nursing Assistant (RNA 2) performed ROM to Resident 80's knees. RNA 1 attempted to straighten and bend the right knee. Resident 80 required slow movements and rest breaks to straighten the right knee and could not straighten the right knee all the way. RNA 2 attempted to straighten Resident 80's left knee, but RNA 2 stated Resident 80 was resisting and did not allow RNA 2 to straighten the left knee from a fully bent position. Resident 80's right ankle was pointed forward away from the body and the left ankle was pointed fully forward and turned toward the middle of the body. Resident 80 did not want RNA 1 and RNA 2 to do any ROM of the ankle and did not want to put on any splints. RNA 1 stated they will report to the charge nurse that Resident 80 refused ROM and refused to wear splints today and will reattempt later in the day. During an interview on 6/9/2026 at 10:50 a.m.,, RNA 1 and RNA 2 stated Resident 80's left ankle could not move very much and the right ankle could move a little. RNA 2 stated he put on both ankle splints on Resident 80 yesterday (6/8/2026) and if Resident 80 was not wearing the right ankle splint, then it meant Resident 80 took it off himself yesterday. During an interview on 6/10/2026 at 9:28 a.m.,, Certified Nursing Assistant (CNA 11) stated Resident 80 could not fully straighten the left leg and the left ankle was turned inward. CNA 11 stated Resident 80 would try to take off the splints on his foot. During an observation and interview on 6/10/2026 at 9:40 a.m., in Resident 80's room, RNA 2 stated Resident 80 agreed to wear the left knee and both ankles splints today. Resident 80's ankles were pointed down and did not fit the ankle splint. RNA 2 stated Resident 80's ankles were stiffer now and pointed down more and both heels did not fit in the back of the ankle splints. RNA 2 stated Resident 80 was not really used to the splint and was fighting to put on the splints. During an interview on 6/10/2026 at 9:55 a.m., with the Registered Nurse Supervisor (RNS 1), RNS 1 stated if a resident had a change or decline in ROM limitation, the RN had to complete an assessment and a change of condition (COC) and inform the physician how the resident was before and how the resident was now. RNS 1 stated RNA staff did inform nursing staff that Resident 80 would take off the splints or refuse ROM exercises. RNS 1 stated if a resident refused for one day, then nursing staff would monitor, but if the resident refused for multiple days, then it was a COC and staff would need to let the physician know that the resident was refusing the RNA program. RNS 1 stated there should have been a COC completed for Resident 80's behaviors or refusing RNA and taking off the splints early, so that staff could assess what the issue was and inform the physician. RNS 1 reviewed Resident 80's medical records and stated a COC assessment was not completed for Resident 80's refusals of RNA program and repeated removal of the splints. During a concurrent interview and record review on 6/10/2026 at 11:28 a.m., with Physical Therapist (PT 1), Resident 80's PT records were reviewed. PT 1 stated Resident 80 received an PT evaluation on 12/18/2024. PT 1 stated he recommended new ankle splints and to continue the left knee splint. PT 1 stated the PT Evaluation indicated Resident 80's ankles were pointed down just a little at that time and had a mild contracture and the ankle splints he recommended would have fit Resident 80 at that time. PT 1 stated he nor anyone from therapy was informed about any decline in ROM in Resident 80 or any RNA reports of Resident 80 refusing ROM or taking off the splints earlier than five hours recommended. PT 1 stated there could be multiple reasons for Resident 80 refusing RNA and the splints including a change in cognition or pain and Resident 80 would need an PT assessment to find out why Resident 80 was refusing RNA. PT 1 stated if therapy was notified of a change of condition for Resident 80, then PT would have completed an evaluation and Resident 80 would have been put on a therapy treatment program to determine why Resident 80 did not want to wear the splints and see if there were other splints or interventions that could have fit Resident 80 better and increase compliance with wearing the splints. During an observation and interview on 6/10/2026 at 1:10 p.m., in Resident 80's room, PT 1 evaluated Resident 80's ROM in the legs. PT 1 stated Resident 80's ankles were almost fixed now (could no longer move). PT 1 asked Resident 80 if he had pain when moving the ankle and Resident 80 said yes. PT 1 reviewed Resident 80's PT Evaluation dated 12/18/2024 and compared Resident 80's evaluation today and PT 1 stated Resident 80's ankle ROM worsened from the last time Resident 80 was evaluated. PT 1 assessed Resident 80's right knee and stated there was a new contracture now in Resident 80's right knee when there was no contracture last time on 12/18/2024. PT 1 stated Resident 80 would need a new splint for the right knee. PT 1 stated the ankle splints Resident 80 currently had could no longer fit because Resident 80's left ankle was inverted and pointed further down and fixed. PT 1 stated the ankle splints would not help Resident 80 anymore because the ankle could no longer get better. PT 1 stated both ankles were contracted at 35 degrees (pointed fully down away from the body) and that was the worst the ankle could get and the most severe impairment. PT 1 stated if therapy was notified earlier, then there definitely could have been interventions PT could have done such as get new splints and try to stretch the leg. PT 1 stated if therapy intervened earlier, therapy could have prevented the ankles from getting worse to this point. During an interview on 6/10/2025 at 1:25 p.m.,, RNA 2 stated RNA would always document in the RNA records if Resident 80 refused and inform the charge nurse. RNA 2 stated RNA staff reported all the time when Resident 80 took off his splints early. During a concurrent interview and record review on 6/10/2026 at 2:12 p.m., with RNS 1, Resident 80's medical record was reviewed. RNS 1 reviewed 2/2026 RNA flowsheet and weekly summaries and stated there were no RNA reports of Resident 80 refusing RNA or taking off the splints. RNS 1 reviewed 3/2026 RNA flowsheet and weekly summaries and stated there was one report of Resident 80 taking off the splints. RNS 1 stated this was when nursing should have started monitoring Resident 80's behaviors but not yet considered a COC. RNS 1 reviewed 4/2026 RNA flowsheet and weekly summaries and stated Resident 80 had three reports of taking off the splints and four reports of refusing to wear the splints. RNS 1 stated these multiple reports of taking off and refusing to wear the splints was a COC and a COC should have been completed in April 2026 for Resident 80. RNS 1 stated a COC should have been completed because the behavior was happening multiple times now and it was a red flag. RNS 1 stated the purpose of a COC was to assess and monitor the resident for 72 hours to see if the resident was getting worse or better and to find a solution to the issue and to inform the physician. RNS 1 stated nursing should have called the physician and ordered an PT evaluation because the facility should find another solution if Resident 80 was repeatedly taking off the splints. RNS 1 reviewed Resident 80's medical records from 2025 to 2026 and stated there was no COC completed for Resident 80. RNS 1 stated if staff completed a COC in April 2026, the facility could have changed the RNA program and staff could have found a solution for Resident 80 earlier. RNS 1 stated if the facility had PT intervene earlier then maybe Resident 80 would not have had the decline in ROM. During a phone interview on 6/10/2026 at 3:06 p.m., with Medical Doctor (MD 1), MD 1 stated he would want to be notified if Resident 80 required any orders, such as a physical therapy evaluation order. During an interview on 6/11/2026 at 10:32 AM with the Director of Nursing (DON), DON stated a change of condition should be completed so staff can check what was going on with the resident and not delay any treatment and intervention. DON stated staff had to report to the physician and do whatever the physician ordered. DON stated if staff delayed completing a COC, then a resident could get worse without any intervention. DON stated when RNA reported Resident 80 was repeatedly refusing and taking off splints, this was considered a COC and a COC should have been completed for Resident 80. During a review of the facility's policies and procedures titled, Change in a Resident's Condition or Status, revised 2/2021, 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. CROSS REFERENCE TO F656 and F688 b. During a review of Resident 122's admission Records undated, the admission Records indicated the facility admitted Resident on 2/13/2020 and was readmitted on [DATE] with diagnoses including history of falling, abnormalities of gait (walking) and mobility (movement), and hemiplegia (complete loss of the ability to move one side of the body) on the left side of the body. During a review of Resident 122's history and physical (H&P) dated 2/14/2026, the H&P indicated Resident 122 did not have the ability to understand and make decisions. During a review of Resident 122's Minimum Data Set (MDS – a resident assessment tool) dated 2/20/2026, the MDS indicated Resident 122 had moderate impairment of the ability to think and make decisions. The MDS indicated Resident 122 used a walker as a mobility device. The MDS indicated Resident 122 needed staff supervision with eating, oral hygiene, toileting hygiene, upper body dressing and needed moderate staff assistance with showering, lower body dressing, putting on or taking off footwear, and personal hygiene. The MDS indicated Resident 122 had an active diagnosis of hemiplegia. During a review of Resident 122's care plan dated 2/21/25, the care plan indicated Resident 122 was at risk for falls or injuries related to abnormalities of gait and mobility and was using a front wheel walker improperly. The care plan indicated goals of decreased significant injury as a result from falls in the next three months. The care plan indicated approach plans of educating Resident 122 about the proper use of front wheel walker, supervising Resident 122 during ambulation (walking) with front wheel walker to prevent falls, and monitor every 1 hour to maintain safety and fall precautions. During a concurrent observation and interview with on 6/10/2026 at 2:53 p.m., Certified Nurse Assistant (CNA) 1, Resident 122 walked in the hallway with the FWW behind them (Resident 122). CNA 1 stated Resident 122 always walked with the FWW walker behind them. CNA 1 stated when we try to instruct Resident 122 to properly use the FWW in the front or move the FWW to the front, Resident 122 will raise his fists or move it back. During a concurrent interview and record review on 6/11/2026 at 9:02 a.m., with Licensed Vocational Nurse (LVN) 7, Resident 122's care plan titled Resident at times is resistive to care, may clench fists when upset, refuses medications sometimes and uses FWW in reverse dated 11/21/2025 was reviewed. LVN 7 stated the approach or interventions of the care plan indicated to notify the physician if refusal increases or behavior worsens. LVN 7 stated Resident 122 started pulling the FWW on 11/21/2025. During a concurrent interview and record review on 6/11/2026 at 9:04 a.m. with Licensed Vocational Nurse 7, Resident 122's physical therapy notes dated 6/12/2022, nursing notes, and change of condition documentation were reviewed. LVN 7 stated there is no documentation that indicated Resident 122's physician was notified that Resident 122 was using the FWW improperly. LVN 7 stated the physician should have been notified. LVN 7 stated the physician could have ordered a physical therapy evaluation for Resident 122. During an interview on 6/12/2026 at 3:18 p.m., with the Director of Nursing (DON), the DON stated it was important to notify the physician of a change of condition to get the resident proper treatment such as a physical therapy evaluation if necessary. During a review of the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, revised February 2021, the P&P indicated the nurse will notify the resident's attending physician or [physician on call when there has been a significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times); and/or when there is specific instruction notify the physician of changes in the resident's condition.

Based on observation, interview and record review, the facility failed to:Develop and implement an individualized fall prevention care plan, for one of three sampled residents (Resident 1) with interventions including reminding the resident to use a front wheeled walker ([FWW] a mobility aid with two wheels on the front legs and rubber-tipped or sliding legs on the back), and calling for assistance before walking.Implement the facility's Policy and Procedure (P&P) titled Care Planning-Interdisciplinary Team ([IDT]- Residents health care team consisting of variousspecialties), which indicated the Resident's IDT was responsible for the development of an individualized comprehensive care plan for each resident.These failures resulted in Resident 1 falling, sustaining a left femur (thigh bone) fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (a progressive state of decline in mental abilities) and abnormality of gait. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/24/2025, the MDS indicated Resident 1 had severely impaired cognitive (thought process) function for daily decision making. The MDS indicated Resident 1 required supervision (helper provides verbal cue as resident completes activity) for self-care activities such as eating, hygiene, getting dressed and mobility such as sitting, standing and walking. The MDS indicated a mobility device walker (FWW) was used. During a review of Resident 1's Physician Order dated 1/16/2023, the Physician Order indicated Ibuprofen (medication used to treat pain) 100 milligram ([mg], a unit of measurement) give 1 tablet by mouth every eight hours as needed for pain 1-10/10 (pain scale of 0 = pain, 1-3 = mild pain, 4-6 = moderate pain, 7 -10 = severe pain). During a review of Resident 1's Fall Risk Assessment, dated 10/8/2025, the Fall Risk Assessment indicated Resident 1 scored a two. A score above 10 was considered a risk for falls.During a review of Resident 1's Physical Therapy ([PT], a healthcare profession focused on improving movement, reducing pain, and restoring physical function through, exercise, manual therapy, and patient education) Evaluation and Plan of Treatment dated 10/2/2025, the PT Evaluation and Plan of Treatment indicated Resident 1 was to be seen for follow up PT treatments to monitor Resident 1's mobility and educate Resident 1 on safe use of FWW. During a review of Resident 1's PT Treatment Encounter Notes dated 10/2/2025 to 10/28/2025, the PT Treatment Encounter indicated Resident 1 used a FWW as an assistive device for gait training and was supervised for transfers, gait training and sitting. During a review of Resident 1's Nursing Weekly Progress Notes dated 1/6/2026 and timed at 9:50 p.m., the Nursing Weekly Progress Notes indicated (1/6/2026 at 9:40 p.m.) facility staff observed Resident 1 in the hallway walking without her FWW, past room [ROOM NUMBER] then suddenly started running and fell on her left side. The notes indicated Registered Nurse Supervisor (RNS) 1 assessed Resident 1 and assisted resident to bed. Resident stated she did not know what happened and reported a pain level of 3/10 (mild pain) on her left hip. Ibuprofen 100 mg as needed given to Resident 1 for 3 out of 10 mild pain. Resident is resting in bed. The notes indicated staff informed Resident 1's physician that Resident 1 had a fall and complained of left hip pain. New orders given to staff to do stat (immediate) x-ray (a medical imaging test produces pictures of the body's internal structures, primarily bones and dense tissues) of the left hip.During a review of Resident 1's Physician Order List dated 1/2026, the List indicated an order dated 1/6/2026 for a left hip x-ray stat and safety monitoring (resident supervision increased if there is a change in resident's condition) every 30 minutes for 72 hours.During a review of Resident 1's Medication Administration Record (MAR) dated 1/2026, the MAR indicated Resident 1 received ibuprofen 100 mg as follows: 1/6/2026, at 10:00 p.m., for 3/10 left hip pain, and on 1/7/2026 at 9:00 a.m., for 10/10 left hip pain.During a review of Resident 1's x-ray interpretation dated 1/7/2026, the x-ray interpretation indicated there was an acute (sudden onset) fracture of the left thigh bone.During a review of Resident 1's Physician Order dated 1/7/2026, the Physician Order indicated, to transfer Resident 1 to a GACH for further evaluation of left hip.During a review of Resident 1's Fall Risk Assessment, dated 1/7/2026 (the day after Resident 1's fall), the Fall Risk Assessment indicated Resident 1 scored above 10 represents risk for potential fall. Resident 1 scored a ve.During a review of Resident 1's GACH Emergency Department (ED) records dated 1/7/2026, the GACH ED records indicated Resident 1 had a fracture of left femur due to a mechanical fall (fall is caused by an external [to the resident] factor) on 1/6/2026. The GACH ED records indicated Resident 1 had 7/10 pain (severe pain) and received ketorolac (a medication used for short-term management of moderate (4-6/10) to severe (7-10/10) pain) 60 mg injection (administered into a muscle with a needle) and a lidocaine patch (a topical, adhesive medicated patch used to relieve pain).During a review of Resident 1's GACH Orthopedic (a medical specialty focused on the diagnosis, treatment, rehabilitation, and prevention of injuries and diseases of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and nerves) Consult records dated 1/8/2026, the GACH Orthopedic Consult records indicated Resident 1 had left hip hemiarthroplasty (a surgical procedure to replace the ball of the left hip joint) surgery on 1/8/2026. During a review of Resident 1's medical records, the medical records there was no care plan for Resident 1's risk for falls and use of a FWW. There was no care plan that was developed and/or implemented prior to Resident 1's fall with injury on 1/6/2026.During a concurrent interview and record review on 1/21/2026 at 11:51 a.m., with RNS 1, Resident 1's Nursing Weekly Progress Notes dated 1/6/2026 was reviewed. RNS 1 stated Resident 1 was not ambulating (walking)with her FWW on the day of the fall but should have ambulated with her FWW. RNS 1 stated there was no care plan in place prior to the fall that occurred on 1/6/2026. RNS 1 stated Resident 1 fall prevention care plan should have been created and implemented before Resident 1's fall on 1/6/2026.During an interview on 1/21/2026 at 1:50 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was alert and oriented to person and place but had periods of confusion. LVN 1 stated Resident 1 ambulated with a FWW. LVN 1 stated Resident 1 should have been ambulating with a FWW on the day she fell, which may have prevented the fall. LVN 1 stated Resident 1 had periods of confusion and may have forgotten to use her walker when she came out of her room and walked down the hallway. LVN 1 stated staff that saw Resident 1 ambulating without her FWW should have noticed and stopped her from ambulating without her FWW.During a concurrent observation and interview on 1/21/2026 at 2:34 p.m., with Resident 1 in her room, Resident 1 stated on the day of the fall (1/06/2026), she exited her room and was walking down the corridor without her FWW and she fell on her left hip. Resident 1 stated she knew she needed her FWW but forgot to take it with her.During a concurrent interview and record review on 1/22/2026 at 9:41 a.m., with RNS 2, Resident 1's PT Evaluation and Plan of Treatment dated 10/2/2025, Physician Orders List dated 10/29/2025 and the resident's care plan titled Resident Care Plan dated 1/12/2026 were reviewed. RNS 2 stated Resident 1 learned to use a FWW when ambulating during PT sessions in the hallway with the Registered Physical Therapist (RPT-a licensed healthcare professional who diagnoses and treats individuals with movement limitations, injuries, or chronic pain to improve quality of life and restore function). RNS 2 stated when Resident 1 transitioned to the Restorative Nursing Assistant (RNA a specialized program focused on rehabilitation techniques that help individuals regain and maintain their highest level of physical functioning, mobility, and independence) Program, the RNA orders indicated Resident 1 was to ambulate with a FWW. RNS 2 stated a care plan was a comprehensive document outlining the interventions, risks, and objectives for the residents' care. RNS 2 stated Resident 1 was a fall risk and used a FWW to ambulate. RNS 2 stated licensed staff should have initiated and implemented a care plan for risk-for-falls with interventions to ensure Resident 1 always used her FWW for ambulating, and the fall could have been prevented.During a concurrent observation and interview on 1/22/2026 at 1:42 p.m., with the Director of Nursing (DON), the video surveillance of the night of the fall was viewed. At 9:43:37 p.m., Resident 1 was observed exiting the room. At 9:43:42 p.m., Resident 1 walked by Certified Nursing Assistant (CNA) 1 and increased her speed. At 9:43:47 p.m., Resident 1 lost her balance and fell to the ground. The DON stated if Resident 1 had her FWW, the FWW could have prevented the fall from happening. The DON stated the IDT did not meet and a care plan was not developed to address Resident 1's risk for falls or use of a FWW. The DON stated a fall risk care plan should have included interventions such as keeping the resident's call light within reach, remove clutter from the room, good lighting, non-skid socks, and reminding Resident 1 to use her FWW. The DON stated Resident 1 was a high fall risk and the care plan should have been implemented before she fell. During a concurrent interview and record review on 1/22/2026 at 4:32 p.m., with the DON, the Fall Risk assessment dated [DATE] and 1/7/2026 were reviewed. The DON stated on 10/8/2025, Resident 1's fall risk score was two and a score above 10 indicated the resident was high risk for falls. The DON stated on 1/7/2026, another Fall Risk Assessment was done, and Resident 1 scored a 5 which indicated Resident 1 was still not a high risk for fall even though Resident 1 fell on 1/6/2026. The DON stated the Fall Risk Assessment was not an accurate assessment of Resident 1's risk for falls because prior to the fall, Resident 1 was not considered a high risk for falls and after the fall, Resident 1 was still not considered a high risk for fall. The DON stated the Fall Risk Assessment did not assess the resident appropriately for risk for falls.During a review of the facility's P&P, titled Care Planning-Interdisciplinary Team, revised September 2013, the P&P indicated the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the residents' comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel such as the resident's Attending Physician; the Registered Nurse who has responsibility for the resident, the Therapists (speech, occupational, recreational, etc.), as applicable; the Director of Nursing (as applicable); the Charge Nurse responsible for resident care; the Nursing Assistants responsible for the resident's care; and others as appropriate or necessary to meet the needs of the residents.During a review of the facility's policy and procedures (P&P) titled, Safety and Supervision of Residents, revised July 2017, indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any speci c accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following such as communicating speci c interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring that interventions are implemented; and documenting interventions. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.During a review of the facility's P&P, titled Resident Mobility and Range of Motion, revised July 2017, the P&P indicated, residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. As part of the resident's comprehensive assessment, the nurse will identify the resident's current mobility status including his or her ability to walk, limitations in movement or mobility. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including gait and balance issues that may lead to falls or fractures. The care plan will be developed by the interdisciplinary team based on. the comprehensive assessment and will be revised as needed. The care plan will include speci c interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The residents and representatives will be included in determining these goals and objectives.

Based on observation, interview and record review, the facility failed to ensure a resident who was a high fall risk, with severe cognitive (ability to think and reason) impairment, and dementia (a progressive state of decline in mental abilities) did not fall and sustain a right hip fracture (a break in the bone) on 1/23/2025 after a previous fall on 3/22/2024 in which he sustained a left hip fracture (10 months part) for one of three sampled residents (Resident 1). The facility failed to: 1. Monitor Resident 1, who was assessed as a high fall risk and who sustained a previous fall with injury (3/22/2024), to prevent further accidents. 2. Supervise Resident 1 while outside on the facility's patio to prevent the resident from falling. 3. Ensure there was continuous supervision on the facility's patio to monitor Resident 1 and other residents to prevent accidents. 4. Ensure staff responded to the sensor alarm leading to the facility's outside patio exit door on 1/23/2025, when Resident 1 opened the door and exited the building onto the outdoor patio unassisted and unbeknownst to facility staff. These deficient practices resulted in Resident 1 falling on 1/23/2025, sustaining a right hip fracture, which required evaluation and treatment at a General Acute Care Hospital. This deficient practice had the potential for other high fall risk residents to be unsupervised and sustain falls and injuries. On 2/21/2025 at 4:40 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), Director of Nursing (DON), and Social Worker (SW) due to the facility's inability to monitor Resident 1's whereabouts and provide supervision to prevent him from falling and to immediately assist Resident 1 following his fall. On 2/23/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After an onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/25/2025 at 1:20 p.m., in the presence of the facility's DON, Social Services Director (SSD) and Nurse Consultant. The facility's IJRP included the following immediate actions: 1. The social services department completed an audit of Fall Risk Assessments for all residents to validate the total number of residents at high risk for falls on 2/22/2025 and determined it to be 53 out of 141 residents. 2. The ADM updated the facility's Zoning Map (a facility map showing all areas in the facility) and Monitoring Log (a log used by facility staff to document the whereabouts of residents who are monitored) to include all external walkways, patios, and interior hallways starting on 2/24/2025. 3. New job responsibilities/descriptions were created for staff assigned to zone monitoring which included 15-minute safety rounds. Staff assigned to monitoring will only be assigned to monitoring starting on 2/21/2025. 4. On 2/22/2025 the facility reviewed, and updated care plans for the 53 identified residents at risk for falls. The care plans were updated to include individualized fall prevention interventions and reassessed those residents who required mobility aids for compliance and proper support. 5. The Director of Staff Development (DSD) conducted an in-service training on the Fall/Accident Prevention Program for all nursing staff on 2/23/2025 and 2/24/2025. Topics included were Fall Prevention and Resident Supervision Policies, Timely Response to Alarms and Emergency Situations, Proper Use of Mobility Aids and Resident Transfers, and Accident Investigation and Documentation Procedures. 6. Beginning 2/24/2025 the DON/designee will collect and review Zone Monitoring Logs daily, and the DON and ADM will review trends in resident fall incidents, response times, and staff compliance. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur (a break in the hip bone), displaced intertrochanteric fracture of the left femur, difficulty walking, and dementia During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/10/2025, the MDS indicated Resident 1 was severely cognitively impaired and exhibited wandering behaviors. The MDS indicated Resident 1 used a walker and wheelchair. The MDS indicated Resident 1 required supervision/touching assistance with walking more than 10 feet. During a review of Resident 1's SBAR (]situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/22/2024, the SBAR indicated Resident 1 had an unwitnessed fall with complaints of left hip pain and slight swelling. During a review of Resident 1's Physician Order dated 3/22/2024, the Physician Order indicated a stat (immediate) Xray (a type of radiation that produces images inside the body to determine injuries) of both hips. During a review of Resident 1's Radiology Interpretation report dated 3/23/2024 and timed at 1:14 p.m., the Radiology Interpretation report indicated Resident 1 sustained a left hip intertrochanteric fracture with varus deformity (a condition where the distal [away from the center of the body or point of attachment] segment of a bone or joint angles inward [bow leg syndrome] consistent with an acute fracture (a sudden break in a bone caused by traumatic injury), and osteoporosis (weak and brittle bones). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated a score of 10 (a score of 10 or higher means there is a high risk for falls). During a review of Resident 1's Physician Order dated 3/28/2024, the Physician Order indicated Resident 1 was to use a front wheel walker ([FFW] (a walking aid with two front wheels and no rear wheels). During a review of Resident 1's at risk for falls Care Plan dated 4/6/2024, the Care Plan indicated its goal was to minimize Resident 1's fall episodes to decrease significant injuries. The Care Plan's interventions indicated staff will anticipate/intervene factors that caused prior falls such as mobility problems, and to use appropriate devices as ordered. During a review of Resident 1's self-care deficit care plan dated 7/12/2024, the Care Plan indicated Resident 1 needed supervision for walking in the room and the corridor, and staff were to assist Resident 1 to ambulate (walk) with his FWW. During a review of Resident 1's Resident Care Conference Note, dated 1/17/2025, the Resident Care Conference Note indicated Resident 1 needed frequent reminders to use his FWW During a review of Resident 1's Nursing Progress Note dated 1/23/2025 at 3:30 p.m., the Nursing Progress Note indicated Resident 1 was found outside on the patio, had an unwitnessed fall, and was unable to move. During a review of the facility's video surveillance footage dated 1/23/2025 and timed at 2:20 p.m., Resident 1 was observed walking on the facility's outdoor patio (known as the Bar B Que patio [a patio where meat is cooked on an outside grill]) unassisted without the use of his FWW as ordered. At 2:39 p.m., (19 minutes after Resident 1 entered the outside patio) Resident 1 attempted to sit down in a chair that was located on the patio but missed the chair and fell to the ground. At 3:23 p.m., (one hour and three minutes after Resident 1 arrived on the outside patio and 44 minutes after Resident 1 fell ) staff were seen coming to assist Resident 1. During a review of Resident 1's Progress Note dated 1/23/2025, the Progress Note indicated Resident 1 was transferred to a GACH via 911 at 4 p.m. During a review of the GACH's Admission Information (Face Sheet) dated 1/23/2025, the Face Sheet indicated Resident 1 arrived in the GACH's emergency room (ER) on 1/23/2025 at 4:21 p.m. During a review of the GACH's Xray report dated 1/23/2025, and timed at 5:10 p.m., the Xray report indicated Resident 1 sustained an acute fracture of the right hip. During a review of the GACH's Clinical Note dated 1/25/2025 the Clinical Note indicated Resident 1 had a right hip percutaneous reduction internal fixation with cephalomedullary nail (a surgery that restores length, alignment, and rotation of the femur). During a review of the GACH's Discharge Summary dated 1/31/2025, the Discharge Summary indicated Resident 1 had acute (something that begins suddenly and last for a short time) anemia (lack of blood) following a surgical procedure. The Discharge Summary indicated Resident 1's hemoglobin ([HGB] a protein containing iron that facilitates the transportation of oxygen in red blood cells) was 8.8 grams/deciliters ([g/dL] a unit of measurement) (normal range is 13.5 g/dL to 17.5 g/dL) and his hematocrit ([HCT] the volume percentage of red blood cells in the blood) was 26.4% (normal range is 41 to 51%). During an interview on 2/14/2025 at 1:25 p.m., Certified Nursing Assistant (CNA) 2 stated on 1/23/2025, during the 3 p.m. to 11 p.m. shift, she was making rounds when she found Resident 1 on the ground outside on the BBQ patio. CNA 2 stated there were no staff on the patio and Resident 1 did not have his FWW. CNA 2 stated, no one responded to the sensor alarm when Resident 1 exited to the patio, to prevent the resident from falling. During an interview on 2/14/2025 at 4:21 p.m., the DON stated during the facility's daily staff meetings, nursing staff discuss high fall risk residents and residents who require increased supervision. The DON stated she did not recall Resident 1 ever being discussed during those meetings. The DON stated Resident 1 was confused and cognitively impaired and he should have been monitored by nursing staff at least every 15 minutes. The DON stated the frequency of Resident 1's supervision was not documented in his clinical record, and it should have been because he was a high fall risk, had fallen previously (3/22/2024) with a fracture. The DON stated there should have been staff monitoring the BBQ patio exit to prevent high risk residents from falling and getting injured. The DON stated when Resident 1 fell on [DATE], he was alone on the patio and staff did not respond to the exit door alarms to ensure Resident 1's safety. During an interview on 2/18/2025 at 11:19 p.m., Licensed Vocational Nurse (LVN) 2, stated she was assigned to Resident 1 from 7 a.m. to 3 p.m., the day of his fall (1/23/2025) but she was not aware of his fall until the next day (1/24/2025). LVN 2 stated staff was supposed to monitor Resident 1 every 30 minutes because he was confused and would forget to use his FWW, which he needed due to his unsteady and wobbly gait (the manner or pattern of walking). LVN 2 stated she discussed with staff Resident 1's constant need for reminders to use his FWW but nothing was done. LVN 2 stated she did not think about the fact that Resident 1 did not have the ability to learn how to use the FWW or understand the importance of using it. LVN 2 stated staff only monitors the BBQ patio consistently during smoking breaks and it was not safe for Resident 1 to be outside on the patio by himself. During an interview on 2/18/2025 at 2:50 p.m., the DON stated Resident 1 was confused and forgetful and should have been monitored every 15-30 minutes because he was a high fall risk and had previously fallen on 3/22/2024 breaking his left hip. During an interview on 2/19/2025 at 10:14 a.m., the Director of Staff Development (DSD) stated on 1/23/2025, CNA 7 and CNA 8 were assigned to monitor the hallways near the outside patio between 12 p.m. and 3 p.m., and they were also assigned to provide care to other residents. The DSD stated no one was given a dedicated monitoring assignment and everyone was responsible to monitor the residents in the hallway. The DSD stated Resident 1 had a history of not using his FWW and constantly needed redirection, but he was not able to retain information on how to use the FWW since the summer of 2024. The DSD stated it was inappropriate to continue teaching Resident 1 to use the FWW or expect him to use it when he had poor cognition and forgetfulness. The DSD stated staff could not watch Resident 1 all the time, even though he was prone to falls unless they assigned a one-to-one sitter (staff that are immediately at hand to help prevent a fall or redirect a resident from engaging in harmful acts). The DSD stated Resident 1 was not monitored appropriately and should have been, because of his unsteady gait, his previous fall on 3/22/2024 and his confusion/forgetfulness to prevent him from falling and sustaining a fracture on 1/23/2025. During a concurrent interview and record review on 2/20/2025 at 1:23 p.m., with the DON, the Resident Care Conference Note dated 1/17/2025 was reviewed. The Resident Care Conference Note indicated Resident 1 needed frequent reminders to use his FWW. The DON stated the Resident Care Conference Note indicated Resident 1's need for constant reminders to use his FWW was inappropriate because Resident 1 was not able to retain information or learn due to his severe impaired cognition. During an interview on 2/20/2025 at 4:20 p.m., the ADM stated in addition to staff who were assigned to monitor the hallway/exits and the BBQ patio, the facility also had an alarm sensor that sounded off when residents were near the exits, which triggered a camera at the nursing stations as a second line of defense to monitor residents. The ADM stated once the alarms triggered the nurses at the nursing stations and staff who were near the exit doors were supposed to assess the situation in person and via the cameras. The ADM stated on 1/23/2025, no one was monitoring the exits when Resident 1 exited the building onto the BBQ patio. The ADM stated if someone had been monitoring the hallway, patio and cameras, they would have noticed Resident 1 go outside and could have intervened before the resident fell and broke his hip. During a review of the facility's undated Policy and Procedure (P&P) titled Fall/Accident Prevention Program the P&P indicated the interdisciplinary team will determine patterns, situations, and behaviors associated with the fall incidence. The P&P indicated staff will be alerted to those residents at risk and trained in the care plan interventions designed to prevent or reduce repeat falls. The P&P indicated the facility will establish a common method of communication to remind staff to monitor residents to prevent falls on the change of shift report or assignment sheets, and staff will be trained on the care plan interventions designed to prevent or reduced repeated falls.

Based on observation, interview and record review, the facility failed to ensure the resident, who was assessed as high risk for falls and had a self-release belt (a device designed for residents needing a reminder to call for assistance before exiting a wheelchair, for limiting unassisted exit and unwanted movement) while in a wheelchair for safety, did not fall out of the wheelchair and sustained injury for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure the Velcro (a type of material that consist of two pieces of cloth that stick together with a system of very small hooks used to fasten) used to secure Resident 1's self-release belt was not worn out and was in functional condition to keep the belt's ties securely fastened to prevent Resident 1 from falling out of the wheelchair when the resident leaned forward. 2. Develop a care plan for Resident 1's use of a self-release belt for the wheelchair with interventions to ensure the resident's safety and prevent falls and injuries. 3. Followed the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised 12/2007, which indicated, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. These failures resulted in Resident 1 falling face forward from the wheelchair when Nursing Assistant (NA 1) was wheeling the resident to the dining room on 11/15/2024 and sustained a nose fracture (broken bone) and a head contusion (a bruise to the brain that causes bleeding and swelling in the brain tissue) requiring hospitalization from [DATE] to 11/16/2024. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including fracture (broken bone) of the nose bones, history of falling, dementia (a progressive state of decline in mental abilities), and kyphosis (an abnormally curved spine). During a review of Resident 1's Physician's Order Summary, the Physician's Order Summary indicated a physician's order dated 4/8/2020, for a wheelchair with a self-release belt to prevent resident from getting up unassisted. During a review of Resident 1's History and Physical (H&P), dated 4/13/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decision. During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated the resident's score was 13 (total score above 10 represents high risk). During a review of Resident 1's Incident Report, dated 4/22/2024, the Incident Report indicated Resident 1 was found on the floor in a fetal position (curled up position) with her head positioned against the bedside table and the wheelchair next to her with the self-release belt wrapped around Resident 1's waist. The Incident Report indicated Resident 1 sustained redness on the right side of the face and a small bump on the forehead. The Incident Report indicated steps taken to prevent recurrence included close supervision. During a review of Resident 1's Care Plan titled, Status Post Fall dated 4/22/2024, the Care Plan goal for Resident 1 was to have no repeat fall or injury. The Care Plan interventions included to provide a safe environment, to ensure the self-release belt properly secured, safety monitoring for 72 hours, apply ice packs to affected area, and monitor vital signs for 72 hours. During a review of Resident 1's Post Fall assessment dated [DATE], the Post Fall Assessment indicated immediate action to prevent fall from recurring included close supervision, make sure self-release belt was properly applied, and other fall precautions followed (not specified). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated the resident's score was 13 (total score above 10 represents high risk). During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated the resident's score was 14 (total score above 10 represents high risk). During a review of Resident 1's Incident Report, dated 6/20/2024, the Incident Report indicated, Resident 1 was seating in the wheelchair with a certified nursing assistant (unknown) standing behind Resident 1. The Incident Report indicated Resident 1 leaned forward with self-release belt on and fell to the floor face down. The Incident Report indicated Resident 1 sustained a golf size bump on the left forehead During a review of Resident 1's Incident Investigation for the incidents occurred on 4/22/2024 and 6/20/2024, the Incident Investigation indicated recommendations to do frequent checks. There was no information documented in the Incident Investigation that resident 1's self-released belt was examined for signed of being worn out. During a review of Resident 1's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated the resident's score was 16 (total score above 10 represents high risk). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 11/22/2024, the MDS indicated Resident 1 was dependent (needed nursing staff to do all of the effort to complete) on staff with eating, oral hygiene, toileting, showering, dressing, and putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 1 was dependent (needed nursing staff to do all of the effort to complete) on staff to roll from left to right, move from sitting to lying, move from lying to sitting, stand from sitting and transferring. The MDS indicated Resident 1 used a restraint (manual method or device that limits a person's ability to move or access their body) daily while in a chair or out of bed to prevent rising. During an observation on 11/27/2024 at 12:00 p.m., in the dining room, Resident 1 was observed in a wheelchair with a self-release belt around her waist. Resident 1 was unable to engage in an interview. During an interview on 12/2/24 at 6:57 a.m., Certified Nursing Assistant (CNA 1) stated Resident 1 used the self-release belt due to Resident 1 inability to sit upright in the wheelchair. CNA 1 stated on 11/15/2024 she witnessed NA 1 pushing Resident 1 in a wheelchair when Resident 1 threw herself out of the wheelchair. CNA 1 stated Resident 1 had the self-release belt on. CNA 1 stated Resident 1's head was bleeding. CNA 1 stated the ambulance was called to transport Resident 1 to the GACH. CNA 1 stated the Velcro on the self-release belt was worn out and did not stick to hold the belt straps (ties) together. CNA 1 stated after Resident 1 fell the facility ordered new self-release belts. During an interview on 12/2/2024 at 9:35 a.m., Restorative Nursing Assistant (RNA 1) stated the self-release belt usually applied around the resident's abdomen and around the wheelchair and secured in the back of the wheelchair with the Velcro straps. RNA 1 stated the resident had to be seated upright in the wheelchair and the resident's back should be positioned against the back of the wheelchair. RNA 1 stated Resident 1 could not stand up on her own. RNA 1 stated if the self-release belt was used a lot the Velcro would become worn out. RNA 1 stated CNA (in general) or charge nurse should notify RNAs if the belt needed to be replaced. RNA 1 stated he had seen some CNAs tie the restraint belt in a knot due to lack of grip from the Velcro. RNA 1 stated the last time (unknown time) the self-release belt was replaced because the Velcro straps were not sticking together because they were worn out. RNA 1 stated Resident 1's self-release belt was replaced after Resident 1 fell on [DATE] and returned to the facility after hospitalization . RNA 1 stated the fall could have been avoided if the resident was checked to ensure she was sitting up straight, not leaning forward, not slouching, and the self-release belt was properly secured with the Velcro. During an interview on 12/2/2024 at 10:29 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was a high risk for fall. LVN 1 stated Resident 1 was unable to follow instructions, was leaning forward while in the wheelchair and was unable to reposition without staff assistance. LVN 1 stated the reason why Resident 1 had the self-release belt was to ensure Resident 1's safety. LVN 1 stated Resident 1's fall could have been prevented if the self-release restraint belt was well secured with the Velcro. LVN 1 stated the Velcro should have been checked if it was securely fastened. During an interview on 12/2/2024 at 1:29 p.m., Registered Nurse Supervisor (RNS 2) stated Resident 1 needed assistance with transferring and was dependent on nursing staff for Activities of Daily Living (ADLs) and needed to be wheeled around. RNS 2 stated Resident 1 was unable to stand up or follow instructions. RNS 2 stated the self-release belt was used to protect the resident from falling while seated in the wheelchair. RNS 2 stated some residents were strong enough to lean forward in the wheelchair and fall if the self-release belt was not fasten/ secured properly. RNS 2 stated after Resident 1's fall on 11/15/2024 a new self-release belts were ordered that have a larger Velcro and were fasten better. RNS 2 stated the self-release belts previously used for Resident 1 had a thinner strip of Velcro. RNS 2 stated Resident 1 was a high risk for falls because Resident 1 was confused, did not know what was safe and tried to move unassisted. During an interview on 12/2/24 at 3:00 p.m., NA 1 stated that in the morning of 11/15/2024, prior to breakfast, NA 1 was instructed to assist Resident 1 to get to the dining room. NA 1 stated Resident 1 was seated in a wheelchair and had a self-release belt on. NA 1 stated while wheeling Resident 1 to the dining room, Resident 1 was sitting back in the wheelchair when she suddenly leaned forward. NA 1 stated that the self-release belt came off from the wheelchair and Resident 1 fell from the wheelchair landing face forward on the floor and was moaning. NA 1 stated she called for help and LVN 2 and RNS 1 came to her summon for help and applied towels and ice packs to Resident 1's face, nose, and head. NA 1 stated Resident 1 was transferred back to her bed after the fall. NA 1 stated Resident 1's fall was avoidable if the self-release belt was well secured/fastened and in working condition. NA 1 stated before wheeling Resident 1 to the dining room, she did not check if the Velcro was securely fastened before wheeling Resident 1 to the dining room. During an interview on 12/2/2024 at 3:47 p.m., Registered Nurse Supervisor (RNS 1) stated Resident 1 had a recent fall on 11/15/2024 before 7 a.m. RNS 1 stated Resident 1 had a wound on the bridge of the nose with minimal bleeding as a result of this fall. RNS 1 stated he was told Resident 1 leaned forward while in the wheelchair and fell forward. RNS 1 stated Resident 1 had the self-release belt on during the fall. RNS 1 stated the self-release belt was used to prevent falls and prevent the resident from getting up unassisted. RNS 1 stated when the resident has a self-release belt the resident should not fall out of the wheelchair when resident leans forward. RNS 1 stated the self-release belt should prevent the resident from falling. During an interview on 12/2/2024 at 4:06 p.m., the Director of Nursing (DON) stated on 11/15/2024 she saw Resident 1 on a gurney (used for transporting residents) transported to the GACH by an ambulance. The DON stated Resident 1 had an injury to her nose. The DON stated Resident's 1 fall could have been avoided if the self-release belt was in good condition without worn out Velcro. The DON stated a new self-release belts were ordered to replace old self-release belts. During a record review of Resident 1's GACH records, titled General Inpatient History and Physical, dated 11/16/2024, the General Inpatient History and Physical, indicated Resident 1 had a right frontal (front) scalp contusion (bruise) and bilateral (affecting two sides) nasal bone fractures. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised 12/2007, 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 .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

Based on interview and record review, the facility failed to ensure a resident, who was totally dependent on staff for care and required a two-person physical assist to complete her activities of daily living ([ADL] task such as bathing, showering, dressing, transferring between surfaces including in and out of bed or a chair, walking, using the toilet and eating) did not sustain an injury while being transferred from a Geri-chair (a large, padded chair that is designed to help seniors with limited mobility) to a bed for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 1) did not transfer Resident 1 from a Geri-chair to a bed by himself without assistance from another staff, per Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/7/2024 and Care Plan, titled, Self-Care Deficit dated 6/3/2023. 2. Ensure CNA 1 reported to a licensed nurse when he heard a popping sound while transferring Resident 1 from a Geri-chair to a bed by himself, without assistance from another staff. 3. Ensure staff followed the facility policy and procedure (P&P) titled, Certified Nursing Assistant (CNA), which indicated to report changes in a resident's condition to a charge nurse and/or supervisor. These deficient practices resulted in Resident 1 sustaining an acute comminuted displaced oblique fracture (the bone breaks into several pieces diagonally across the width of the bone) of the distal (the part of the body that is away from the center of the body than another part) right femoral (thigh bone) shaft (straight part of thigh bone), requiring Resident 1 to be transferred to a General Acute Care Hospital (GACH) on 8/13/2024. At the GACH Resident 1 underwent a retrograde intramedullary nailing (a metal rod is inserted into the center of the femur then fixed at both ends with screws) surgical procedure to the right femur to repair the fracture. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simple tasks) and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 1's MDS, dated [DATE], the MDS indicated, Resident 1's cognitive skills for daily decision making were moderately impaired (decisions were poor, cues/supervision required). The MDS indicated Resident 1 required dependent assistance (helper does all of the effort) from two or more staff for chair to bed/bed to chair transfers, rolling from left to and right, toileting and personal hygiene. During a review of Resident 1's Care Plan, revised 6/3/2023, the Care Plan indicated Resident 1 had self-care deficits with bed mobility, transfers, personal hygiene, bathing, and dressing. The Care Plan's goal indicated, Resident 1's ADL needs would be met every shift. One of the Care Plan's interventions included to have a two-person assist for Resident 1's transfers and bed mobility. During a review of Resident 1's Situation Background Assessment, and Recommendation ([SBAR] a form of communication between members of a health care team) communication form, dated 8/13/2024, the SBAR indicated there was swelling above Resident 1's right knee and right posterior (back of ) thigh. The SBAR indicated Resident 1 had facial grimaces and moaning during repositioning. During a review of Resident 1's Physician's Order Report dated 8/13/2024 and timed at 2 p.m., the Physician's Order Report indicated an order to obtain a right hip and right knee X-ray (a medical procedure that creates pictures of the structures of the inside of the body) due to swelling and to rule out a fracture. During a review Resident 1's right hip X-ray Report, dated 8/13/2024, the X-ray Report indicated Resident 1 sustained a right hip intertrochanteric fracture (a broken hip) with varus deformity (a condition that causes an abnormal position of the knee joint and lower leg bone). Resident 1's right knee X-ray Report indicated a distal femoral oblique fracture (a break in the thigh bone, or femur, that occurs just above the knee joint and has an angled line across the shaft). During a review of Resident 1's Physician's Order Report dated, 8/13/2024 and timed at 10 p.m., the Physician's Order Report indicated to transfer Resident 1 to the GACH via paramedics. During a review of the GACH's Emergency Department (ED) Provider Note, dated 8/13/2024, the GACH's ED Provider Note indicated, Resident 1 was admitted to the GACH ED on 8/13/2024, at 10:40 p.m. During a review of the GACH's X-ray report, dated on 8/13/2024, the X-ray report indicated Resident 1 sustained an acute comminuted displaced oblique fracture of the distal right femoral shaft. During a review of the GACH's Surgical Case Report, dated 8/17/2024, the Surgical Case Report indicated, Resident 1 underwent a retrograde intramedullary nailing of the right femur on 8/17/2024. During a telephone interview on 8/15/2024, at 9:44 a.m., Resident 1's Family Member (FM 3) stated, she and FM 2 visited Resident 1 on 8/13/2024, around 11:20 a.m., and found Resident 1 grimacing in pain and noted her right thigh was really swollen. FM 3 stated, they asked staff to assess Resident 1. During a telephone interview on 8/15/2024, at 11:20 a.m., and a subsequent interview at 3:09 p.m., CNA 1 stated on 8/13/2024 at approximately10 a.m., Resident 1 was in her room sitting in a Geri-chair. CNA 1 stated Resident 1's diaper needed to be changed, so he pulled Resident 1 up from the Geri-chair to put her in bed so he could change her diaper. CNA 1 stated when he pulled Resident 1 up from the Geri-chair he heard a popping sound that sounded like something hitting plastic. CNA 1 stated he looked around to see if he could figure out where the popping sound came from, but he could not find anything. CNA 1 stated at the time he heard the popping sound; he noticed that Resident 1 became more agitated than usual, but he did not pay much attention to it because Resident 1 had a behavior of being agitated during care. CNA 1 stated he transferred Resident 1 from the Geri-chair to the bed by himself without assistance from other staff because Resident 1's family was coming to visit her, and he wanted her to be ready before they arrived. CNA 1 stated he knew Resident 1 needed a two-person assist with transfers, but he thought that was more for female CNAs, he was a guy, and it was not necessary for him to ask for help unless Resident 1 was combative or became irritable. CNA 1 stated it was probably better to have extra help when caring for Resident 1 and he should have asked someone to help him transfer the resident from the Geri-chair to the bed. CNA 1 stated, he was a little concerned about Resident 1 when he heard the strange popping sound, so he waited with her until she calmed down and then left Resident 1's room. CNA 1 stated he did not report to anyone when he heard the popping sound when he transferred Resident 1. CNA 1 stated, later he heard that Resident 1's hip was fractured, that was when he realized the popping sound he heard could have been when Resident 1's hip broke. CNA 1 stated he should have reported the popping sound he heard when he transferred Resident 1 from the Geri-chair to the bed. During an interview on 8/15/2024, at 11:55 a.m., the Unit Manager (UM 1), who was a Licensed Vocational Nurse (LVN), stated Resident 1 required a two-person assist for transfers because Resident 1 was bed bound and totally dependent on staff for care. During a telephone interview on 8/15/2024, at 1:51 p.m., LVN 1 stated Resident 1 required two people to assist during her care, repositioning, and transfers, because she had a tendency of grabbing and holding onto staff's arms. LVN 1 stated during the morning huddle (a short nursing staff stand-up meeting in which residents care needs are reviewed and discussed) on 8/13/2024 at 6:45 a.m., they were told Resident 1 needed a two-person assist. LVN 1 stated CNA 1 did not report to her that he heard a popping sound while transferring Resident 1 from the Geri-chair to the bed. During a telephone interview on 8/15/2024, at 4:22 p.m., 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) stated, a two-person assist is required to prevent accidents and injuries during transfer and care. The PT stated Resident 1 required a two-person assist to complete most of her ADLs in order to be safe, especially during transfers from a chair to a bed. During an interview on 8/15/2024, at 4:34 p.m., the Director of Staff Development (DSD) stated, they (nursing staff) have shift huddles every morning at 6:45 a.m., where they discuss residents' safety during care. The DSD stated, she mentions during every huddle that most of the residents require two people to assist during care for their safety. The DSD stated, CNA 1 should have called for help from other staff when he provided care to Resident 1 to prevent any injury. The DSD stated CNA 1 should have reported to LVN 1 immediately after hearing a popping sound. During an interview on 8/15/2024, at 5 p.m., the Director of Nursing (DON) stated, Resident 1's incident could have been avoided if CNA 1 had requested assistance to transfer Resident 1. The DON sated CNA 1 should have reported to a licensed nurse immediately after hearing a popping sound so Resident 1 could have been immediately assessed and there was no delay in the resident's care. During a review of facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated to implement interventions to reduce accident risks and hazards. During a review of facility's undated P&P titled, Body Mechanics, the P&P indicated to ask another staff member if you are going to need assistance. During a review of the facility's undated P&P titled, Certified Nursing Assistant (CNA), the P&P indicated, to report changes in patient's condition to a charge nurse and/or supervisor.

Based on observation, interview, and record review, the facility failed to ensure the nursing staff immediately initiate basic life support ([BLS] care healthcare professionals provide to anyone who's heart stops beating suddenly) including ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of three sampled residents (Resident 1), who became unresponsive on [DATE] while in the dining room. The facility failed: 1. Ensure the Licensed Vocational Nurse ( LVN 3) did not instruct Certified Nursing Assistant (CNA 5) to wheel Resident 1 out from the dining room back to Resident 1's room so that CPR could be provided in the resident's room. 2. Ensure LVN 3 and CNA 5, when they found Resident 1 unresponsive, did not waist critical time by placing Resident 1 on his wheelchair then wheeling the resident back to his room, and transferring the resident on his bed instead of immediately initiating CPR. 3. Ensure the nursing staff initiated lifesaving measures, including CPR, immediately when Resident 1 was found unresponsive and pulseless. 4. Ensure staff called 911 as soon as Resident 1 was found unresponsive. As a result, there was an eight-minutes delay in starting Resident 1's CPR. Resident 1 was pronounced dead on [DATE], at 6:03 p.m. These deficient practices placed 58 residents, who had a Full Code (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) status at risk not to receive life saving measures timely, including CPR. On [DATE] at 3:24 p.m., the Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Administrator (ADM),the Director of Nursing (DON) due to the facility's failure to provide timely basic life support (BLS) to Resident 1, including immediate initiation of CPR. An IJ Removal Plan ([IJRP], an intervention to immediately correct the deficient practices) was requested. On [DATE] at 4:25 p.m., the ADM submitted an acceptable IJRP. After onsite verification of IJRP implementation through observation, interview, and record reviews, the IJ was removed on [DATE] at 5:45 p.m., in the presence of the ADM, the DON, and Director of Staff Development (DSD). The IJRP included the following: a. On [DATE], CNA 5 and Licensed Vocational Nurse (LVN 3) were in-serviced and counseled by the DON regarding immediate emergency response to a resident who was choking or found unresponsive. For choking, staff must initiate the Heimlich maneuver. For the unresponsive resident, staff will call the resident's name to establish responsiveness; if there is no response, facility staff will assess for breathing and pulse. Cardiopulmonary resuscitation (CPR) will be initiated if a resident is found with no breathing or pulse. b. On [DATE],[DATE] and [DATE], the DON and DSD provided an in-service regarding the emergency management of a resident chocking and cardiopulmonary arrest. c. On [DATE], the DON coordinated with American Heart Association Accredited Basic Life Support (BLS) Instructor, an outside provider, to provide an in-service, education, and conduct a competency assessment, to the nursing staff. d. On [DATE], the American Heart Association Basic Life Support Instructor will provide re-certification training to the listed nursing staff: One (1) Registered Nurse (RN), one (1) LVN, and two (2) CNAs will be attending the training. e. On [DATE], the DSD conducted an audit on RNs, LVNs, and CNAs for the current Basic Life Support Certification. Based on the record review, one RN, one LVN, and two CNAs must be re-certified. The 4-nursing staff with a lapsed CPR card were removed from the daily schedule until completion of the CPR recertification. f. The DON reviewed the 127 residents' health records, based on the data collected using the facility Matrix System, there are 112 residents that are Full codes, and 15 residents that a Do Not Resuscitate. ([DNR] a person has decided not to have CPR attempted on them if their heart or breathing stops) g. The ADM enrolled the DSD in the Red Cross Basic Life Support (BLS) Instructor's Course to ensure RNs, LVNs and CNAs will undergo direct training from an in-house certified Basic Life Support (BLS) instructor. The DSD will submit a report to the Director of Nursing (DON) of the list of nursing staff who completed the Cardiopulmonary Resuscitation (CPR) training weekly, including the new hire. The DSD will complete the course on [DATE]. h. The DSD or designee will conduct a monthly call for a Code Blue Mock Drill. The licensed nurses will continue to monitor the safety of the residents, supervise them during mealtime, and be available ,d+[DATE] to provide basic life support (BLS) in the event of a Code Blue emergency. Emergency responder must immediately assess the resident. In the event of chocking a Heimlich maneuver must be delivered. In an episode of cardiac arrest, the staff will immediately assess the resident, if no pulse or breathing noted, one staff must stay with the resident while another staff will verify the code status of the resident, once confirm that resident has a full code status, if the surrounding area is safe, a resident will not be transfer or remove from the location, immediately start the cardiopulmonary resuscitation (CPR). One staff must bring the emergency cart (E-cart)/supplies, one staff must call for 911, staff will continue to provide cardiopulmonary resuscitation until the Emergency Medical Services (EMS) arrived. The Director of Nursing (DON) will be immediately notified. Quality Assurance: The Director of Staff Development (DSD) will submit the Code Blue Mock Drill Report to the Director of Nursing (DON) monthly. The Director of Nursing (DON) will submit the report to the Quality Assurance and Utilization Management Committee quarterly during the Continuous Quality Improvement (CQI). Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including blindness, essential hypertension (high blood pressure), seizure disorder ( a sudden, uncontrolled burst of electrical activity in the brain), and dementia (the loss of cognitive functioning -thinking, remembering, and reasoning ) with psychosis ( person is disconnected from reality). During a review of Resident 1's Minimum Data Sheet ([MDS]- a standardized assessment and care screening tool) dated [DATE] indicated Resident 1 had severely impaired cognitive skills (ability to learn, understand, and make decisions) for daily decision making and required supervision or touching assistance for eating, upper body dressing, partial or moderate assistance for oral hygiene, toileting, putting on and taking off footwear, maximal assistance for shower and lower body dressing. Resident 1 has severely impaired vision. The MDS indicated Resident 1 did not have Physician's Order for Life Sustaining treatment ([POLST] a written medical order from a physician that specify the types of medical treatment resident want to receive during serious illness).During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated [DATE], SBAR indicated Resident 1 status was a Full Code. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a concurrent interview and record review on [DATE] at 3:37 p.m., with Registered Nurse (RN 2) Resident 1's Nursing Progress Notes dated [DATE] were reviewed. The Nursing Progress Notes indicated Resident 1 died of cardiac arrest (heart stops beating suddenly) while he was having dinner in the dining room when suddenly became unresponsive, not breathing, and without pulse on [DATE] at 5:27 p.m. RN 2 stated the Nursing Progress Notes indicated CPR was not initiated until Resident 1 was wheeled out from the dining room back f to Resident 1's room. During an interview on [DATE] at 4:30 p.m., RN 2 stated he was not present in the dining room when Resident 1 became unresponsive , but staff informed him, and he came to the dining room to help. RN 2 stated if Resident 1 was a Full code the licensed nurses should have immediately start CPR as soon as Resident 1 become unresponsive and not breathing. RN 2 stated it was important to initiate CPR right away when Resident 1 became unresponsive, not breathing and without the pulse, because every second counts and time was a factor to save Resident 1's lives. During viewing on [DATE], at 9:35 a.m., of the facility's recorded video footage for [DATE], and concurrent interview with the ADM, the video recording indicated that on [DATE] at 5 p.m., Resident 1 was sitting on a wheelchair in the dining room waiting for his dinner to be served. The recorded video demonstrated that at 5:27 p.m., while Resident 1 was having dinner, CNA 5 was running toward Resident 1's direction. The recorded video demonstrated Resident 1, while on the wheelchair, slumped forward and was not moving. The video demonstrated CNA 5 picked Resident 1 up and performed the Heimlich maneuver. Resident 1 was remaining unresponsive. CNA 5 placed the resident back on a wheelchair and wheeled Resident 1 out of the dining room back to his room. At 5:35 p.m., crash cart was brought in Resident 1's room and at 5:43 p.m., paramedics arrived. The video recording indicated there was an eight-minutes delay from the time Resident 1 slumped forward and became unresponsive until staff initiated Resident 1's CPR During an interview on [DATE] at 9:07 a.m., CNA 5 stated he was responsible for taking care of Resident 1 while in the dining room on [DATE]. CNA 5 stated he thought Resident 1 was choking when Resident 1 became unresponsive during dinner. CNA 5 stated he performed a Heimlich maneuver but Resident 1 continue to be unresponsive. CNA 5 stated LVN 3 came and assessed Resident 1's airway. CNA 5 stated LVN 3 said she cannot see any food blockage in Resident 1's mouth. CNA 5 stated Resident 1 continued to be unresponsive. CNA 5 stated she asked LVN 3 to perform CPR but was told not yet. CNA 5 stated CPR was not provided to Resident 1 when Resident 1 remained unresponsive and LVN 3 confirmed the resident had no pulse. CNA 5 stated if Resident 1's CPR was started right away we could have saved his life. CNA 5 added that LVN 3 did not call 911 at the time when Resident 1 became unresponsive and not breathing. CNA 5 stated LVN 3 instructed him to wheel Resident 1 out from the dining room back to Resident 1's room so that CPR can be provided. CNA 5 stated LVN 3 was concern for Resident 1's privacy and not to make other residents in the dining room panic. During an interview on [DATE] at 12:18 p.m. LVN 2 stated LVN 3 came and help when Resident 1 was observed unresponsive. LVN 2 stated Resident 1 was grabbing his chest and then became unresponsive, so staff thought Resident 1 was choking. LVN 2 stated CNA 5 provided Heimlich maneuver while LVN 3 assessed the airway. LVN 2 stated CPR was not started in the dining room right away when Resident 1 became unresponsive and had no signs of pulse. LVN 2 stated that there was a delay in initiating CPR, and no one called 911 for emergency services. LVN 2 stated CPR was initiated when Resident 1 was back in his room and transferred back to bed. LVN 2 stated that CPR was not done on the floor in the dining room out of concern for the resident's privacy and to prevent other residents in the dining room to panic. During an interview on [DATE] at 11:50 a.m., LVN 2 stated on [DATE] at approximately 5:27 p.m., Resident 1 was sitting on his wheelchair in the dining room. LVN 2 stated Resident 1 lost consciousness when CNA 5 was doing the Heimlich maneuver. LVN 2 stated CNA 5 sat Resident 1 on his wheelchair, wheeled Resident 1 back to his room and carried Resident 1 to his bed. LVN 2 stated CPR was not initiated right away on the scene (dining room). LVN 2 stated that every second mattered to save Resident 1's live. LVN 2 stated if CPR was started right away when Resident 1 became unresponsive there could be a chance of the resident survival. During an interview on [DATE] at 12:05 p.m., the DON stated CPR should not be delayed, once resident became unresponsive, not breathing and no pulse, staff should respond quick in an emergency and initiate CPR. During an interview on [DATE] at 12:10 p.m. CNA 5 stated LVN 5 and LVN 3, who responded when Resident 1 became unresponsive, did not initiate CPR right away and did not call 911. During an interview on [DATE] at 3:40 p.m., RN 1 stated that CPR should have been initiated right away when staff identified Resident 1 was unresponsive and not breathing. RN 1 stated CNA 5 and LVN 3 should not have taken Resident 1 to his room and place Resident 1 on bed before starting CPR, because time was very critical and important. The DON stated CNA 5 and LVN 3 should have initiated CPR as soon as Resident 1 was found unresponsive and possibly could have saved Resident 1's life. During a review of an online article titled, American Heart Association 2020 CPR and Emergency Cardiovascular Care Committee Guidelines, the article indicated, the adult basic life support algorithm (a process or set rules to be followed) for healthcare providers indicated to verify for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse simultaneously (at the same time). The guidelines further indicated if there was no breathing, or only gasping, with no pulse, to immediately begin CPR and perform cycles of thirty chest compressions (the act of applying pressure to someone's chest to help blood flow) and two breaths. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines During a review of the facility's P&P titled Cardiopulmonary Resuscitation, (undated) the P&P indicated Establish the need for CPR, send another person to call for emergency services, remain with the resident and call for help by following your facility policy for calling a code or getting emergency assistance.

Based on observation, interview and record review, the facility failed to ensure a resident, who was under conservatorship (a legal status in which a judge appoints a person [conservator] to manage the financial and personal affairs of a minor or incapacitated person) with a history of attempted elopement (an unauthorized departure of a patient from an around-the-clock care setting without the facility's knowledge and supervision), and assessed as high risk for elopement, did not elope from the facility for one of eight sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1, who on 3/23/2024, had attempted to elope from the facility by climbing over the patio's fence, did not elope from the facility on 6/16/2024 by climbing over the patio's fence. 2. Accurately assess Resident 1 for wandering (walk around without any clear purpose or direction) and elopement risk to prevent the resident from leaving the facility unsupervised. Resident 1 attempted to climb over the facility's fence on 3/23/2024 and on 6/16/2024 (2 months and 3 weeks later), he successfully climbed over the patio's fence and has not been found as of 7/8/2024. 3. Ensure on 6/16/2024 at 8:49 p.m. Resident 1 was supervised while he was on Station A patio. 4. Ensure staff followed facility's policy and procedure (P&P) titled, Elopement Risk Assessment which indicated residents should be evaluated upon admission, quarterly, annually and with any significant change of condition. Resident 1's Elopement Risk Assessments dated 2/15/2024 and 6/3/2024, indicated Resident 1 was not assessed for the risk of elopement. 5. Ensure staff responded to the sound of an alarm when door, leading to Station A patio, was opened on 6/16/2024, at 8:49 p.m., and Resident 1 gained the opportunity to walk through the patio door, climb over the fence, and eloped from the facility. As a result of these deficient practices, Resident 1 eloped from the facility on 6/16/2024 at 8:51 p.m. and has not been found as of 7/8/2024. These deficient practices placed Resident 1 at risk for exposure to harsh environmental conditions (rain and/or cold), hypothermia (a dangerously low body temperature), injury from motor vehicle accidents, medical complications related to his diagnosis of schizoaffective disorder (a mental condition characterized by abnormal thought processes and unstable mood) without receiving prescribed medication including Valproic Acid (medication for schizoaffective disorder), Abilify (antipsychotic [treat mental disorder] medication ), and Lithium (medicine used to treat mental illnesses ), lack of food with the risk of malnutrition (health problems that may arise due to lack of nutrients), dehydration (abnormally low fluid levels in the body), and possible death. According to the weather forecast report for the area where the facility was located the air temperature on 6/16/2024 was in the mid 70's degrees Fahrenheit (F) during the day and in the low 60's degrees F at night. https://weather.com According to https://crimegrade.org/safest-places-in- overall crime grade for violent crimes for the area, where the facility was located, the crime grade was F (meaning a violent crime was much higher than the average United States city). On 6/21/2024 at 1:28 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Director of Nursing (DON) due to the facility's failure to assess, monitor and supervise Resident 1 to prevent his elopement from the facility on 6/16/2024. On 6/24/2024 at 4:15 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP]) interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 6/24/2024 at 8 p.m., in the presence of the facility's Administrator (ADM), DON and Minimum Data Set Nurse (MDSRN). The IJPR included the following immediate actions: 1. The facility created zone mapping with areas of location: Station A by the time clock, exit to the barbeque patio between Stations A and B, and exit at Station B close to the side gate. Staff will be assigned to the designated areas for close monitoring and supervision of the residents. 2. A chair will be provided for an assigned staff (clinical or non-clinical staff) every shift. The purpose of the zone map for the staff was to do a visual check, ensure the resident's safety, and prevent residents from elopement. Responsibility of the assigned staff will redirect the resident to go back inside the facility, and if the resident declines, the staff will notify the nursing staff for further assistance. 3. Developed a Zoning Shift Log for the staff assigned to Station A and Station B to sign in every shift. 4. Created an hourly monitoring log for residents assessed as high risk for elopement. The licensed staff will document the hourly location of each resident. The Director of Staff Development (DSD) will assign staff for the zoning shift. The Hourly Monitoring Log will be part of the Certified Nurse Assistant (CNA) responsibility in each shift. 5. The unit managers will collect data daily. The unit managers will submit the reports collected daily to the Director of Nursing (DON). 6. Three (3) camera monitors were installed in each station (Station A, B and C). The three existing doors were installed with sound alarms. When the resident opens the door, an alarm triggers a sound to notify staff who can visually check the monitor. Staff (licensed and non- licensed) must proceed to the area (patio) to encourage the resident to go back inside the facility unless a zoning staff member assigned was present. 7. On 6/21/2024 facility installed a mesh surrounding the Station A patio to prevent residents from climbing the fence. 8. Facility requested a quote from a fence company to extend additional three foot angled in Station A patio fence. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, insomnia (sleeplessness), and iron deficiency anemia (a condition in which the body does not have a sufficient amount of iron). During a review of Resident 1's History and Physical (H&P), dated 11/21/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/30/2024, the MDS indicated Resident 1 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) with eating, oral hygiene, toileting hygiene, showering/ bathing, and upper and lower body dressing, and required partial to moderate assistance with personal hygiene. The MDS indicated Resident 1 required supervision with walking 10 feet, 50 feet with two (2) turns, and 150 feet. During a review of Resident 1's care plan titled, Resident 1 had attempted to elope by climbing over the fence, dated 3/23/2024. There were no interventions to prevent Resident 1's elopement. During a review of Resident 1's Elopement Risk assessment dated [DATE], 3/23/2024, and 6/3/2024 indicated the Elopement Risk assessment dated [DATE] and 6/3/2024, did not illustrate Resident 1 was assessed for the risk of elopement. However, Resident 1's Elopement Risk assessment dated [DATE], indicated Resident 1 was assessed as being at risk for elopement. During a review of Resident 1's 72-hour Monitoring Notes, dated 6/16/2024, and timed at 9:20 p.m., the 72-hour Monitoring Notes indicated Resident 1 was last seen by CNA (unidentified) at 8:40 p.m., inside his room. The 72-hour Monitoring Notes indicated that at 9:20 p.m., the facility staff were unable to locate Resident 1 in the facility. The 72-hour Monitoring Notes indicated facility staff was alerted to look for Resident 1 inside the facility and surrounding area outside the facility. At 10:45 p.m. facility staff called local general acute care hospital (GACH) for Resident 1's possible admission. At 10:50 p.m., Resident 1's physician was notified. During a concurrent interview, and record review on 6/18/2024, at 5:15 p.m., with the ADM, the facility's recorded video footage for 6/16/2024 was reviewed. The video footage revealed that on 6/16/2024 at 8:49 p.m., CNA 1 was sitting at the Nursing Station A, diagonally across from the Nursing Station A there was a door leading to the patio surrounded by the 'chicken wire' (chain link) fence about 10 feet and 5 inches high. At 8:49 p.m., Resident 1 was seen exiting Station A patio door, located approximately 10-15 feet from Nursing Station A. CNA 1 did not follow Resident 1 outside to the patio area. The recorded video footage illustrated that at 8:51 p.m., Resident 1 was seen climbing over the patio fence and left the facility. The ADM stated the facility was a secured facility (facility secured with locked doors to prevent residents from exiting the premises at will). The ADM stated staff had to check the residents, who were assessed as a high risk for elopement, whereabouts hourly. The ADM stated there were no staff assigned on Station A to monitor patio door as residents were free to walk around and sit in the patio. The ADM stated all residents were at risk of leaving the facility and had to be monitored hourly, to know their whereabouts. During an interview on 6/18/2024, at 6:20 p.m., Unit Manager (UM 1) stated on 6/16/2024 at 8:20 p.m., Resident 1 approached her on Station C and asked for a gauze dressing for his wound (unspecified location). UM 1 stated she told Resident 1 she would see him later when she finished with wound care for another resident. UM 1 stated at 9:20 p.m., she started to look for Resident 1 as the resident had not returned to Station C. UM 1 stated she checked Resident 1's room but he was nowhere to be found. UM 1 stated she directed Licensed Vocational Nurse (LVN 1) to look for Resident 1 in the facility. UM 1 stated UM 2 looked for Resident 1 and the Registered Nurse Supervisor (RNS) called the police. UM 1 stated there should have been staff assigned to Station A patio area when residents go out on the patio, especially at nighttime to ensure residents safety. During an interview on 6/18/2024, at 8:15 p.m., CNA 3 stated, she was the assigned to care for Resident 1. CNA 3 stated she was working on Station C and saw Resident 1 last time in his room at 8:40 p.m. on 6/16/2024. CNA 3 stated Resident 1 was wandering around the facility and was not staying in one place. CNA 3 stated Resident 1 should have been on 1:1 monitoring (staff provides one to one nursing or observation care to a resident for a period of time) so he would have been watched more closely. During an interview on 6/20/2024, at 10:41 a.m., LVN 1 stated, Resident 1 should have been on 1:1 monitoring because Resident 1 walked around the facility a lot and could elope easily. LVN 1 stated there should have been staff to watch the residents when residents were on the patio because the residents could fall or tried to elope like Resident 1. During a concurrent observation and interview on 6/20/2024 at 4:10 p.m., with the Maintenance Supervisor (MS), the MS opened the door leading to Station A's patio and a sound like a doorbell was heard. The MS stated the sound was to alert staff that a resident was exiting outside to the patio. At the time of observation there were no staff observed coming to the patio area to check if a resident was leaving Station A and was going to the patio area. During an interview on 6/20/2024 at 4:40 pm., CNA 1 stated, on 6/16/2024 at around 8 p.m., she was passing snacks and saw Resident 1 walking between Station A and Station B. CNA 1 stated the facility staff were aware Resident 1 was a high risk for elopement. CNA 1 stated Resident 1 should have been on 1: 1monitoring to closely watch him. CNA 1 stated Resident 1 always was on 1:1 monitoring, but on 6/16/2024 Resident 1 was not on 1:1 monitoring, and she does not know why. During an interview on 6/20/2024, at 4:52 p.m., CNA 2 stated on 3/23/2024, he witnessed Resident 1 tried to leave the facility by attempting to squeeze himself in between the metal pole, where the fence was attached, and the building wall, but could not fit. Resident 1 then started walking around on the patio and then suddenly, Resident 1 walked over to another side of the fence, stood there for a minute, and started to climb over the fence. CNA 2 stated he ran and started to climb the fence to stop Resident 1. CNA 2 stated he redirected Resident 1 back into the patio. CNA 2 stated after this incident on 3/23/2024, Resident 1 should have been supervised and monitored every time he goes to the patio as he was a high risk of elopement and would attempt to elope again. During an interview on 6/20/2024, at 5:17 p.m., RNS stated, Resident 1 was a wanderer (moving from place to place without a fixed plan) because he was constantly walking around the facility. The RNS stated residents with high risk for elopement should be supervised to know their whereabouts every hour. The RNS stated the residents (in general) assessed as high risk for elopement should be monitored and supervised hourly to know their whereabouts. The RNS stated a resident, who goes to the patio should be supervised to avoid any incident of elopement or fall. The RNS stated there should be staff present on the patio to watch and monitor the residents. The RNS stated a resident, who assessed as high risk for elopement, should have whereabouts checked every hour and that what staff do hourly. During a concurrent interview and record review on 6/20/2024, at 6:24 p.m., with UM 1, Resident 1's care plan titled, At risk for elopement related to medical condition, schizoaffective disorder, and an attempt to elope by climbing the fence on 3/23/2024, was reviewed. UM 1 stated Resident 1's care plan indicated there were no selected intervention from pre-determined interventions for Resident 1, who had a history of climbing over the fence. UM 1 stated the interventions such as supervise the resident closely (pay special and careful attention to the resident), conduct regular rounds (to do consistent rounds which was hourly), and place Resident 1 on 1:1 monitoring was not selected and not implemented to prevent Resident 1 from elopement. During a concurrent interview and record review on 6/21/2024, at 12 p.m., with the DON, the DON stated the residents who were a high risk for elopement should have been on 1:1 monitoring. Resident 1 should been on 1:1 monitoring as he had a history of elopement attempt on 3/23/2024. The DON stated she was not aware Resident 1 was not on 1:1 monitoring. The DON stated if Resident 1 would have been on 1:1 monitoring Resident 1 would not eloped. The DON stated the importance of Resident 1 to be on 1:1 monitoring was for his safety. After reviewing Resident 1's care plan and Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) notes, the DON stated there was no documentation indicating IDT meeting was held and an investigation, of Resident 1's elopement attempt on 3/23/2024 was done The DON stated the care plan interventions were not selected to indicate what interventions were in place to prevent Resident 1 from elopement. During a review of the facility's policy and procedure (P&P) titled, 'Elopement Prevention,' ([undated]), indicated, it was the facility's policy to identify residents at risk and intervene accordingly, and to establish a plan of care when the risk factors are present. If a resident is determined to be at risk, a care plan goal with approaches to ensure safety will be implemented as determined by the IDT.

Based on observation, interview, and record review, the facility failed to transfer one of three sampled residents (Resident 1) using a two-person assist as per the facility's training manual for the use of a mechanical lift (a device used to move residents from one location to another). Resident 1, who had a high risk for falls and was totally dependent on staff for all care was transferred from the bed to a Geri-chair (a wheeled stretcher that can be configured into a chair position used for transporting residents) with a mechanical lift and a one-person physical assist which resulted in injury to Resident 1. This deficient practice of not using a two-person physical assist while using the mechanical lift resulted in the lift falling to the side causing the sling bar (metal bar suspended on the lifting arm of the machine in which the lifting sling (device in which residents are positioned in to be lifted) is attached) to hit Resident 1 in the face sustaining a comminuted nasal fracture (broken bones in several places) and contusion (bruising) to Resident 1's eyelid and periocular (area surrounding the eyeball) area. Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation, care, and treatment. Findings: During a review of Resident 1's Admission Record it indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. During a review of Resident 1's care plan titled, Self-care deficit dated [DATE] indicated Resident 1 was totally dependent on the staff during transfers, locomotion on unit, eating, dressing, bathing, toilet use, and personal hygiene. During a review of Resident 1's care plan titled, Risk for falls dated [DATE], it indicated the staff should use appropriate device as ordered. During a review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated [DATE], it indicated Resident 1 was totally dependent in care and required full staff performance when transferring to or from bed, chair, and or wheelchair. During a review of a Situation, Background, Assessment, Recommendation ((SBAR) an internal communication), dated [DATE] and timed at 6:15 a.m., indicated Resident 1 had a laceration (deep cut) on the bridge of her nose. The SBAR indicated the physician ordered a stat (done immediately) x-ray, neuro checks (brain function and nervous system assessment) to be performed every 72 hours, application of an ice pack to the nose, and a mild pain reliever, as needed for pain. During a review of the facility's Incident /Investigation Form, dated [DATE] and timed at 6:30 a.m., indicated Resident 1 had a laceration (deep cut) to nasal bones and was taken to a GACH Emergency Department (ED). The form indicated the root cause of Resident 1's injury was improper lifting and safety rule not enforced. During a review of Resident 1's Physician orders, dated [DATE] and timed at 6:35 a.m., it indicated an order for [REDACTED]. During a review of Resident 1's Physician orders, dated [DATE] and timed at 4 p.m., it indicated an order for [REDACTED]. During a review of Resident 1's GACH ED Physician note, dated [DATE], it indicated Resident 1 was brought in by ambulance after an accident with a mechanical lift with injury to the nasal bridge. The ED note indicated Resident 1 presented with [MEDICAL CONDITION] (swelling) and discoloration underneath both eyes. The ED's physician note, dated [DATE] and timed at 5:19 a.m., indicated Resident 1's [DIAGNOSES REDACTED]. The ED notes indicated Resident 1 had a computed tomography ((CT) x-ray in which computer controls the motion of the x-ray to produce an image) scan. The results of the CT scan indicated Resident 1 had a comminuted (break of bone into more than two parts) and displaced (moved from natural position) fracture with collapse of the nasal ridge and a [MEDICAL CONDITION] septum (bone that separated the two nostrils). During a review of Resident 1's Nursing Progress Note, dated [DATE] and timed at 6:15 a.m., it indicated at 6:15 a.m. that day, Certified Nursing Assistant (CNA) 3 reported Resident 1's nose was bleeding. Licensed Vocational Nurse (LVN) 1 responded and applied pressure and an ice pack to Resident 1's nose. The nursing progress note indicated the physician ordered an x-ray, ice pack to nasal bone, and neuro checks to be performed every 72 hours. The nursing progress note indicated CNA 3 stated, I was trying to transfer the resident (Resident 1) from the bed to the Geri chair using the lift, but the hanger swung around and hit resident's nose. During a review of Resident 1's Interdisciplinary Committee Minutes (IDT), dated [DATE], indicated Resident 1 had an unavoidable accident (sic) that caused injury during transfer from the bed to the Geri-chair with use of the mechanical lift. The IDT note indicated staff failed to spread the lift's base that caused it to fall and hit the resident's face that caused trauma. During a telephone interview, on [DATE] at 8:30 a.m., Resident 1's responsible party (RP 1) stated the facility's staff called her on [DATE] to notify her Resident 1 had an accident and was transferred to the hospital. RP 1 stated the facility informed her that a mechanical lift arm hit Resident 1 on her nose and Resident 1's nose was fractured. During an interview, on [DATE] at 1:35 p.m., CNA 1 stated there must be two people to assist Resident 1 in and out of the lift. CNA 1 stated, If the lift was being used properly, there should not be any way for the bar to hit a resident in the face because one staff should hold the bar while the other staff puts the resident in the swing. During a concurrent interview and observation , on [DATE] at 1:45 p.m., CNA 2 stated We make sure there are two staff members when we use the Hoyer lift (mechanical lift). The only way the swing bar can hit the resident's head is if we slide the lift in wrong. The bar should not swing. The other staff should hold the bar to prevent it from swinging. During a concurrent interview and observation , on [DATE] at 2:15 p.m., the Director of Nursing (DON) stated she believed an LVN (LVN 1) entered Resident 1's room after the incident and saw the CNA (CNA 3) working alone. During a telephone interview, on [DATE] at 2:36 p.m., CNA 3 stated, When I came into Resident 1's room, I had no one to help, so I decided to carry her alone. I tried to be careful and position her (Resident 1), but the Hoyer lift fell sideways while I was putting her in the Geri-chair. The center part that swings, hit her (Resident 1) in the head and she fell on to the Geri-chair. The bar hit her directly on the nose. I was frustrated because I was all alone. CNA 3 stated after Resident 1 was hit the licensed nurse put ice on her nose to stop the bleeding. During a telephone interview, on [DATE] at 7:37 a.m., LVN 1 stated at 6:15 a.m. on [DATE], CNA 3 came and told her Resident 1 was bleeding. LVN 1 stated she entered the room and saw Resident 1 in a Geri-chair bleeding from her nose. LVN 1 stated CNA 3 stated the mechanical lift turned around and hit the resident's nose. LVN 1 stated there should always be two staff members operating the mechanical lift and CNA 3 did not ask her for help. During an interview, on [DATE] at 8:14 a.m., the Director of Staff Development (DSD) stated CNA 3 forgot to open the mechanical lift legs appropriately and the mechanical lift fell to the side. The DSD stated Resident 1 did not fall to the floor but the mechanical lift's swing hit Resident 1 in the face, because the legs were not opened properly, and the mechanical lift was unstable. The DSD stated CNA 3 was working alone and the facility's number one rule was to not to work alone, especially when using the mechanical lift. The DSD stated the staff were aware they are supposed to use a two-person assist while operating the mechanical lift. During an interview, on [DATE] at 8:34 a.m. the DON stated, The CNA (CNA 3) said she did not open the legs of the mechanical lift and because of that, the machine dropped, and the swing hit Resident 1 on the nose. According to what the CNA (CNA 3) wrote in the interview, she was working alone, and it was a requirement for two people work together to use this machine. During an observation of the facility's video surveillance camera with the administrator on [DATE] at 9:30 a.m. indicated the following occurred on [DATE]: 1. At 6:10 a.m., CNA 3 was observed entering Resident 1's room alone. 2. At 6:19 a.m., CNA 3 exits Resident 1's room alone and proceeds to Nurse Station B. 3. At 6:20 a.m., LVN 1 and Registered Nurse (RN) 1, accompanied by CNA 3 went back to Resident 1's room. A review of the facility's policy and procedure (P/P), revised in ,[DATE] and titled, Falls and Fall Risk, Managing, it indicated staff would 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. A review of the facility's in-service training manual titled Hoyer Lift Device for Transferring Patients indicated The Hoyer lift should always be used with two people. One person should be helping control movement of patient while the other operates the lifting mechanism and opens the legs of the lift for optimal stability. Remember, one person should always maintain control of the patient in the sling while the second person operates the lift. Never, never, never, use a two-person Hoyer lift by yourself. Patients have slipped, tipped, and fallen out of the slings and have been seriously injured and some have died . Follow manual and healthcare facility instructions regarding the Hoyer lift to the letter.

Based on observation, interview and record review, the facility's staff failed to adhere to a resident's plan of care, which indicated when the resident was resistive to care the staff would retreat/withdraw if the resident refused and they failed to follow the facility's policy and procedure, Aggressive Behavior Management which indicated stipulated abuse was not tolerated by anyone, including staff for one of two sampled residents (Resident A). Resident A was observed on the facility's video surveillance (live close monitoring) with Certified Nursing Assistant 1 (CNA 1) taunting Resident A by stomping his foot at him and laughing at him while attempting who attempted to lure Resident A into a female resident's room (room [ROOM NUMBER]) but Resident A refused. CNA 1 was seen following Resident A into the same female's room where CNA 1 stayed for approximately two minutes then left the room without Resident A. where CNA 1 physically abused Resident A. Resident A was found, in the same female's room, by the facility's staff (CNA 2), shortly thereafter, with a bloody nose and swollen eye. This deficient practice resulted in Resident A being hit in the face physically abused by CNA 1, sustaining fractures (broken bones) to his eye and nose. Resident A was and required a transferred to a general acute care hospital (GACH) for evaluation, care and treatment. Resident A was diagnosed with [REDACTED]. A review of the facility's Center for Medicare and Medicaid Services ((CMS) a federal agency) Resident Census and Conditions Form 672, completed by the facility's Administrator (ADM), on 3/21/2020 indicated the facility had a census of 141 residents with 115 residents with dementia (progressive loss of mental ability) and mental behavioral healthcare needs. On 3/19/2020 at 9:45 a.m., a system failure was identified due to the facility's failure to ensure residents were free of abuse. An Immediate Jeopardy ((IJ) a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was declared under F600. The facility's Administrator (ADM) and The Director of Nurses (DON) were notified of the serious non-compliance that threatened Resident A's the resident's health and safety. On 3/22/2020 at 1:30 p.m., the facility submitted an acceptable plan of action (POA) and the Department notified the ADM the IJ was lifted after an onsite verification and confirmation the POA was implemented via observation, interview and record reviews as follows: 1. An immediate notification of all facility staff for mandatory in-service conducted by an outside source on Abuse Prevention including Alzheimer's and Dementia 2. The in-service was successfully held with a total of 93 employees. The remaining employees will be in-serviced on March 25, 2020. All other employees who were unavailable will be in-serviced prior to the start of their work. 3. A web-based training that is professionally acknowledged by the Department will be presented regarding Aggressive Behavior Management. 4. The Interdisciplinary Team ((IDT) a team of professionals working for a common goal for the resident) created a measurement on how to monitor wandering and aggressive residents. Behavioral Angels will be assigned and posted at designated locations and will be responsible to monitor that location (hallway, rooms and outside areas) to ensure wandering residents will be constantly re-directed to the proper locations. 5. A list of wandering residents and resident's with aggressive behaviors was distributed to all staff, so those residents would be constantly monitored to prevent untoward incident. Three Behavioral Angels will be assigned to the 7-3 shift, two Behavior Angels will be assigned to the 3 p.m. -11 p.m. (evening) shift and one Behavior Angel will be assigned to the 11 p.m. -7 a.m. (night) shift. 6. Care Plans for residents who wander and who have behaviors are being reviewed and updated according to the specific needs of the resident. 7. The ADM and the DON will ensure all staff attend and understand the importance of the lesson plan, random questioning and demonstration from staff will occur quarterly on Abuse Prevention, Alzheimer's and Dementia management. Findings: A review of Resident A's Admission Records indicated Resident A was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident A had a [DIAGNOSES REDACTED]. A review of a Resident A's care plan, dated 11/19/18 and titled, Resident on [MEDICAL CONDITION] medications related dementia with behavior disturbances manifested by Resident A resistance to ADL care (activities of daily living, such as grooming and toileting) and physical aggression. The goals indicated Resident A's behavior would decrease and he would not harm himself or others. The staff's approaches included approaching the resident in a calm and unhurried manner, redirect the resident's attention as appropriate and to withdraw if the resident has an outburst and approach at alternate time. A review of Resident A's Minimum Data Set (MDS), an assessment and care screening tool, dated 2/28/2020 indicated Resident A had modified independence in cognitive (thought process) skills for daily decision-making. The MDS indicated along with delusions (beliefs firmly held, contrary to reality), Resident A showed inattention and disorganized thinking. Resident A exhibited physical behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. The MDS indicated Resident A was totally dependent on staff for toilet use and required an extensive two-person physical assist to complete his personal hygiene and bathing. Resident A was incontinent (involuntary voiding of urine and stool) of both bowel and bladder functions. The MDS indicated Resident A's active [DIAGNOSES REDACTED]. A review of Resident A's Licensed Personnel Weekly Progress Notes (LPWPN), dated 3/12/2020 and timed at 2:10 p.m., indicated Resident A was found in another resident's room sitting on the floor and was noted with left eye swelling (an abnormal enlargement due to an accumulation of fluid), redness and pain. Another LPWPN, dated the same day and timed at 2:20 p.m. indicated a physician's orders [REDACTED]. A LPWPN, dated 3/12/2020 and timed at 4 p.m. indicated Resident A was transferred to the GACH and returned to the facility the same day at 11:15 p.m. A review of Resident A's GACH Admission Records indicated the resident was seen in the emergency department (ED) on 3/12/2020. Resident A's history of present illness indicated an OD (left eye) periorbital (surrounding the eye socket) swelling. A computed tomography ((CT) a scan that allows the physician to see inside the body) of the facial bones was done with the following results: 1. Comminuted fracture ((broken bones) splinter of the bone into more than two fragments) left orbital floor (one or more of the bones surrounding the eye typically caused by a direct blow to the central orbit from a fist or ball) extending to the medial (middle) orbital wall and left lamina papyracea (a smooth, oblong bone plate) with approximately a millimeter depression of the fracture fragments in the left maxillary (jaw) sinus (an air filled opening). 2. Mild thickening and [MEDICAL CONDITION] (swelling) involving the left inferior rectus muscle (a muscle inside the eye socket) 3. Multiple anterior (front) nasal bone fractures with adjacent (near) soft tissue swelling. A review of Resident A's GACH discharge instructions, dated 3/12/2020, indicated the following: 1. [MEDICATION NAME] (mild pain reliever) 325 milligrams ((mg) unit of measurement), two tablets (650 mg) by mouth every four to six hours as needed for pain or fever. 2. Latanoprost (ophthalmic solution used to treat pressure in the eye by decreasing liquid in the eye) 0.005% ophthalmic (eye) drop, instill one drop in both eyes daily at bedtime. 3. Ice or cold pack on eye injury for 10 to 20 minutes at a time, every one to two hours for the next three days or until the swelling goes down 4. Keep the head elevated when sleeping 5. Do not blow the nose, dab it with a tissue if necessary 6. Eat soft food to decrease jaw pain 7. Follow-up with head and neck surgery clinic, schedule appointment as soon as possible 8. Schedule a follow-up appointment with physician as soon as possible A review of an online article titled, What is an Orbital fracture? indicated a blowout fracture is a break in the floor or inner wall of the orbit or eye socket, which could be caused by getting hit with a baseball or a fist (http://www.aao.org/eye-health/diseas/what-is-orbital-fracture 9/28/17). On 3/17/2020 at 2:27 p.m., during an interview, the ADM, who is the abuse coordinator, stated a nurse reported on 3/12/2020 that Resident A had redness and swelling to his left eye and blood coming from his nose. The ADM stated the facility's surveillance video was reviewed on 3/12/2020 and Resident A was observed going into a female resident's room [ROOM NUMBER] which was on Station C on the same day (3/12/2020). A male CNA (CNA 1) followed Resident A into the female resident's room [ROOM NUMBER] and was in the room with Resident A for approximately two minutes, per the video. The ADM stated the surveillance video revealed approximately a minute later, Resident A was found in room [ROOM NUMBER] with injuries to his eye and nose. On 3/17/2020 at 2:35 p.m., a review of the facility's video surveillance, without audio, dated 3/12/2020 with the administrator, indicated the following was observed: At 1:56:34 p.m., CNA 1, a large male, was observed walking towards Resident A along a hallway. CNA 1 approached Resident A at 1:56:39 p.m. Resident A struck out at CNA 1 at 1:56:44 p.m. several times as CNA 1 was observed to continue to walk behind Resident A and moving away from Resident A as the resident tried to strike out at CNA 1. CNA 1 continued walking behind Resident A. At 1:57:11 p.m., CNA 1 was observed attempting to lure Resident A into the first door of the female resident's room [ROOM NUMBER] (the room [ROOM NUMBER] has two entrances). Resident A was seen saying something to CNA 1 while continuing to strike out at CNA 1. Resident A refused to go into the first door of room [ROOM NUMBER] with CNA 1. At 1:57:19 p.m., CNA 1 was observed stomping the floor, with his foot, at Resident A and laughing at, appearing to taunt (insult; provoke) Resident A. At 1:58:07 p.m., Resident A was observed walking into the second door of the female resident's room [ROOM NUMBER]. At 1:58:12 p.m., CNA 1 was observed following Resident A into the female resident's room [ROOM NUMBER]. At 2:00:44 p.m., CNA 1 was observed leaving the female resident's room [ROOM NUMBER] without Resident A. CNA 1 was observed lingering near the room until 2:00:50 when CNA 2 was observed interacting with CNA 1. At 2:01:08 p.m., a janitor (Janitor 1) was observed entering the female resident's room [ROOM NUMBER]. At 2:01:14 p.m., CNA 2 was observed entering the female resident's room [ROOM NUMBER] and then almost immediately exiting the room (2:01:26 p.m.), passing CNA 3 who was entering the female resident's room [ROOM NUMBER]. At 2:01:50 p.m., CNA 2 was observed walking a short distance away from room [ROOM NUMBER] and interacting with CNA 1, who was leaning against the wall a short distance away from room [ROOM NUMBER]. CNA 2 was observed saying something to CNA 1 (2:01:56 p.m.) and then they both began walking back towards the female resident's room [ROOM NUMBER]. CNA 2 handed CNA 1 a pair of gloves (2:01:59 p.m.) and CNA 1 put the gloves on and he (CNA 1) and CNA 2 entered room [ROOM NUMBER] together. CNA 1 appeared reluctant to enter room [ROOM NUMBER]. At 2:03:55 p.m., CNA 2 was observed pushing Resident A out of the female resident's room [ROOM NUMBER] in a wheelchair. On 3/17/2020 at 4:54 p.m., and during a subsequent interview, the same day at 5:20 p.m., the DON stated Resident A was alert and oriented times one (knows his name) and was ambulatory (walks) but required total care. The DON stated Resident A would walk up and down the hallway continuously and could become combative with staff. The DON stated Resident A could not hold a conversation but usually mumbled or answered with one word. The DON stated there was a resident (Resident B) in the female resident's room [ROOM NUMBER] when Resident A was found in the room. The DON stated Resident B was paranoid (thinking shaped by fear and anxiety) but had not been known to be combative with staff or residents. On 3/18/2020 at 8:34 a.m., during a telephone interview, CNA 3 stated she was working on Station C when she heard staff needed assistance in the female resident's room [ROOM NUMBER]. CNA 3 stated when she got to the female resident's room [ROOM NUMBER], Resident A was standing at the foot of Bed E (Resident B's bed). CNA 3 stated there was blood on Resident B's bed, on the floor and a little under Resident A's nostril. CNA 3 stated she tried to assist Resident A to a wheelchair but he was combative and she left the room because there were two other CNAs in the room helping Resident A. CNA 3 stated she did not believe Resident B assaulted Resident A because she was lying in bed very calm and she had never been physically aggressive with anyone. On 3/18/2020 at 8:39 a.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated she was at Station A (3/12/2020) when she saw CNA 2 pushing Resident A in a wheelchair down the hallway. LVN 1 stated Resident A had a swollen eye and there was a small amount of blood coming from his left nostril. LVN 1 stated Resident A was disoriented and combative and CNA 2 took Resident A to his room. LVN 1 stated Resident A could not tell what happened. LVN 1 stated Resident A usually walked around the facility all day going into other resident's rooms. LVN 1 stated she had not seen Resident A having problems with other residents. On 3/18/2020 at 2:43 p.m., during a telephone interview and a subsequent in-person interview on 3/19/2020, at 10:17 a.m., the Director of Staff Development (DSD) stated following the incident with Resident A on 3/12/2020, she conducted an in-service with all the staff on abuse. The DSD stated she had plans to conduct an in-service regarding care of dementia residents and how to handle aggressive behavior and forgetfulness, but it would not be for a couple of weeks. The DSD stated she had not been formally trained as a DSD due to training being cancelled. On 3/19/2020 at 8:25 a.m., during an interview, CNA 2 stated at approximately 1:40 p.m., on 3/12/2020 she wanted to change Resident A's diaper and asked CNA 4 to bring Resident A to her, but CNA 4 reported Resident A was being aggressive so she (CNA 2) went to get Resident A. CNA 2 stated when she got to Resident A he was still being aggressive so she left him alone and went to change other residents. CNA 2 stated later she saw CNA 1 and asked him if he would bring Resident A back to his room, but CNA 1 declined because he stated Resident A was being too aggressive. CNA 2 stated after she completed changing her other residents, she went looking for Resident A but did not find him on Station B so she went to Station C and saw him in the female resident's room [ROOM NUMBER]. CNA 2 stated Resident A looked confused and disoriented and was holding onto the foot of a bed. CNA 2 stated when she got closer to Resident A to ask him what was wrong, she saw blood coming from his nose dripping onto the bed. CNA 2 asked Janitor 1 if he had seen anything and Janitor 1 told her he had not and then stated she asked CNA 3 for help. CNA 2 stated she left the room to get a charge nurse and saw CNA 1 a short distance from room [ROOM NUMBER] leaning against the wall. CNA 1 asked her what was happening, and she told him Resident A was bleeding. CNA 2 stated Resident A was confused and combative and she was not sure he understood what was being asked or if his answers were true. CNA 2 stated she could not recall any resident being physical with Resident A. On 3/19/2020 at 4:07 p.m., during an interview with the use of an interpreter, CNA 1 stated CNA 2 asked him if he could help bring Resident A to her because he (Resident A) was wet and needed to be changed. CNA 1 stated he went to Station C where he had seen Resident A and found Resident A near room [ROOM NUMBER]. CNA 1 stated he asked Resident A three times to come go to his room, but Resident A did not respond. CNA 1 stated Resident A swung at him a couple of times but he (CNA 1) moved away so Resident A would not hit him. CNA 1 stated he did not want to touch Resident A because he was being aggressive but he knew Resident A would not turn around so he tried to get Resident A to go into the first door of room [ROOM NUMBER] and get Resident A to come out of the second door. CNA 1 stated Resident A went into the second door of room [ROOM NUMBER] and he (CNA 1) followed him into the room. CNA 1 stated he tried to get Resident A to come with him, but Resident A put his fist up to him like he wanted to fight then turned and went next to the bathroom. CNA 1 stated he asked Resident A to come with him again, but Resident A put his fist up again, grabbed the bathroom door, went into the bathroom and closed the door. CNA 1 stated he tried to open the bathroom door but Resident A was pulling it shut and Resident A was very strong. CNA 1 stated he could not open the door, so he just left the room. CNA 1 stated he was not assigned to care for Resident A but was asked to help bring the resident to his room. CNA 1 stated Resident A goes into other resident's rooms multiple times and when he would report to the charge nurse that Resident A was in someone's room the charge nurse would tell him to just leave Resident A. CNA 1 stated when he left Resident A in the bathroom Resident A was ok. On 3/22/2020 at 1:29 p.m., during an interview, Janitor 1 stated he was walking past the female resident's room [ROOM NUMBER] (3/12/2020) and saw a blanket on the floor, and he went into the first door of the female resident's room [ROOM NUMBER] to pick the blanket up so no one would fall over it. Janitor 1 stated he then saw Resident A walking around the foot of a bed pulling the privacy curtains. Janitor 1 stated he did not see Resident A's face and did not know at that time Resident A was bleeding. Janitor 1 stated he knows Resident A can be aggressive, so he left the room to get a nurse to get Resident A out of the female resident's room [ROOM NUMBER]. Janitor 1 stated he saw CNA 2 and asked her to come get Resident A from the room. Janitor 1 stated when the CNAs sat Resident A on the bed that was when he (Janitor 1) saw Resident A's left eye was swollen. On 3/22/2020 at 1:37 p.m., during an interview, CNA 4 stated she was CNA 2's partner the day Resident A was injured (3/12/2020). CNA 4 stated she saw Resident A in the female resident's room [ROOM NUMBER] and the resident was unable to tell what happened to him. On 3/26/2020 at 4:45 p.m., during a telephone interview, LVN 2 stated she was at Station A when she received a report that Resident A was found sitting on the floor in the female resident's room [ROOM NUMBER]. LVN 2 stated she went to Resident A's room and found Resident A sitting on his bed with his left eye swollen. LVN 2 stated she does not know who injured Resident A. A review of the facility's undated policy and procedure titled, Aggressive Behavior Management, indicated the purpose of the policy was to protect the residents and staff from harm and to prevent the resident from injuring themselves or others. The policy indicated for the staff to give the aggressive resident space. A review of the facility's undated policy and procedure titled, Abuse Prevention and Investigation indicated the facility will not condone resident abuse by anyone, including staff members.

Based on observation, interview and record review, the facility's nursing staff failed to initiate cardio-pulmonary resuscitation ((CPR) an emergency lifesaving procedure done when breathing or the heart stops) timely and call for emergency services (911), as per the facility's policy and procedure and according to nursing standard of practice for one of one resident (Resident C). Resident C was found unresponsive, pulseless (having no perceptible pulse), not breathing and the facility's staff failed to initiate CPR and call 911 timely. The staff also failed to ensure all emergency equipment was maintained on the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations), as the AMBU bag (an artificial manual breathing unit) had to be discarded during CPR when the face mask portion of the bag was missing. This deficient practice resulted in a delay in CPR to being initiated as a life-sustaining measure for Resident C due to the staff inability to perform effective CPR when Resident C was found unresponsive. Resident C was pronounced deceased on [DATE] at 10:49 a.m. by the paramedics. On [DATE] at 6:25 p.m., a system failure was identified regarding the competence of the facility's licensed nursing staff were competent to perform life-sustaining emergency care. An Immediate Jeopardy ((IJ) a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident) was declared under F678. The facility's Administrator (ADM) and the Director of Nurses (DON) were notified of the serious non-compliance that threatened the residents' health and safety. On [DATE] at 1:15 p.m., the facility submitted an acceptable Plan of Action (POA). After onsite verification and confirmation via observation, interview and record review the POA was implemented the ADM was notified the IJ was lifted at 1:30 p.m. The acceptable POA was applied as follows: On [DATE] at 1:30 p.m., the facility submitted an acceptable Plan of Action (POA). The ADM was notified the IJ was lifted, while the surveyor was on site, after verification and confirmation the POA was implemented via observation, interviews and record reviews. The acceptable POA was applied as follows: 1. All staff involved with Resident C's emergency care were counseled regarding timely response. 2. The DON provided in-services to all staff regarding reporting residents' change of condition. 3. The Quality Assurance Nurse inspected both crash carts and reviewed inventory against the Crash Cart Items list to ensure the crash cart was completely stock. 4. All staff were provided a web-based CPR class that was professionally acknowledged by the Department. 5. The DON and/or Director of Staff Development (DSD) will conduct and visually oversee a random quarterly mock code blue (imitation of an emergency situation for the purpose of teaching and giving feedback) to determine how staff respond to an emergency. The mock code blue will be recorded and presented to the ADM for review and/or recommendation. 6. The emergency crash cart monitoring was assigned to each shift Registered Nurse (RN) Supervisor. Any missing item(s) must be replaced immediately, documented and reported to the Quality Assurance Nurse. Findings: On [DATE], at approximately 10:30 a.m., while in the facility for an unrelated investigation, Resident C was observed, in her room, lying in bed on her back with just a diaper on. There was a brownish-color secretion on her face, upper body and bed. Resident C's skin was pale, her abdomen was distended (with swelling) and the resident was not moving. Certified Nursing Assistant 5 (CNA 5) was in the room with a towel in her hand and was asked by surveyor, What's going on? she replied, The resident (Resident C) died and she and the other CNA (CNA 6) were getting supplies to clean her up. CNA 5 was asked who pronounced the resident deceased , and CNA 5 stated she and CNA 6 did. At approximately 10:33 a.m., the same day, the Director of Staff Development (DSD) entered the room and asked, What's going on? and the Surveyor informed the DSD the CNAs stated the resident (Resident C) was dead. The DSD quickly left the room. The CNAs were asked if they had reported Resident C's death to anyone and CNA 5 stated she had reported it to the charge nurse ((LVN 3) Licensed Vocational Nurse 3). The Surveyor stepped out of Resident C's room into the hallway and observed the DSD moving quickly toward Station A asking if anyone had called 911. At approximately 10:35 a.m., the same day, two LVNs licensed nurses (LVN 3 and LVN 4) were observed entering going into Resident C's room with a crash cart and an oxygen tank. LVN 3 was observed placing a back board (recommend use when doing chest compression during CPR as a hard surface) under Resident C's back and beginning chest compressions. The DSD entered the room at approximately 10:37 a.m. and was observed getting an AMBU bag from the crash cart, but the facemask attached to the AMBU bag was broken and, so the DSD was observed placing put a face mask on Resident C's face. for oxygen administration. The AMBU bag was observed under Resident C's bed not being used during CPR. There was no respiration given to Resident C. LVN 4 was observed performing chest compressions on Resident C after approximately five three to four rounds of 30 chest compressions, a check of Resident C's pulse was not conducted. there was no observations the resident's pulse was checked during CPR. The paramedics arrived at approximately 10:45 a.m. and took over Resident C's emergency care. The paramedics pronounced Resident C deceased at 10:49 a.m. A review of Resident C's Admission Records indicated Resident C was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident C's [DIAGNOSES REDACTED]. A review of Resident C's Minimum Data Set (MDS), a resident's assessment and care screening tool, dated [DATE] indicated Resident C's cognitive (thought process) skills for daily decision-making were moderately impaired. The MDS indicated Resident C required an extensive assistance to complete her activities of daily living ((ADLs) everyday activities, such as eating, bathing, dressing, grooming and toileting). Resident C was totally dependent on staff for dressing, toilet use, personal hygiene and bathing and was incontinent (involuntary voiding of urine and stool) of bowel and bladder functions. A review of Resident C's Licensed Personnel Weekly Progress Note dated [DATE] and timed at 10:31 a.m. indicated Resident C was noted in bed with coffee ground emesis (brownish in color vomit that looks like coffee grounds; occurs due to the presence of blood in the vomit) around her mouth and mattress. Resident C was unresponsive to tactile (touch) or verbal stimulation and appeared pale. Staff notified the charge nurse immediately. The charge nurse assessed Resident C and was unable to palpate (feel) a pulse or any vital signs. The charge nurse called for assistance and initiated STAT (urgent) call procedures. The crash cart was taken to the room and the RN supervisor called 911. Resident C was given 10 liters of oxygen per minute (LPM) via a face mask as CPR continued. The paramedics arrived and took over the resuscitation measures. The paramedics were unable to resuscitate Resident C and pronounced her deceased at 10:49 a.m. On [DATE] at 10:51 a.m., during an interview, a paramedic in Resident C's room was asked what time they were called, and he stated, after looking at the Paramedic Run Sheet, they were dispatched by the facility at 10:37 a.m. that morning, by the facility staff (six minutes after Resident C was found unresponsive). On [DATE] at 11:36 a.m., during an interview, CNA 6 stated at approximately 10:20 a.m., she went into Resident C's room to change her diaper and noticed brown fluid coming from Resident C's mouth and nose. CNA 6 stated she tapped Resident C on her shoulder, but Resident C did not respond. CNA 6 stated CNA 5, who was also in the room, and she told her (CNA 5) to called the charge nurse (LVN 3). CNA 6 stated LVN 3 came to the room, took Resident C's pulse and then the left room left to get the crash cart. CNA 6 stated she knew Resident C was dead because she did not respond and had brown fluid coming from her nose and mouth. A review of an online article, by the American Red Cross titled, CPR Steps indicated before giving CPR the person should check the scene and the person and make sure the scene is safe and tap the person on the shoulder and shout Are you ok, to ensure the person needs help. The article indicated the next thing should be done is to call 911 for assistance and/or send someone to get help and never leave the person unattended @https://www.redcross.org/take-a-class/cpr/performing-cpr/cpr-steps. On [DATE] at 11:57 a.m., during an interview, CNA 5 stated she went to Resident C's room at approximately 10:15 a.m. that morning and began changing the resident in the bed next to Resident C bed. CNA 5 stated CNA 6 told her to look and when she looked over at Resident C and she saw black colored stuff coming from Resident C's mouth. CNA 5 stated she called for LVN 3 to come to the room. CNA 5 stated LVN 3 came to the room, checked Resident C and left. On [DATE] at 12:09 p.m., during an interview and a subsequent telephone interview on [DATE] at 10:23 a.m., LVN 4 stated at approximately 10:25 a.m., to 10:30 a.m. on [DATE], LVN 3 came to him and asked him for help. LVN 4 stated he told LVN 3 he was busy doing a wound treatment and to call the RN supervisor. LVN 4 stated he heard LVN 3 page the RN supervisor (RN1) two times and then he (LVN 3) left to go back to Resident C's room. LVN 4 stated LVN 3 came back to him a second time and asked him to come because he really needed his help. LVN 4 stated when LVN 3 told him he thinks he needed the crash cart, and he (LVN 4) told LVN 3 him he should have called for help from the room and not have left Resident C unattended. LVN 4 stated he and LVN 3 went to get the crash cart and an oxygen tank. LVN 4 stated when they entered Resident C's room, LVN 3 started chest compressions on Resident C and at some point, he (LVN 4) took over chest compressions until the paramedics arrived. On [DATE] at 12:34 p.m., during an interview and a subsequent telephone interview on [DATE] at 2:13 p.m., LVN 3 stated at approximately 10:30 a.m., he was sitting at Station A when CNA 5 came to him and stated can you go check Resident C she is was not looking good. LVN 3 stated when he got to the room, he saw black stuff coming from Resident C's mouth and he tapped Resident C on her shoulder and asked her if she was ok but there was no response, no chest rise and no pulse. LVN 3 stated he went to Station A to ask LVN 4 for help. LVN 3 stated LVN 4 told him to page RN 1, which he did, then he and LVN 4 went to get the crash cart and oxygen tank. LVN 3 stated when they got to the room, Resident C was not responsive and she had no pulse. LVN 3 stated he began chest compressions then LVN 4 took over chest compressions while he was setting up the oxygen. LVN 3 stated he left the room to get a stethoscope, which was at Station A, and when he got back to the room the DSD was there. LVN 3 stated the DSD put a face mask on Resident C and instructed him to turn the oxygen up to 10 LPM. LVN 3 was asked what he should have done when he found Resident C unresponsive, LVN 3 stated he should have stayed in the room with Resident C and called for help to get the crash cart and to call for 911 while he started CPR. On [DATE] at 1 p.m., during an interview, the Director or Nursing (DON) stated LVN 3 should have stayed with Resident C and asked the CNAs who were in the room to get help while he began CPR. On [DATE] at 3:35 p.m., during an interview, the DSD stated the AMBU bag was not complete; the part of the bag that goes over the face and nose (face mask) was missing. The DSD stated she did not want to waste time looking for another AMBU bag, so she placed a regular face mask on Resident C because she wanted the resident to receive oxygen during CPR. On [DATE] at 10:23 a.m., during a telephone interview, the Assistant Director of Nursing (ADON) stated she was on Station C caring for another resident at approximately 10 a.m., when she was paged STAT to Resident C's room [ROOM NUMBER]c. The ADON stated she went to Resident C's room [ROOM NUMBER] and saw LVN 3 and LVN 4 were already there, so she left the room to call 911 but she saw the DSD had already called 911. The ADON stated she went back to the room and saw LVNs 3 and LVN 4 were working on Resident C, so she left to escort 911 to the room when they arrived. On [DATE] at 1:45 p.m., the facility's surveillance video regarding Resident C was reviewed with the ADM and the timelines were as follow: 10:18:25 a.m. - LVN 4 goes into Resident C's room with a treatment cart 10:25:03 a.m. - LVN 4 leaves Resident C's room 10:29:15 a.m. - CNA 5 goes into Resident C's room 10:29:32 a.m. - CNA 6 goes into Resident C's room 10:30:43 a.m. - CNA 5 leaves Resident C's room while looking around 10:31:08 a.m. - CNA 5 goes back into Resident C's room 10:31:19 a.m. - LVN 3 runs into Resident C's room 10:31:30 a.m. - LVN 3 runs out of Resident C's room 10:33:01 a.m. - Surveyor enters Resident C's room 10:33:49 a.m. - DSD enters Resident C's room 10:34:14 a.m. - DSD leaves Resident C's room 10:34:21 a.m. - Surveyor steps out of Resident C's room into the hallway 10:35:21 a.m. - LVN 3 enters Resident C's room with an oxygen tank 10:35:27 a.m. - LVN 4 enters Resident C's rooms with a crash cart 10:35:31 a.m. - Surveyor steps back into Resident C's room 10:35:44 a.m. - ADON goes into Resident C's room 10:35:53 a.m. - Surveyor comes out of Resident C's room 10:36:02 a.m. - ADON leaves Resident C's room 10:36:57 a.m. - LVN 4 leaves Resident C's room 10:37:15 a.m. - Surveyor goes into Resident C's room 10:37:47 a.m. - DON goes into Resident C's room 10:38:07 a.m. - LVN 4 goes into Resident C's room 10:38:40 a.m. - DSD goes into Resident C's room 10:42 a.m. - LVN 3 leaves Resident C's room 10:42:33 a.m. - DON leaves Resident C's room 10:43:57 a.m. - LVN 3 enters Resident C's room 10:44:23 a.m. - DON goes into Resident C's room 10:45:05 a.m. - DON leaves Resident C's room 10:45:10 a.m. - LVN 3 runs out of Resident C's room 10:45:32 a.m. - LVN 3 goes into Resident C's room 10:46:51 a.m. - Paramedics enters Resident C's room A review of the DON, DSD, LVN 3, LVN 4, CNA5 and CNA 6's employee files indicated they were CPR certified in basic life support ((BLS) another term for CPR until full medical care at a hospital can be provided). A review of an undated facility's policy and procedure (P/P) titled, Emergency Procedures indicated the purpose was to ensure residents receive emergency care promptly. If the resident does not have orders for no CPR, and the vital signs are absent, call 911 and start CPR. A review of an undated facility's policy and procedure titled, Cardiopulmonary Resuscitation indicated the purpose was to restore or maintain breathing or pulse for residents in emergency situations and to prevent brain damage. The P/P included for the staff to check the resident's respirations and pulse; send another person to call 911 for emergency services; remain with the resident and call for help. At the end of each 30 compressions give two full breaths and repeat cycle until help arrives or exhausted and unable to continue. On [DATE], at 8:55 a.m., during a telephone interview, the DON stated, it is the night shift staffs responsibility to check the crash cart to make sure it is complete. The DON stated the restorative nursing assistants (RNAs) were checking the oxygen and crash carts. According to the facility's Emergency Cart Contents two Ambu bags were part of the inventory. A review of the facility's Oxygen Room Inventory list, dated [DATE] the emergency cart was signed off as complete

Based on interview, record review, and a review of the facility's video surveillance, the facility's nursing staff failed to implement the resident's care plan regarding wandering/elopement behavior for one of two resident (Resident A). This deficient practice resulted in Resident A wandering the facility unsupervised and sustaining fractures to his left eye and nose and placed Resident A at risk for continued wandering into other resident's rooms and risk of continued injuries. Findings: A review of Resident A's Admission Records indicated Resident A was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident A had a [DIAGNOSES REDACTED]. A review of Resident A's Minimum Data Set (MDS) Assessment, dated 2/28/2020, indicated Resident A had modified independence in cognitive (thought process) skills for daily decision-making. The MDS indicated along with delusions (beliefs firmly held, contrary to reality), Resident A showed inattention and disorganized thinking. Resident A exhibited physical behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. Resident A was totally dependent on staff for toilet use and required an extensive two-person physical assist to complete his personal hygiene and bathing. Resident A was incontinent (involuntary voiding of urine and stool) of both bowel and bladder functions. The MDS indicated Resident A's active [DIAGNOSES REDACTED]. According to a Care Plan, dated 11/19/18, Resident A was high risk for elopement related to (r/t) dementia. Goals for Resident A included remaining safe within the facility. Interventions/Approaches to be used included supervising Resident A closely, placing Resident A on a 1:1 observation, developing an activities program to divert Resident A's attention and if Resident A is wandering in a potentially unsafe area or situation redirect him to a safer area. On 3/17/2020 at 4:54 p.m., during an interview, the Director of Nursing (DON) stated Resident A was alert but only oriented times one (to name). The DON stated Resident A ambulates (walks) continuously around the facility and wanders in and out of other resident's rooms. The DON stated Resident A takes other resident's sheets from their beds when he wanders into their rooms. The DON stated Resident A was combative with staff but did not recall him being combative with other residents. The DON stated staff have been instructed to redirect Resident A when he wanders into other's rooms. On 3/19/2020 at 8:25 a.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated Resident A walks around the facility and constantly gets into other resident's room. CNA 2 stated Resident A is usually easy to redirect but sometimes he does not cooperate and they need to get assistance. CNA 2 stated she has not had any training on how to handle residents who wander. On 3/19/2020 at 4:07 p.m., during an interview, via an interpreter, CNA 1 stated, Resident A goes into other resident's rooms multiple times and when he reports it to the charge nurse (C/N) that Resident A is in another resident's room the C/N tells him to just leave the resident. On 3/19/2020, the facility's video surveillance (without audio) was viewed with the Administrator present indicating on 3/12/2020, at 1:58:07 p.m., Resident A was observed walking into room [ROOM NUMBER], a six bed female room. A review of Resident A's Licensed Personnel Weekly Progress Notes, dated 3/12/2020 and timed at 2:10 p.m., indicated Resident A was found in another resident's room sitting on the floor and was noted with left eye swelling, redness and pain. The note indicated the same day at 2:20 p.m., a physician order [REDACTED]. The note indicated, Resident A was transferred to the GACH on 3/12/2020 at 4 p.m. and returned to the facility the same day at 11:15 p.m. A review of Resident A's GACH Admission Records indicated the resident was seen in the emergency department (ED) on 3/12/2020. Resident A's history of present illness indicated an OD (left eye) periorbital (surrounding the eye socket) swelling. A CT ((computed tomography) a scan that allows doctors to see inside the body) of the facial bones was done with the following results: 1. Comminuted (a break or splinter of the bone into more than two fragments) left orbital floor fracture (a fracture of one or more of the bones surrounding the eye typically caused by a direct blow to the central orbit from a fist or ball) extending to the medial (middle) orbital wall and left lamina papyracea (a smooth, oblong bone plate) with approximately a millimeter depression of the fracture fragments in the left maxillary (jaw) sinus (an air filled opening). 2. Mild thickening and [MEDICAL CONDITION] (swelling) involving the left inferior rectus muscle (a muscle inside the eye socket) 3. Multiple anterior (front) nasal bone fractures with adjacent (near) soft tissue swelling. On 4/20/2020 at 1:56 p.m., during a telephone interview, the Administrator stated the facility did not have a policy for care plans specifically for residents who wander.

3. During the initial tour of the facility on 4/17/19 at 9:40 a.m., Resident 19 was observed in bed. There was no call light observed within reach. The call light was observed to be about three feet away from the head of the bed. During a concurrent observation and interview on 4/17/19 at 9:44 a.m., CNA 3 stated that Resident 19 would not be able to reach his call light because it is too far from the bed. A review of Resident 19's admission record indicated the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of MDS, dated [DATE], indicated Resident 19 had severely impaired cognitive (ability to make decisions of daily living) skills for daily decision making. According to MDS the resident required extensive assistance with activities of daily living such as dressing, eating, toileting and personal hygiene. MDS indicated Resident 19 used a walker and/or a wheelchair for mobility. During an interview on 4/19/19 at 7:51 a.m., the director of nursing (DON) stated Resident 19 did not have a bell to use to summon for help. DON stated this places the resident at risk of accidents such as falling of the bed, and needs (such as being wet and needing to be changed, or wanting to get up off the bed and transfer to the wheelchair) not being met. A review of the undated facility policy titled Call Lights, indicated the purpose of call lights is to meet the resident's requests and needs within an appropriate time period. To ensure that all residents (even those who are confused) have access to the call signal at all times and know how to use it. To obtain a hand bell if the resident cannot use the regular signal cord. 2. According to Resident 99's admission record the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE] indicated Resident 99 had a moderate impairment of cognitive (ability to remember, learn and make decisions) skills for daily decision making. According to the MDS Resident 99 used a walker for mobility. During an interview on 4/17/19 at 8:30 a.m., Resident 99 stated l have to get up and get the nurses because they do not answer my call light. I do not know how to operate this call light and I cannot get to it. Concurrently, during an interview, Resident 99 was observed trying to pull/push a white box named Code Alert (inactive new call light system). At the same time CNA 2, CNA 6 and LVN 2 were not able to state what the white box was or to demonstrate how to operate the call light. Also, at the same time, the MS was at Resident 99's bedside and stated the facility is in the process of installing a new call light system and the Code Alert box is the new call light system which has not been activated. The MS was observed pulling back the privacy curtains exposing the existing call light system. Resident 99 was observed attempting to reach the existing call light button, however was unable. Resident 99 then stated to MS what is the use when l cannot get to it. Based on observation, interview and record review, the facility failed to: 1. Ensure the existing (old) call light system was operable in all of the residents' rooms and had visual and audible signals above the residents' rooms and at the nursing stations to alert the staff of residents needs and prevent possible falls and injuries for 34 of 137 residents. 2. Have the measures in place to ensure the residents were monitored for their needs and care prior and during new call light system installation. 3. Ensure the maintenance staff was routinely monitoring the existing call light system for proper function, to document and maintain a log. 4. Identify that there were 34 residents with inoperable call lights. 5. Ensure Resident 19 had the call light within reach to communicate the needs. 6. Ensure the nursing staff was answering Resident 99' call light. 1. On 4/18/2019 at 7:15 a.m., upon entrance to the facility there was no posting at the entrance door or anywhere in the facility to notify staff, visitor, and residents of ongoing repairs to the facility's call light system or any indication that call lights system was undergoing repair and/or replacement. On the initial tour of the facility 4/17/19 at 7:30 a.m., there were two call lights systems observed in residents' rooms. One call light system was an existing system with switch pull mechanism and the second system was a new system in a form of box with a hidden cord inside the box to pull. The facility's current census was 137 residents. There were three nursing stations. On the initial tour of the facility 4/17/19, there were identified 34 residents with inoperable existing call lights. At the same time the new call light system was not activated and not functional. On 4/18/19 at 7:45a.m., during a walk through the facility's Nursing Station C with a certified nursing assistant 9 (CNA 9), the call lights for 13 residents in room [ROOM NUMBER] Bed A, 2 Bed A, 3 Bed A, B and C, 4 Bed A and B, 7 Bed A and B, 8 Bed A, 11 Bed A, and 15 Bed A and B were observed not to have a visible signal (light was not coming on) above the entrance door when call lights were activated inside the room. In two residents' Rooms 32 Bed B and 41 Bed B the call lights were inoperable due to absent switches which were needed to activate the call lights. What station? During a call light system observation on 4/18/19 at 10:58 a.m., in the presence of the licensed vocational nurse 4 (LVN 4) stated while in room [ROOM NUMBER] l do not know what this white box is for. They did not tell us about it. LVN 4 confirmed that Rooms 49 (3 beds), 50 (six beds), 54 (3 beds), 60 (six beds) and 62 (3 beds) call lights failed to have a visible signal outside of the rooms above the entrance door. Concurrently, during the observation of call lights function at the Nursing Station C, there was no audible signal while the call lights were activated in room [ROOM NUMBER], 50, 54, 60 and 62. At the same time LVN 4 verbally verified that there was no audible signal on the control call lights' panel at the Nursing Station C or visual signals at the residents' rooms' doors to alert staff of a residents' need of assistance. During an interview on 4/18/19 at 1:47 pm., the maintenance supervisor (MS) stated l just now learned that rooms 49, 50, 54, 60 and 62 call lights were nonfunctional. The MS stated that the constructed electric company had disconnected some wires on the existing call light system, which he had just fixed. When asked about routine call light inspection log, the MS stated l do not have a log for the call light system check. When asked how MS verified that the new call light system installation did not interfere with the existing call light system, the MS stated, l did not know we had to have a posting about new call light installation and notify the Department of Public Health about the project. During an interview on 4/18/19 at 2:20 pm., the MS stated the Administrator told to MS that the contracted electric company would obtain all necessary permits to install the new call lights system and that the Administrator removed the posting from California's Office of Statewide Health Planning and Development (OSHPD) ( the leader in collecting data and disseminating information about California's healthcare infrastructure; promotes an equitably distributed healthcare workforce, and publishes valuable information about healthcare outcomes). The MS stated the facility's inspector of record the existing call lights system was still working and that the facility was waiting on the fire Marshall to come and inspect the new call light system before the facility made the switch from existing system to a new call light system. The MS stated the crew was working on the new call light system and inadvertently cut wires for the existing/current call light system, rendering call lights out of order. The MS stated l understand the dangers of not having a call light. The residents may have a medical emergency, call for assistance, or fall. The MS stated the facility's inspector of record failed to check if the existing/ current call light system was operable. The facility's inspector of record was not responding to the phone calls and was not available for interview. According to the invoice from the facility's contracted electrical company dated 10/19/18, the call lights system replacement project began on 10/29/18. The facility did not have any system in place to monitor the residents, who were dependent on staff for care, and to ensure their needs were addressed and care provided during call lights system replacement project starting on 10/19/18. On 4/18/19 at 2:42 p.m., during an interview with the director of nursing (DON) stated I knew they were switching the call lights system, but I am not aware of any plans during the switch to address the residents needs; to me the call lights are a maintenance business. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, section G Function Status, of 34 residents' affected by inoperable call lights, indicated that 18 residents' required the use of mobility devices (e.g. wheelchair and/or walking cane), four of 18 residents' were totally dependent on staff for transfer and required two plus physical assistance, five of 18 residents' required extensive assistance from staff for transfer, and six of 18 residents' required limited assistance from staff for transfer. On 4/19/19 at 1:48 p.m., the facility's Administrator and DON were informed the survey team identified noncompliance with likely serious adverse outcome due to inoperable call light systems and the Immediate Jeopardy (IJ) was called. Both administrator and DON were informed of the need for the immediate corrective action plan. On 4/19/19 at 7:45 p.m., the Administrator and DON presented the immediate corrective action plan for removal of IJ. The facility's plan of action included the following: a. Provide an in-service to the facility's staff on the importance of making rounds every 15 minutes, all rooms, all stations to monitor residents' needs and safety secondary to call light system failure. This will be done immediately until existing (old) call light system is working or new call light system is in effect. b. The licensed nurses will supervise every 15 minutes monitoring and report to DON for any concerns. c. All staff on duty will observe for residents' safety and needs. CNA 1 on Station A, B and C on all shifts to make room rounds every 15 minutes and CNA 2 on Station A, B and C on all shifts will be designated to cover breaks. Each licensed staff on Station A, B and C will designate break times to ensure all 137 residents in the facility will be monitored and needs attended to. Licensed staff will make rounds on Station A, B and C on each shift, CAN 1 and CAN 2 will initial on the monitoring log on each station each 15 minutes during the interruption of the call light system. The new call light system is being currently serviced with an estimated date of completion of 4/30/19. Installation of the new call light boxes began (MONTH) 2019. If the extension is needed the facility will notify the Department of Health while work is being completed on the new call light system. d. The residents monitoring every 15 minutes will be documented on the monitoring log until call light system is fully functional. e. DON will inform administrator for any issues regarding this situation. f. OSHPD permit is posted in the front lobby and will stay until the new call light system is in place and properly functioning. Charge Nurse/RN supervisor will monitor for compliance every shift and will report to DON for any concerns. DON will report to the Administrator for further concerns. On 4/19/19 at 7:45 p.m., the plan was accepted, however the IJ was not abated because the facility did not proceed with implementation of the plan of action (POA) as stated. On 4/20/219 at 7:13a.m., during the observation of POA implementation, a large pool of a yellow liquid was observed in front of the bathroom door in room [ROOM NUMBER]. There was a resident in Bed A asleep at the time of the observation. On 4/20/219 at 7:15a.m., during the observation, CNA 7 was observed conducting every 15 minutes check in residents' rooms. CNA 7 was observed knocking on the door of room [ROOM NUMBER] than entering the room. CNA 7 documented something on her clipboard, and then proceeded to the next room. On 4/20/19 at 7:19 a.m., during an interview, CNA 7 stated she was trained by the facility to check the residents room every 15 minutes to check for the risk for falls and to check if the residents' need anything while call lights were inoperable. CNA 7 stated that she did not see the large pool of yellow fluid in front of the resident's bathroom door in room [ROOM NUMBER]. CNA 7 stated that the liquid on the floor places an increases risk for falls and injury for the residents and should have been reported to the housekeeper as well as to take the measures to ensure residents' safety. However, CNA 7 was unable to identify other concerns that would place the residents at risk for impairment of safety. CNA 7 stated she will report pool of liquid on the floor to the housekeeper immediately. On 4/20/19 at 8:20a.m., during an interview, CNA 8 stated that every 15 minutes' checks were performed by staff to monitor the residents for safety, to ensure that residents were in bed and were comfortable while call lights were inoperable. However, CNA 8 was unable to identify concerns that would place the residents at risk for impairment of safety. On 4/20/19 at 9:01a.m., during an interview, the Administrator confirmed that staff were unaware of what safety hazards to look for during every 15 minute checks while call lights were inactive. The Administrator stated there was a need to provide an in-service to all facility staff about a safety hazards to identify during every 15 minutes' checks. The Administrator stated that POA would be updated to reflect the additional education provided. The survey team did not abate an IJ secondary to unresolved safety risk. Administrator was notified. On 4/21/19 at 1:06 p.m., during an observation of POA implementation and concurrent interview, RN 3 stated that due to short staffing the charge nurses were supervising the room monitoring. During an interview on 4/21/19 at 1:35 p.m., LVN 2 stated it has been everybody's responsibility to monitor residents in their rooms. During an interview on 4/21/19 at 2:12 p.m., RN 3 stated we are short staffed, some called in and one staff member had to go home. Everybody has been monitoring the residents. We have not been able to assign one person per station as indicated in the POA. RN 3 stated that going forth he will assign one person per station per shift. This person will be responsible to monitor residents in their rooms every 15 minutes. During an interview on 4/21/19 at 3 p.m., the Administrator stated we have not been able to assign staff only for monitoring but we will for the incoming shifts. Administrator verbalized understanding that the IJ was not abated due to the POA is not being implemented. During the observation of POA implementation on 4/22/19 at 9:15 a.m., the MS stated I have checked the existing/old call light system and some of the rooms and restrooms call lights are not functioning. Concurrently, during an observation of the existing/old call light system function, room [ROOM NUMBER], 16, 19, 20, 29, 30, 31, 32, 57, 58 and 60 restrooms and room [ROOM NUMBER] Bed A, B and C, room [ROOM NUMBER] A, and room [ROOM NUMBER] Bed A and B, call lights failed to have a light on (visible signal) above the entrance doors and visible and audible signal on the call light system panel at the Nurses Stations A, B and C. During an interview on 4/22/19 at 10:00 a.m., the MS stated the electric company was aware that the call light system did not function appropriately however the company would not be at the facility until 4/23/19. During the observation of POA implementation on 4/22/19 at 10:28 a.m., CNA 6 was observed knocking on room [ROOM NUMBER] restroom door that was closed however, there was no response from the restroom. CNA 6 then stated, There may be a resident in the restroom and walked away. When asked how CNA 6 was able to tell that a resident was safe in the restroom she stated, You are right, I should check the restroom. The team did not to abate the IJ on 4/22/19 secondary to unresolved safety risk. Administrator was notified. On 4/23/19, after verification of POA being implemented as outlined and the electric company was in process to repair old call light system the IJ was abated on 4/23/19 at 11:22 a.m.

Based on interview, and closed record review, the facility failed to ensure one of 27 sampled residents (109) had the following: 1. Ensure Resident 109's, who was assessed a high risk for falls and sustained five falls prior the sixth fall with an injury, had preventative measures for falls and implementation in the care plan for falls. 2. Ensure each of Resident 109's fall was investigated to evaluate the circumstances of each fall, the effectiveness of preventative measures and to consider other interventions to effectively safeguard the resident from falls and injuries. 3. Ensure a common side effects of [MEDICATION NAME] ((antipsychotic medications) treat mental disorder) such as dizziness, sedation, sensation of spinning or whirling, [MEDICAL CONDITION] (low blood pressure) were ruled as a potential causative factor of Resident 109's falls. 4. Ensure, the nursing staff, attending physician and consultant pharmacist reviewed Resident 109's medications, and their combinations which could relate to falls or fall risk such as those that have side effects of dizziness or [MEDICAL CONDITION], per facility's policy on Fall Risk Assessment. These deficient practices resulted in Resident 109 to fall on 3/8/19 and sustained a right [MEDICAL CONDITION]. Resident 109 had falls on 4/13/18, 6/23/18, 7/4/18, 10/30/18 and 2/17/19 proceeding a fall on 3/8/19 with the fracture of a right hip. On 3/8/19, Resident 109 was transferred to the acute care hospital for further evaluation and treatment. Findings: According to Resident 109's Face Sheet, the resident was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. bone mass). According to the physician order, dated 10/12/10, the licensed nurses had to monitor Resident 109's orthostatic [MEDICAL CONDITION] (decrease in systolic (the top number)) of the blood pressure ((BP) reading that refers to the amount of pressure in your arteries during the contraction of your heart muscle) of 20 millimeters of mercury (mm Hg) or a decrease in diastolic (the bottom number of the blood pressure reading) blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position) while the resident was receiving antipsychotic medications such as [MEDICATION NAME]. The physician's instructions were as follows: to take BP while the resident was lying down and sitting up once a week on Saturday on 7 a.m., to 3 p.m. shift. On 7/02/17, there also was a physician's orders [REDACTED]. On 02/11/18, the physician's orders [REDACTED]. According to the Web Internet reference, the most commonly reported adverse reactions across [MEDICATION NAME] clinical trials are: central nervous system (CNS) reactions which including sedation, dizziness, sensation of spinning or whirling, headache, and tremor; cardiovascular reactions, including abnormally low blood pressure ([MEDICAL CONDITION]), blood pressure drops upon standing. (https://www.webmd.com/drugs/2/drug-5194/[MEDICATION NAME]-oral/details). According to the Minimum Data Set (MDS), a standardized assessment and care- screening tool, dated 4/18/18, Resident 109 had severely impaired cognitive skills for daily decisions making, had trouble concentrating on things frequently, had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconnections or beliefs that are firmly held, contrary to reality). According to the MDS Resident 109 was receiving an antipsychotic [MEDICATION NAME] (a powerful tranquilizers used specially to treat [MEDICAL CONDITION]). According to the MDS dated [DATE], Resident 109 had severely impaired cognitive skills for daily decision making and was distractible with disorganized thinking and was able to perform activities of daily living ((ADL), transfer from bed to chair, walk in room, dressing, and toilet use) independently. According to the MDS Resident 109 had a fall since initial admission without an injury. According to the MDS the resident was receiving antipsychotics medications. On 4/23/19 at 8:20 a.m., during an interview with the registered nurse 1 (RN1) and review of Resident 109's Fall Risk Evaluation form, RN 1 stated the resident's total score was 10 or higher and the resident was considered a high risk for falls. A review of Fall Risk Evaluation form dated 4/13/18, 07/13/18, 10/9/18, and 01/14/19, indicated Resident 109 was assessed with [REDACTED]. A review of the care plan for bleeding nose secondary to fall, dated 04/13/18, indicated the goal for the resident was not to have complications within next 72 hours and the interventions were documented such as to check vital signs per protocol and pain, monitor response to medication, encourage fluid intake, notify physician for any unusual significant changes in condition, facial x-ray. In this care plan was documented Resident 109 had a skin discoloration below both eyes and chin, and a swelling around both eyes. There was no documented goal for the resident's skin discoloration and swelling around both eyes or chin skin discoloration. The approaches listed included to monitor the resident for pain, medicate the resident as ordered, provide a safe environment, and to monitor for any visual discomfort. On 04/23/19 at 9 a.m., a review of the Licensed Personnel Weekly Progress Notes, dated 04/13/18, were conducted with the registered nurse 1 (RN1). There was documented that a certified nursing assistant 99 (CNA 99) reported to a licensed nurse that Resident 109 was found lying on the floor. According to this note a licensed nurse went immediately to the resident's room. Resident 109 was lying on the floor face down near her bed with bleeding nose. Resident 109's had swelling on her face and no skin discoloration present at that time. A review of Resident 109's clinical record indicated there was no documented evidence the causative factors of the resident's fall on 4/13/18, were investigated and identified, care plan interventions were evaluated for effectiveness and new interventions were considered to prevent further falls. There was no documentation indicating that potential side effects of [MEDICATION NAME] was evaluated as one of possible causative factors. According to the review of Licensed Personnel Weekly Progress Notes, dated 6/23/18 at 7 p.m., Resident 109 was in a shower with CNA 101. When the resident's clothes were removed CNA 101 noted Resident 109 had bluish, purplish discoloration on the left hip with swelling. The discoloration was measured 26.0 centimeters (cm) by 8.0 cm. In this Progress Note was documented that the resident had pain three out 10 on a zero to ten pain scale where zero is no pain and ten is the worse pain possible. Resident 109 was asked what happened, however the resident was unable to relay due to [MEDICAL CONDITION] and language barrier. It was documented Resident 109 was able to move lower extremity and the resident's physician was notified same day at 7:05 p.m. There was a physician's orders [REDACTED]. According to the x-ray report dated 6/23/18 at 8:36 p.m., indicated Resident 109 had no acute fracture. A review of the care plan for the left hip swelling and skin discoloration, dated 6/23/18, indicated a short term goal was to heal swelling and skin discoloration in 14 days with the following interventions: to monitor the resident for presence of pain every shift, to provide medication as ordered, provide safe environment, STAT X-ray as ordered, notify the physician on any unusual change in condition and handle resident gently. During an interview with RN 1 on 4/23/19 at 9:10 a.m., stated the care plans should guide the nursing staff to prevent the resident from further falls. RN 1 stated, These care plans for falls are vague. A review of Resident 109's clinical record indicated there was no documented evidence the causative factors of the resident's fall on 6/23/18 were investigated and identified and care plan interventions were evaluated for effectiveness and new interventions were considered to prevent further falls. There was no documentation indicating that potential side effects of [MEDICATION NAME] was evaluated as one of possible causative factors. According to Licensed Personnel Weekly Progress Notes, dated 7/4/18 at 2:45 p.m., Resident 109 was found sitting on the floor in the hallway. When the resident was asked what happened stated I slid down. In the notes was documented that the resident's body check was done, with complaint of pain to the left hip of three out of 10 on zero to ten pain rating scale. There was no swelling or redness noted and the resident was able to move lower extremities without difficulty. In the notes was documented that Tylenol 650 milligram (mg) was given to the resident for pain and neurological ((neuro)- an assessment which include, at a minimum, pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity to light; and equality of hand grip strength) check was done per facility's protocol. A review of the physician's telephone order dated 7/04/18, at 5:15 p.m., indicated to conduct neuro check for 72 hours secondary to fall. According to the physician's telephone order dated 7/06/18 at 2 p.m., the physical therapist (PT) was ordered to conduct the Resident 109 evaluation only and according to the physician order [REDACTED]. A review of the care plan for status [REDACTED]., neuro check for 72 hours, provide safe environment at all times, observe for signs and symptoms of pain, and to notify the physician for significant change of condition, to remind frequently to call for help when needed, and physical therapy evaluation and treatment as ordered. A review of Resident 109's clinical record indicated there was no documented evidence how frequently the nursing staff will remind Resident 109 to use a call light for help. There was no documented evidence the causative factors of the resident's fall on 7/4/18 were investigated and identified and care plan interventions were evaluated for effectiveness and new interventions were considered to prevent further falls. There was no documentation indicating that potential side effects of [MEDICATION NAME] was evaluated as one of possible causative factors. According to Short Term Physical Therapy Goals, dated 7/06/18, Resident 109 had decreased strength, impaired bed mobility, decreased ability to perform functional transfers, impaired standing balance, and impaired gait. The resident's goals included: to improve strength, improve bed mobility, improve transfers, improve standing balance, improve sitting balance and improve gait. The approaches included: to provide range of motion exercises (ROM), therapeutic strengthening exercises, bed mobility training, and transfer training. A review of PT discharge notes, dated 8/1/18, indicated Resident 109 reached prior level of function (PLOF) as a result of skilled interventions and the resident demonstrated little or no physical impairments as a result of skilled PT rehabilitation. According to the Licensed Personnel Weekly Progress Notes, dated 10/30/18 at 7:30 p.m., indicated, Resident 109 was noted with purplish discoloration on a right anterior (front) upper arm with slight swelling approximately 8.0 cm by 5.0 cm. In the notes was documented that Resident 109 was assisted back to her room and was asked what happened. The resident stated, I do not remember. In the notes was documented the resident was able to move right arm without any difficulty or limitations, ice pack was applied and Tylenol 650 mg given for complaint of pain two of ten (2/10) on a zero to ten pain rating scale. In the notes, there was no documentation about where Resident 109 was found before she was assisted back to her room. A review of the care plan for the purplish discoloration on a right upper anterior arm secondary to fall on 10/30/18, indicated the goal for the resident was to have discoloration on a right upper arm resolve within 14 days without any complications. The interventions included: to take the resident's vital signs per facility's protocol and as needed, to monitor for swelling and assess for pain or discomfort, and to notify the physician for any significant changes in the resident's condition. A review of Resident 109's clinical record indicated there was no documented evidence the causative factors of the resident's fall on 10/30/18 were investigated and identified and care plan interventions were evaluated for effectiveness and new interventions were considered to prevent further falls. A review of the Licensed Personnel Weekly Notes, dated 2/17/19 at 5 p.m., indicated Resident 109 was observed limping on her right side while walking in hallway. On 4/24/19 at 11:35 a.m., RN 1 read the notes and stated, the resident claimed she fell in her room and complained of pain pointing on her right hip. RN 1 stated this was an unwitnessed fall. A review of the physician's orders [REDACTED]. According to the x-ray report dated 2/17/19 at 8:08 p.m., Resident 109 did not have a right [MEDICAL CONDITION]. The care plan, dated 2/17/19, for the limping on right side due to unwitnessed fall the goal for the resident was to have no complications. The approaches included: to check the resident's vital signs every shift, assess for pain, pain management, neuro check for 72 hours, and provide safe environment. A review of Report of Incident Investigation dated 2/17/19, indicated that prior to resident 109's fall on 2/17/19 the measures instituted before this fall were frequent reminders and hourly checks. In this report was documented Resident 109 was confused and had poor safety awareness and new preventative measures after this fall were to remind Resident 109 to use a call light for assistance and hourly checks. There was no documented evidence the preventative measures prior to the fall on 2/17/19 were evaluated for effectiveness and plan of care was revised to reflect other preventative interventions. According to the Report of Incident Investigation dated 2/17/19, the preventative measures after the fall remained the same. There was no documentation indicating that potential side effects of [MEDICATION NAME] was evaluated as one of possible causative factors. During an interview on 4/24/19 at 9:57 a.m., the director of nursing (DON) stated, Honestly, I do not have any other investigative reports except for the resident's fall 2/17/19. DON stated that the facility did not implement any interventions outside of physical therapy to prevent repeated falls or investigate the unknown injuries and falls. During an interview on 4/24/19 at 10:37 a.m., the administrator stated that investigative reports were handled by the DON. The administrator stated I do not have any investigations of Resident 109's falls. I will ask the assistant DON if she has any. The administrator stated that during a meeting last year in (MONTH) (YEAR), previous DON mentioned falls was an issue. The administrator stated she will ask the DON now to focus on fall prevention. During an interview on 4/24/19, at 11:31 a.m., RN 1 stated there was not any investigative reports for Resident 109's falls given to her by the previous DON. RN 1 stated the facility was responsible to conduct an investigation of falls and unknown injuries. RN 1 stated, No, we did not look at medications that could cause the resident's falls. According to the Licensed Personnel Weekly Notes., dated 3/08/19 at 10 p.m., Resident 109 complained of pain to right side of pelvis and right femur (thigh bone) and the physician was notified. There was a physician's orders [REDACTED]. According to the x-ray report dated 3/08/19, Resident 109 had the right hip femoral neck fracture with [MEDICAL CONDITION]. On 3/08/19, at 10:40 p.m., there was a physician's orders [REDACTED]. On 4/24/19 at 8:44 a.m., DON stated she was not sure if the resident sustained [REDACTED]. The DON stated we want to make sure the residents are monitored and reminded not to get out of bed without assistance. The DON stated that usually we do the investigation and document in the Investigative Report after each fall. The DON confirmed there was no record available to indicate Resident 109's falls were investigated to evaluate the causative factors to the resident's falls. According to Resident 109's admission record, the resident was readmitted back to the facility on [DATE]. According to the physician's orders [REDACTED]. There was another order for [MEDICATION NAME] 5/325 mg two tablets by mouth every four hours PRN for severe pain due to the fracture of unspecified part of a neck of a right femur. According to the MDS dated [DATE], Resident 109 was sometimes understood (ability is limited to making concrete requests). The MDS assessment indicated the resident had the ability to sometimes understands others (responds adequately to simple, direct communication only), was totally dependent on staff in transferring and toilet use, required extensive one-person physical assistance with dressing, locomotion on (how resident moves to and between locations in his/her room and adjacent corridor on same floor) and off unit (how resident moves to and returns from off-unit locations). A review of the facility's policy on Fall Risk Assessment, undated, indicated the following: a. The nursing staff, attending physician and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk such those that have side effects or dizziness or [MEDICAL CONDITION]. b. The staff will look for the evidence of a possible link between the onset of falling (or increase on falling episodes) and recent changes in the current medication regiment. c. The nursing staff and attending physician will assess the resident for medical condition (such as those that cause dizziness or [MEDICAL CONDITION]) or sensory impairments (such as decreased vision and [MEDICAL CONDITION]) that may predispose to falls. d. Assessment data will be used to identify underlying medical condition that may increase the risk of injury from falls (such as [MEDICAL CONDITION]). e. The staff will identify environmental factors that may contribute to falling, such as lighting and room layout. f. The staff and the physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the facility's Guidelines for Assessing Falls and Their Causes, indicated the following: I. The purpose of the Guidelines is for assessing a resident after the fall and to assist in identifying causes of the fall. a. After the fall to clarify the details of the fall, such as what the individual was trying to do at the time of the fall occurred. b. Evaluate chains of events or circumstances preceding a fall. c. Continue to collect and evaluate information until the cause of the fall is identified or it is determined the cause cannot be found. II. When a resident falls, the following information should be recorded in the resident's clinical record: a. The condition in which the resident was found. b. Assessment data, including vital signs and any observed injuries. c. Interventions, first aid, or treatment administered. d. Notification of the physician and family, as indicated. e. Completion of a fall risk assessment. f. Appropriate intervention taken to prevent future falls.

Based on interview and record review, the facility's staff failed to follow its policy regarding using facility escorts to accompany residents to outside appointments; the physician's orders [REDACTED]. Resident 1, who had a history of [REDACTED]. Resident 1 eloped from the courthouse and was missing for 16 days. Resident 1 was later found by police living in an apartment that the resident had broken into. The apartment was located approximately 20 miles away from the facility. These deficient practices resulted in Resident 1 having to be treated at a general acute care hospital (GACH) for scabies (a skin condition with mites that burrow into the skin and causes an itchy rash) and [DIAGNOSES REDACTED] (low levels of potassium, (a mineral that helps the body maintain fluid balance and muscle function), in the blood that can cause abnormal heart beat and muscle cramps), jeopardized the resident's safety and had the potential to result in serious harm, impairment, injury or death to Resident 1. Findings: A review of Resident 1's Admission Facesheet indicated the resident was admitted to the facility on (MONTH) 2, (YEAR). Resident 1's [DIAGNOSES REDACTED]. The record indicated Resident 1 was conserved (a person appointed by a judge to make legal decisions on behalf of another person). A review of Resident 1's Minimum Data Set (MDS), a care-screening and assessment tool, dated (MONTH) 11, (YEAR), indicated a Brief Interview for Mental Status (BIMS) score of 9 (8-12 mild impairment), which indicated that Resident 1 had problems with memory and cognition (thought process). The MDS indicated Resident 1 had hallucinations (seeing, hearing, smelling, tasting or feeling things that don't exist outside of the mind), delusions (having false or unrealistic beliefs, thoughts or opinions) and difficulty focusing attention. According to the MDS, Resident 1 was independent in walking and did not use any assistive devices. The MDS indicated Resident 1 had wandering behaviors one to three days a week and did not have an active discharge plan. A review of Resident 1's care plan titled Potential for Elopement, dated (MONTH) 2, (YEAR) , with a latest review date of (MONTH) (YEAR), indicated the resident was at high risk for elopement due to a history of elopement from the resident's previous facility. The care plan goal indicated Resident 1 would remain safe within the facility unless accompanied by staff. The staff's interventions included recording the resident's attempts to leave the facility, closely supervising the resident, hourly visual checks and following elopement protocol if the resident was missing. The care plan indicated Resident 1 had a previous elopement from the facility on (MONTH) 27, (YEAR). A review of Resident 1's Nurse Progress Notes, indicated the following: 1. On (MONTH) 27, (YEAR), at 5 p.m., Resident 1 eloped from the facility. The note indicated that at 8:10 p.m., Resident 1's family member notified the resident's conservator that the resident was currently at their home, which was located about 22 miles away from the facility. According to the note, at 9:45 p.m., Resident 1 was returned to the facility by the Police Department (PD). 2. (MONTH) 21, (YEAR), at 8 a.m., Resident 1 went to a court appointment and was accompanied by a staff escort. The note indicated Resident 1 returned to the facility on the same day, at 1:25 p.m. 3. (MONTH) 26, (YEAR), at 8:50 a.m., Resident 1 left the facility for a court appointment. The resident left with two sack lunches and the resident's medical record. There was no documentation indicating the resident had a facility escort accompanying her to the court appointment . 4. (MONTH) 26, (YEAR), at 10:40 a.m., the facility received a call from the courthouse notifying them that Resident 1 had gone missing while waiting to be seen by the judge. 5. (MONTH) 27, (YEAR), at 12:45 p.m., the Director of Nursing (DON) called the missing person hotline to follow up on Resident 1 and Resident 1 was discharged from the facility as Against Medical Advice (AMA). A review of Resident 1's (MONTH) (YEAR) Physician order [REDACTED]. 1. (MONTH) 28, (YEAR), Resident 1 could go out of the facility on pass with staff. 2. (MONTH) 27, (YEAR), Resident 1 was at risk for elopement and needed to be monitored every shift; day, evening and night for attempts to leave the facility. 3. (MONTH) 27, (YEAR), at 1 p.m., Resident 1 was discharged from the facility as AMA while on pass at court. 4. (MONTH) 27, (YEAR) at 1:05 p.m., Resident 1 was discharged from the facility as Absent Without Leave (AWOL) while on pass to court. A review of Resident 1's Elopement Risk Assessment, dated (MONTH) 11, (YEAR), indicated the resident was confused, forgetful and would wander out of the facility if given the chance to do so. A review of Resident 1's Psychiatric Evaluations, dated (MONTH) 8, (YEAR) and (MONTH) 6, (YEAR), indicated Resident 1 was at risk for elopement and had attempts to leave the facility. A review of the facility's Census History report, dated (MONTH) 10, (YEAR), indicated Resident 1 was discharged from the facility on (MONTH) 27, (YEAR) at 1 p.m. The report indicated Resident 1 was AWOL and her return to the facility was not anticipated. According to the report, Resident 1 was readmitted to the facility on (MONTH) 12, (YEAR) at 5:30 p.m. (16 days later). A review of Resident 1's Laboratory Results, dated (MONTH) 17, (YEAR) indicated Resident 1's potassium level was 4.7 (Normal Reference Range (NRR) = 3.5-5.0 milliEquivalents per liter (mEq/L). A review of the GACH's history and physical examination [REDACTED]. Resident 1 reported having had a rash for one week and was treated for [REDACTED]. According to the examination, Resident 1's potassium level was 2.9 and the resident had to be treated with 60 milliequivalents (mEq) of potassium and given intravenous ((IV) through the vein) fluids for hydration. A review of the GACH's Discharge Summary, dated (MONTH) 12, (YEAR), and timed at 1:48 p.m., indicated Resident 1 was discharged to the facility on (MONTH) 12, (YEAR). On (MONTH) 10, (YEAR), at 1:24 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was not at risk for elopement and was unaware of Resident 1's previous court elopement. CNA 1 stated to keep residents safe and prevent additional elopement incidents, it was important to know if residents were at risk for elopement or if the resident had a history of [REDACTED]. On (MONTH) 10, (YEAR), at 2:22 p.m., during an interview, the Social Services Director (SSD) stated when residents at risk for elopement needed to leave the facility for outside appointments, they were to be sent with an escort from the facility. On (MONTH) 13, (YEAR), at 10:35 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had a history of [REDACTED]. LVN 1 stated Resident 1 was sent to her court appointment on (MONTH) 26, (YEAR) without an escort . According to LVN 1, it was not safe to send Resident 1 outside of the facility without an escort because the resident could elope and it was the facility's responsibility to keep the resident safe. On (MONTH) 13, (YEAR), at 11:10 a.m., during an interview, Resident 1 stated she was at her court appointment and wanted to go home. Resident 1 stated she caught a bus to her old apartment located approximately 10 miles away from the courthouse. Resident 1 stated she stayed at the apartment until police came and brought her back to the facility. According to Resident 1, she was able to leave the court because the facility did not send her with a staff escort. Resident 1 stated, about a year prior, she was able to elope from the facility using keys she found in the hallway. Resident 1 stated she used the keys to open the locked front doors and exit from the facility. On (MONTH) 13, (YEAR), at 11:50 a.m., during an interview, Receptionist 1 (REC 1) stated the facility was a locked facility and the only way to enter the unlocked front lobby area was with a key or buzzer located at the receptionist desk. REC 1 stated when the transportation company arrived to take Resident 1 to her court appointment, on (MONTH) 26, (YEAR), she overhead paged for the resident to be brought up to the lobby. REC 1 stated once Resident 1 arrived to the front locked double doors, she used the buzzer to open the doors and let Resident 1 into the front lobby area. REC 1 stated Resident 1 did not have an escort when she entered the front lobby and did not have an escort when she left the facility with the transportation agency. REC 1 denied knowing that Resident 1 required an escort when leaving the facility and going to outside appointments. On (MONTH) 13, (YEAR), at 12:40 p.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated there was a physician order [REDACTED]. According to the DSD, the elopement attempts should have been documented on Resident 1's Medication Administration Record [REDACTED]. The DSD stated if the elopement monitoring wasn't documented, it wasn't being done. A review of the facility's undated policy titled, Resident Pass Policy, indicated the policy's purpose was to establish guidelines for residents to leave the facility under pre-approved conditions. The policy indicated pass orders would be obtained from the physician and nursing would review the pass orders prior to the resident leaving the facility. A review of the facility's undated policy titled, Transportation to Outside Appointments, indicated to ensure residents returned to the facility safely, residents would be transported to outside appointments in the facility van and with a staff escort. A review of the facility's undated policy titled, Missing Resident, indicated when a resident could not be located after a search, the facility staff would notify regulatory agencies.

Based on observation, interview, and record review, the facility failed to ensure its residents have the right to be free from abuse by not protecting one of 28 sampled residents (Resident 121), from abuse. Certified Nurse Assistant 1 (CNA 1) punched Resident 121 in the face and cursed at her. This deficient practice resulted on Resident 121 crying inconsolably for half an hour and verbalizing fear of CNA 1. By 4/13/17, Resident 121 was still affected by the verbal and physical abuse from CNA 1. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 3/28/18, indicated Resident 1 had moderate cognitive (ability to think, reason, and make decisions) impairment, was able to walk without assistance and needed supervision with activities of daily living (ADLs). During an interview with the Administrator on 4/12/18 at 8:55 a.m., she stated that on 3/22/18, the Activity Director (AD) and the pastor (a volunteer) observed Resident 121 crying while standing in the coffee line (residents wait in line for coffee outside the activity room). The AD and the pastor asked Resident 1 why she was crying but Resident 1 did not want to answer. The AD and the pastor notified the charge nurse who informed the Administrator and the Director of Nursing (DON). The Administrator stated that as part of the investigation, she and the Director of Nursing (DON) separately interviewed Resident 121 and she gave the same information: CNA 1 took her into another residents' room, room [ROOM NUMBER], punched her on the face. CNA 2, was in the room, witnessed the abuse and did nothing about it. The Administrator indicated that, as soon as they learned about the alleged abuse, they initiated an investigation and CNAs 1 and 2 were both suspended. Upon completion of the investigation, the facility terminated employment of CNAs 1 and 2. On 4/12/18 at 12 p.m., Resident 121 was observed in the dining room, sitting with other residents. Resident 121 did not exhibit aggressive or threatening behavior. Resident 121 was alert and oriented to name, place, time, and situation. On 4/13/18 at 11:02 a.m., during an interview, Resident 121 stated CNA 1 had been cursing at her and calling her a, [***] ever since she started working at the facility. Resident 121 remembered reporting the verbal abuse to Licensed Vocational Nurse 4 (LVN 4) but LVN 4 made her feel they did not care to address the situation and tolerated CNA 1's behavior. Resident 121 stated she did not feel good about the verbal cursing and name-calling. Resident 121 stated she was relieved and felt safer when the Social Services Designee (SSD) informed her that both CNAs no longer worked at the facility. On 4/18/18 at 10:25 a.m., during an interview, the AD stated that on 3/22/18, she was working with the Pastor when she observed Resident 121 standing in line for coffee and was upset. The AD stated Resident 121 was crying so much. The AD stated Resident 121 was traumatized about something, but because of crying, the AD could not understand what Resident 121 was trying to tell her. The AD stated she had never seen Resident 121 crying like that before. The AD stated she called Nursing Station A to inform the nurses about Resident 121. The AD stated that on the following day, she spoke to Resident 121, who was calm and able to explain what happened to her. The AD stated Resident 121 told her CNA 1 took her out of the coffee line and into room [ROOM NUMBER]. The AD stated Resident 121 told her she was really afraid of CNA 1, and would only feel comfortable and safe if she did not see CNA 1 again. On 4/18/18 at 11:01 a.m., during a telephone interview, CNA 1 stated on 3/22/18 at around lunch time, Resident 121 entered the dining room but since that was not her assigned dining room, CNA 1 re-directed Resident 121 to leave the room. While re-directing Resident 121, CNA 1 stated she felt something hit the back of her neck. Upon inspection, CNA 1 stated it was a napkin, then she saw Resident 121 ran away from the door. CNA 1 stated that same afternoon, she was walking to the activity room when she saw Resident 121 in the coffee line. CNA 1 stated she asked Resident 121 if they could talk. CNA 1 stated she brought Resident 121 into room [ROOM NUMBER], asked Resident 121 what was going on with her, and to inquire about her behavior that morning. CNA 1 stated she asked Resident 121 if there was something she could do for her. Resident 121 told CNA 1 that she did not mean to do it (throw the napkin) and apologized for her behavior. CNA 1 stated she told Resident 121, This may be something I need to talk to your sister about. When asked what the facility process was, if there were concerns with a resident, CNA 1 stated she was supposed to let the charge nurse know. When asked if there was anyone else in the room, CNA 1 stated CNA 2 came to the room and asked Resident 113 to use the restroom. CNA 1 denied touching or hitting Resident 121. On 4/18/18 at 11:34 a.m., during a telephone interview, CNA 2 stated that on 3/22/18, she went inside the room where she observed CNA 1 and Resident 121 having a conversation. CNA 2 stated she was in the room to assist Resident 113, who was on a bowel and bladder program (B&B), to the restroom; she went inside the restroom and closed the door for privacy. CNA 2 stated she did not hear CNA 1 saying aggressive words, did not see CNA 1 hitting Resident 121, and did not hear Resident 121 calling for help. CNA 2 stated that when she was done assisting Resident 113 and came out of the restroom, both CNA 1 and Resident 121 were no longer in the room. On 4/18/18 at 11:47 a.m., a telephone interview was attempted with Licensed Vocational Nurse 4 (LVN 4); however, LVN 4 did not return the call. On 4/18/18 at 11:48 a.m., during a telephone interview, the volunteer pastor stated that on 3/22/18, he arrived at the facility at around 3 p.m. and observed Resident 121 sobbing while she was standing in the coffee line outside the activity room. The pastor stated he has been visiting the facility since 2003, for [AGE] years, and described the sobbing as unusual behavior for Resident 121. The pastor stated he approached Resident 121 and asked her what was wrong; Resident 121 mumbled something he could not understand. The pastor stated he handed her a Bible, which she took but continued sobbing for half an hour. On 4/18/18 at 12:46 p.m., the Evaluator reviewed the facility camera recording of the day of the incident with the Administrator. The hallway camera showed the following: -At 12:30 p.m., CNA 1 entered the Winter dining room. -At 12:40 p.m., CNA 1 was closing the door. Resident 121 was in the hallway and observed throwing something at CNA 1 then continued to walk down the hallway. The camera inside the Winter dining room showed the following: -At 12:30 p.m., CNA 1 was sitting on a chair. CNA 1 then got up and took a chair to assist feeding a resident who was seated on the table closest to the door. -At 12:40 p.m., Resident 121 was seen entering the dining room. CNA 1 pushed her chair back and blocked Resident 121 from going into the room. CNA 1 got up from her chair, and placed her hand on Resident 121's right arm. Resident 121 pulled her arm away from CNA 1 then walked out the door. -At 3:14 p.m., Resident 121 was walking in the hallway leading to the activity room then stood in line with other residents. -At 3:15 p.m., CNA 1 was walking down the hallway with CNA 2 behind her. CNA 1 approached Resident 121. CNA 1 held the resident's arm and led her to the opposite side of the hallway, inside the room. -At 3:17 p.m., CNA 2 was seen coming out of the room first (contrary to her statement during interview), followed by Resident 121. -At 3:18 p.m., CNA 1 was seen coming out of the room, stopping in front of where Resident 121 was standing, who was back in line. CNA 1 was seen pointing and talking to Resident 121. CNA 1 then walked down the hallway. -At 3:19 p.m., the Pastor and AD approached Resident 121 and talked to Resident 121. During a concurrent interview with the Administrator, she stated the room across from where Resident 121 was standing was room [ROOM NUMBER], an all-male room. The Administrator stated there was no reason for CNA 1 and CNA 2 to take Resident 121, who was a female, into the male room. Regarding CNA 2's statement for Resident 113 needing toilet assistance, the Administrator stated Resident 113 was continent (had full control of bladder function), was ambulatory and was not on a B&B program. The Administrator stated CNA 2 was in the room but did not report the incident. On 4/18/18 at 1:15 p.m., during an interview, the Administrator stated she did not call the police. She stated that there was too much going on, We did not report the incident. The Administrator stated Resident 121's sister called the police. On 4/19/18 at 8:57 a.m., during an interview, the Director of Staff Development (DSD) stated abuse training was offered to all new employees then annually and when necessary. The DSD stated that abuse allegations were to be reported to the California Department of Public Health (CDPH), police and Ombudsman (resident advocate). The DSD stated Resident 121 never reported any abuse in the past and was not known to make up stories. A review of the facility's undated policy titled, Abuse Prevention and Investigation indicated the facility will not condone resident abuse by anyone, including staff members and other residents. In the event an employee has been accused of abuse/neglect, the Administrator will be informed immediately and the employee will be suspended pending an investigation. All alleged incidents of abuse and neglect will be thoroughly investigated. If upon any investigation, an employee's intentional action or inaction resulted in abuse, neglect and mistreatment, appropriate action will be taken up to include termination of employment and reporting to the local law enforcement agency.

Based on observation, interview, and record review, the facility failed to supervise and provide a secured environment for one of two sampled resident (Resident 2) by failing to: 1. Identify Resident 2's risks for elopement (an unauthorized absence of an admitted resident from the boundaries of a facility without staff knowledge). 2. Identify hazards and risks in the environment that enabled Resident 2 to elope. 3. Identify that Resident 2 was not a suitable candidate for admission. The facility's brochure titled Welcome indicated persons who would climb fences or continually attempt to leave the facility would not be suitable candidates for admission. Resident 2, whose previous occupation was a tree trimmer, was admitted to the facility with a known risk for elopement. The resident was admitted on [DATE] at 1 p.m. to the facility and was identified as missing from the facility on 4/10/15 at 8 p.m., 31 hours after admission. The licensed nurse did not conduct an elopement risk assessment at admission, in accordance with the facility's policy and procedure, to identify Resident 2 as a risk for elopement. The licensed nurse did not monitor the whereabouts of Resident 2, in accordance with the licensed progress notes, dated 4/10/15 at 5 p.m., to prevent the resident from leaving the secured facility unnoticed. The facility staff did not know how Resident 2 eloped from the facility and did not conduct an investigation to identify the hazards and risks in the environment that enabled the resident to elope from the secured facility grounds. During the investigation, the small uncovered patio and the trash area were identified having moveable structures and trash bins that could potentially enable a resident at risk for elopement, to leave the facility unnoticed. The facility had security cameras at exit doors but the facility staff did not know if these security cameras were working and if a staff was assigned to monitor the security monitors to determine how a resident eloped and prevent a resident from eloping. These deficient practices resulted in Resident 2's leaving the secured facility grounds unnoticed and had the potential to result in Resident 2's change of condition while in the street due to lack of access to medications, and injury and death from accidents. These deficient practices also placed residents, who were at risk for elopement, to remain unsupervised and leave the facility unnoticed. On 4/17/15, at 5:45 p.m., an immediate jeopardy (IJ) was declared and the facility's registered nurse supervisor (RN 1) was notified of the serious findings. At 6:45 p.m., the director of nursing (DON) was notified of the immediate jeopardy situation upon her arrival at the facility. The facility did not have an administrator at the time. The facility submitted a plan of correction (POC) for the IJ removal. Findings: On 4/16/15 at 4:30 p.m., an anonymous call was received by the Department to report Resident 2 s elopement from the facility on 4/10/15. The report indicated that The facility had not done anything about it or reported it. Other residents have gone AWOL (absence without leave or permission, also called elopement) also in the past and facility fails to report it. On 4/17/15, at 2:20 p.m., an unannounced visit was made to the facility to investigate a complaint regarding neglect and quality of care/resident's safety. A review of Resident 2's admission records indicated the resident was admitted to the facility on [DATE] at 1 p.m., with [DIAGNOSES REDACTED]. Resident 2's previous occupation was a tree trimmer. The resident was under conservatorship (a guardian and protector is appointed by a judge to manage the financial affairs and/or daily life of another due to physical or mental limitations, or old age). A review of the Notification of Patient's Admission from the acute care hospital, dated 4/2/15, indicated Resident 2 was admitted to the hospital's psychiatric department on 4/2/15 due to 5250 involuntary psychiatric hold (Section 5250 is a section of the California Welfare and Institution Code which allows a qualified officer or clinician to involuntarily confine a person deemed to have certain mental disorders, that makes the person a danger to him and/or others and/or gravely disabled, for up to 14 days, following an involuntary hold for three days.). The Psychiatry Progress Note from the acute care hospital, dated 4/4/15, indicated that Resident 2 was admitted to the hospital because of being a high risk for elopement with severe cognitive problems. The report also indicated Patient is cognitively impaired, can't (sic) take care of himself when left alone in the community. The RN Shift Assessment at the acute care hospital, dated 4/5/15 and 4/6/15, indicated Resident 2 was an AWOL risk, and the resident was being monitored for impending signs of seizure activity, related to a history of seizure disorder (a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and other mental/behavioral manifestations). Resident 2 was discharged from the acute care hospital and was admitted to the facility on [DATE]. The facility had the resident's clinical records from the acute care hospital at the time of the resident's admission. A review of the facility's document titled Welcome, undated, indicated the facility specializes in providing care to the confused, wandering, geriatric person. The facility provides a secure environment. The main entrance doors and perimeter fences are locked to egress, permitting residents to wander throughout the facility and its outside walkways and patios, while maintaining as safe an environment as possible. Persons who are combative, who could climb fences or continually attempt to leave the facility would not be suitable candidates for admission. A review of an undated facility's policy and procedure titled Elopement, indicated that The admitting nurse will complete the elopement assessment form to identify new residents at risk for elopement. All nursing and non-nursing staff will be alerted on residents who are at high risk for elopement. Resident 2's clinical record was reviewed with the registered nurse supervisor (RN 1), on 4/17/15, at 4:15 p.m. There was no documented evidence in the resident's clinical records that Resident 2 was assessed for elopement risk. During a concurrent interview, when asked if the facility completed an elopement risk assessment for newly admitted residents; RN 1 stated, Medical Records (staff) said we do not have an Elopement Risk Assessment form. RN 1 was asked how the facility knew if a resident was at risk for elopement. RN 1 stated, We just base it from the report received from other facility and observation of the resident. A review of the Interim Plan of care, dated 4/9/15, indicated Resident 2 walked independently. The plan of care, dated 4/10/15, indicated Resident 2 was a smoker, alert, confused, had short attention span, and wandered all about. The approaches included to inform and encourage the resident to attend the activities program. There was no care plan developed to identify, address, and manage the resident's risk for elopement. A review of the licensed nurses progress notes, dated 4/9/15 at 8:39 p.m., indicated Resident 2 had episodes of pacing aimlessly in the hallway and the resident was redirected to his room. At 9 p.m., Resident 2 appeared anxious and agitated. Haldol (an antipsychotic medication) 5 milligrams with Benadryl (a sedative) were given by mouth. The licensed nurses progress notes completed by a night shift (from 11 p.m. on 4/9/15 to 7 a.m. on 4/10/15) licensed nurse indicated Resident 2 was constantly pacing the whole night. On 4/10/15 at 5 p.m., the licensed nurse progress notes indicated Resident 2 appeared to be calm but continued to ask about going home to his brother. The licensed nurse documented that the staff would encourage the resident to join the activities to help adjust to the facility, and would continue to monitor the resident. The licensed nurses progress notes, dated 4/10/15 at 8 p.m., indicated the nursing staff made the charge nurse aware of Resident 2 not being found in his room or around the facility. A room to room search was done and Resident 2 was still not found. The nursing staff recalled seeing the resident during the smoke break at 6 p.m. and also walking throughout the facility. Resident 2 was noted using the phone to call his brother and conservator. The staff called the local police department. On 4/11/15 at 6:50 a.m., the resident's conservator/legal representative was notified. On 4/17/15, at 2:30 p.m., during an interview with the director of nurses (DON), she stated Resident 2 was a newly admitted resident to the facility and was discovered missing by the staff on 4/10/15 during the evening shift (3 p.m. to 11 p.m.). The DON stated the charge nurse notified her that evening that the resident was missing, and the staff reported the incident to the police and the resident's conservator/legal representative. The DON stated they did not know where Resident 2 was or how the resident was able to elope from the facility grounds. During the interview, on 4/17/15 at 2:30 p.m., the DON stated there was no investigative report completed and that everything was written on the nurse (progress) notes in Resident 2's clinical record. The DON stated she could not provide the facility's policy and procedure on elopement, assessment, and prevention. The undated facility policy and procedure titled Elopement, indicated that Complete an Incident Report and document the event in the resident's medical record. On 4/17/15, at 2:45 p.m., during an interview with the licensed vocational nurse (LVN 1), who was the charge nurse on 4/10/15, she stated it was around 8 p.m. when a certified nurse assistant told her that Resident 2 was missing. LVN 1 stated between 6:30 p.m. to 6:45 p.m. that evening, she had observed Resident 2 talking to his brother on the telephone by the nursing station and the resident looked upset. LVN 1 stated, I can hear the brother yelling at him (Resident 2) over the phone. LVN 1 stated that after the phone call, she asked Resident 2 what happened and the resident stated that he called his brother because he wanted to go home. Resident 2 informed LVN 1 that My brother said to stop calling him and I will live here for life. During the interview, on 4/17/15 at 2:45 p.m., LVN 1 stated they searched all over the facility but it was unclear how Resident 2 eloped. LVN 1 stated the police came before 9 p.m. on 4/10/15, after she reported the resident missing from the facility. LVN 1 reviewed Resident 2's clinical record during the interview, on 4/17/15 at 2:45 p.m. After reviewing the resident's clinical record, LVN 1 stated she could not find any risk assessment for elopement that was completed on resident's admission. LVN 1 stated she remembered Resident 2 as very alert. She stated, If I see him in the streets, I wouldn't think he had any type of cognitive impairment. Since the facility did not conduct an investigation to determine how Resident 2 was able to elope from the secured facility grounds and did not evaluate the hazards and risks in the environment that enabled Resident 2 to elope, an inspection of the facility's exit doors, outdoor uncovered areas and walkways, and patios was conducted with the maintenance/housekeeping staff on 4/17/15, from 3:20 p.m. to 3:55 p.m. The inspection was conducted to determine possible breaches in the secured facility grounds that enabled Resident 2 to leave the facility unnoticed. During the inspection with the maintenance/housekeeping staff, the facility's outdoor uncovered areas and walkways, and small uncovered patio were observed surrounded or enclosed by a perimeter fence. The perimeter fence was approximately 10 feet from the ground and the top area of the perimeter fence was caved inward towards the facility grounds. The enclosed small uncovered patio at the side of the facility's building was observed to have a moveable wooden picnic bench/table placed under the roof of the building; a vending soda machine that was placed below the roof; and a concrete wall with the wall's top area protruding below the roof. During a concurrent interview, when asked how high the facility's roof from the ground in the small uncovered patio was, the maintenance /housekeeping staff stated it was 8 feet. According to the Nursing Assessment and Evaluation, dated 4/9/15, Resident 2 was five feet six inches tall. The moveable wooden picnic table, the vending soda machine, and the concrete wall were observed as potential enablers, which could support the weight of a resident at risk for elopement, in an attempt to elope from the facility grounds through the roof. During the inspection with the maintenance/housekeeping staff, two residents were observed on the small uncovered patio. The residents were wandering freely at the small uncovered patio without staff supervision. According to the maintenance/housekeeping staff, the residents had access to the enclosed outdoor uncovered areas and walkways, and uncovered patio 24 hours a day, 7 days a week. During the inspection with the maintenance/housekeeping staff, from 3:20 p.m. to 3:55 p.m., an unlocked exit door leading to the outside trash area from the facility's building was observed with several trash bins with wheels that can be rolled or moved. The trash area was surrounded by a perimeter fence. The top area of the perimeter fence was caved-in. The roof of the facility's building was located adjacent to the fence. The moveable trash bins were observed as potential hazards and risks in the trash area that could enable a resident at risk for elopement to hang on to the caved-in perimeter fence and climb on the roof in an attempt to elope. During the inspection with the maintenance/housekeeping staff, from 3:20 p.m. to 3:55 p.m., security cameras were observed outside the building at each exit door. The maintenance/housekeeping staff stated only the administrator had access to the monitors of the security cameras. On 4/17/15, at 4:15 p.m., during an interview, RN 1 was asked who had access to the monitors for all the security cameras installed around the facility, she stated, she does not have access to the security cameras and does not know if the security cameras worked. RN 1 stated, ever since she started working at the facility on 2011, she had not seen any monitors for the security cameras or learned anything about how the security camera works. On 4/17/15, at 5:45 p.m., an immediate jeopardy (IJ) was declared and the facility's registered nurse supervisor (RN 1) was notified of the serious findings. At 6:45 p.m., the director of nursing (DON) was notified of the immediate jeopardy situation upon her arrival at the facility. The facility did not have an administrator at the time. The facility submitted a plan of correction (POC) for the IJ removal. On 4/17/15, at 8:15 p.m., the IJ was abated after the DON and director of social services presented their immediate plan of correction (POC). The POC included the installation of additional fence by 4/20/15; the immediate placement of facility staffs at all exit doors to supervise and monitor the residents' movements in and out of the building around the clock; the removal of elopement enablers, such as the picnic table/bench from the enclosed small uncovered patio. The facility also established plans to remove other enablers, such as initiating plans with the vending machine vendor to remove the vending machine located within the enclosed exterior of the building by 4/18/15.

Based on observation, interview, and record review, the facility failed to provide a safe and secure environment and supervision that led to an elopement of one of one sampled resident (Resident 1), who had a history of [REDACTED]. The facility failed to conduct a risk assessment and develop a care plan to address Resident 1's risk for elopement. The facility had no established policy and procedure on elopement, risk assessment and prevention. This failure placed Resident 1, who had no ability to make decisions, was unable to speak and was receiving seizure medications, at risk for serious injury and harm including death. As of this date, 2/4/15, Resident 1 had not been found. Resident 1 was admitted to this locked facility (a health facility providing therapy for substance abuse, mental illness and or other behavioral problems) on 10/2/13, with the [DIAGNOSES REDACTED]. to talk, understand the spoken word and also their reading and writing), and seizure disorder (episodes of disturbed brain activity that cause changes in attention or behavior). On 12/1/14, Resident 1 used a wheelchair as an enabler to climb unto a storage shed in order to jump over a chain-linked fence to the outside of the facility. On 12/3/14, the facility failed to implement immediate corrective actions when Resident 1 eloped from the facility. On 12/3/14 at 6 p.m., the director of nursing (DON) was notified of an Immediate Jeopardy (IJ) situation. The facility developed an immediate action plan in response to the IJ. The facility's immediate action plan included the following: 1. Remove all wheelchairs, trash cans, and other enabling means of egress from exterior areas surrounding chain link fence. 2. Secure two areas of additional fencing around large maintenance shed and around fence area on Station A's patio. 3. Immediately develop and implement absent without official leave (AWOL) policy and assessment tool to identify, in an ongoing manner, residents with potential elopement risks. 4. Ongoing monitoring of perimeter fencing will be performed every 30 minutes by nursing staff and the logs from these inspections will be reported to the quality assurance committee for evaluation. 5. In-services will be given to all staff members regarding the new policy and procedure for AWOL assessment using the new form on order. 6. The perimeter fencing will be inspected by our safety committee for any possible egress during our safety inspections. The results of these inspections will be reported to the quality assurance for monitoring and follow-ups. On 12/4/14 at 2:30 p.m., the IJ was abated with the administrator and DON when the facility implemented the above plan of corrections. Findings: On 12/2/14 at 11 a.m., the DON stated Resident 1 was last seen on 12/1/14 at 5 a.m. in the winter dining room. On 12/2/14 at 6:45 a.m., the staff members were not able to locate Resident 1 for breakfast and then notified the DON. The DON stated they searched the facility and the perimeter and drove around in the community in order to find Resident 1. The DON stated they notified the Police Department and the Department of Public Health. The DON stated the staff found a wheelchair next to the storage sheds and believed that Resident 1 used it as a climbing device to jump over the chain-linked fence to the outside of the facility. On 12/2/14 at 11:30 a.m., during the tour of the facility and the surrounding grounds, there was a large plastic trash can that was not secured in the barbeque patio and could be moved and used as a climbing device. The perimeter was fenced in with a chain link fence approximately eight feet high separating the facility from a freeway however, by the electric pole in Station A patio, a section of the fence was approximately six feet high. By the barbeque patio, next to the side of the building, there were two large storage sheds. According to the DON, that was where they found the wheelchair that they believe Resident 1 used to climb unto the storage shed in order to jump over the chain-linked fence to the outside of the facility. The two storage sheds created a blind spot where a resident could jump the fence and not be seen. The roof of the large storage shed was broken on the corner and the top of the chain link fence was bent on the same side. The DON stated there were surveillance cameras by the sheds but she had not been able to access them for several weeks and they have not developed a system to monitor the activities captured on the cameras. The DON stated they had not developed a system for the staff members to make rounds outside the facility in order to secure the perimeters. On 12/2/14 at 12 p.m., the social service director (SSD) stated Resident 1 was known to have walked away from another facility prior to his admission to the facility. The SSD stated the discharge planner at the hospital wanted Resident 1 admitted to a locked unit. When asked why, she stated Resident 1 was not able to care for himself and needed supervision, and it meant to watch Resident 1 so he would not walk away from the facility. A review of Resident 1's clinical records indicated he was admitted to the locked facility on 10/22/13, with [DIAGNOSES REDACTED]. The Minimum Data Set assessment (provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated 12/21/14, indicated Resident 1 could not speak, sometimes staff could understand him, Resident 1 usually understands, had short-term and long term memory problems, was moderately impaired in daily decision making, needed supervision with ambulation off the unit and required extensive assistance (staff provided weight bearing support) with dressing, hygiene, and bathing. A review of the social work discharge planning notes dated 10/8/13 indicated Resident 1 had a history of [REDACTED]. The re-evaluation of the discharge planning notes dated 1/17/14 indicated Resident 1 required supervision due to his history of walking away from facilities. A review of the care plan dated 10/15/13 indicated Resident 1 needed supervision, oversight, cuing, and assistance with his activities of daily living (ADLs) due to the effects of dementia and history of traumatic brain injury, seizure disorder and aphasia. The short term goal was to assist Resident 1 with ADLs to help maintain a comfortable and safe status. The action/approaches were to provide assistance as needed. There was no documented evidence in Resident 1's clinical records of elopement risk assessments and there was no plan of care developed to address Resident 1's risk for elopement and preventive measures. On 12/2/14 at 12:20 p.m., after a review of Resident 1's clinical records, the DON stated there was no care plan for elopement risk and there were no elopement risk assessments conducted. The DON stated the facility did not have a policy and procedure on elopement, assessment and prevention. On 2/4/15 at 10 am, the SSD stated Resident 1 was never found.