Every finding on record at Laguna Honda Hospital & Rehabilitation CTR D/P SNF

Based on observations, interviews, and record reviews, the facility failed to ensure that pureed foods were prepared in the proper form and consistency for eight sampled residents (Residents 17, 34, 220, 317, 339, 389, 488 and 551) during the lunch meal on July 13 and 14, 2026. This failure has the potential to result in choking and food that is unpalatable and nutrient-deficient to the residents which can compromise their medical and nutrition status.During a review of the lunch menu for 7/13/26, showed for the Puree Full diet the following food items were to be served: Beef Puree with Au Jus Sauce, Beef Puree with LS (low sodium) [NAME] Sauce, Mashed Potato, Peas Puree, Light Peach Puree.During an interview with the Food Service Director (FSD) on 7/13/26 at 11:16 AM, the FSD stated they purchase protein puree items from a vendor, and the facility kitchen staff prepares side food items. The FSD stated there is no launch date for the facility to start using the International Dysphagia Diet Standardization Initiative (IDDSI - is a globally standardized framework used in nutrition and healthcare to describe the thickness of liquids and the texture of modified foods for individuals with difficulty swallowing, a condition called dysphagia).During a lunch meal service observation in the kitchen on 7/13/2026 starting at 11:18 AM, the pureed green peas on the residents' lunch plates were spread all over the plate. The puree peaches in bowls on the trays appeared thin. During a concurrent review of the lunch meal tickets for Residents 317, 339, and 34, showed the diets were for Puree Full with the thin puree food items on the lunch trays.During a kitchen observation and concurrent interview on 7/13/2026 at 2:45PM, Food Service Worker (FSW) 1 was observed boiling green beans for puree. FSW 1 did not drain the water from the kettle before starting to puree. FSW 1 added three (3) 8 ounces jars of powder thickener while pureeing the green beans with a large handheld robot coupe immersion blender. During an interview with FSW 1 at this time, FSW 1 stated he was using 25 pounds of green beans for 130 servings. FSW 1 stated the process of pureeing the green beans. He fills water to cover the green beans in the kettle to boil and used a handheld robot coupe blender to puree the green beans after boiling. FSW1 further stated, he used the same water to cook the green beans to prepare the puree and will add 1 jar (8 ounces) of thickener but eventually added two more jars (total of 3 jars). FSW 1 confirmed he would not strain or drain out any of the water prior to pureeing the food. FSW 1 stated the consistency he was looking for was when there were drops would stop dropping when he picked up a small pan and picked up some puree green beans. Drops were observed to still be dropping from the small pan at this time. During observation and interview on 7/14/2026 at 10:16 AM, Food Service Worker (FSW) 2 was observed making pureed carrots. FSW 2 stated, the pureed carrots are for 145 portions and that 35 pounds of fresh carrots were used. FSW 2 further stated, she boiled it for 30-35 minutes with water just over the carrots and used the same water to blend. If it's too thin, FSW 2 stated thickener is to be added but this time no thickener was added. FSW 2 confirmed there's no need to drain the water after cooking and that all water was used to puree the carrots.During observation and interview on 7/14.2026, 10:27 AM, with Food Service Worker (FSW) 3, FSW 3 just finished pureeing pears and peaches. Multiple hotel pans on the cart were filled with pureed pears and peaches. FSW 3 stated he strained the peaches from the can the day prior because peaches are soft and have lots of juice then blended it until smooth. FSW 3 also stated, he does not have to drain the pears the day prior due to pears are thicker. FSW 3 stated, he is looking for an applesauce consistency, but peaches are thinner because they are soft and for as long as they are blended smoothly, it is okay. FSW 3 stated, he does not add any thickener, just the fruit. The pureed pears in the hotel pans were observed having applesauce consistency but the pureed peaches looked thinner than applesauce. During a review of the lunch menu for 7/14/26, showed the Puree Full diet with the following food items to be served: Carrots Puree, Chicken Puree, Creamy Polenta, Mashed Potato, and Strained Piccata Sauce.During a lunch meal service observation in the kitchen on 7/14/2026 at 11:27 AM, the puree carrots spread all over the residents' lunch plates. During a review of the lunch meal tickets for Residents 389, 551, 488, 220, and 17 showed PUR-FULL that indicated a puree diet. The lunch trays were observed to have the puree carrots on the plates that were spread over the plate.During a review of the facility's Peas Puree 2023 recipe, the Peas Puree 2023 recipe indicated, Production Date: Monday, 7/13/2026. Ingredients of the recipe indicated the following: 24 pounds of frozen green peas, 5 3/4 ounces of instant food thickener, 1 pound + 7 ounces of water, 2 7/8 teaspoon of table salt not iodized bag. The instructions indicated, . 3. Strain peas from all water by placing a colander or perforated hotel pan. Make sure vegetables do not have excess water when planning in [NAME] chopper. 4. Place cooked peas in [NAME] Chopper and puree until smooth in consistency and texture; Not too thick; Not too thin. During a review of the facility's [NAME] Beans Puree 2023 recipe, the [NAME] Beans Puree 2023 indicated Production Date: Monday, 7/13/2026 . Ingredients and Instructions indicated, 24 pounds of frozen green beans, 5 ounces of Instant Food Thickener, Water 2 1/2 quart, Salt Table Not Iodized Bag 2 1/2 Teaspoon. 3. Strain green beans from all water by placing a colander or a perforated hotel pan. Make sure vegetables do not have excess water when placing in a [NAME] chopper. 4. Place cooked green beans in chopper, add Nutri Care and puree until soft in consistency, and texture; not too thick; not too thin. Do not compromise consistency, color or texture.During a review of the facility's Carrots Puree 2023 recipe, the Carrots Puree 2023 recipe indicated, Production Date: Tuesday, 7/14/2026. Ingredients of the recipe indicated the following: 31 pounds of diced carrots 1/2 inch, 7 3/4 ounces of instant food thickener, 31 gallons of water and 1 1/3 tablespoons of table salt, not iodized. The instructions indicated, . 2. In a cooking vessel, add potable water and bring to a boil (212 degrees F-CP). Add carrots to boiling water and cook for 6-8 minutes or bright in color (165 degrees F - CCP). Please assure not to overcook carrots. 3. Strain carrots from all water by placing a colander or perforated hotel pan. Make sure vegetables do not have excess water when placing in [NAME] chopper. 4. Place cooked carrots in [NAME] chopper, add Nutri Care, and puree until soft in consistency and texture; not too thick; not too thin. Do not over puree to compromise consistency, color, or texture.During an interview on 7/15/2026 at 2:25 PM with the facility's Chief Dietitian, the Chief Dietitian stated, not my expectation when showed with pictures of the pureed green peas, pureed carrots, and pureed peaches that were taken on 7/13/2026 and 7/14/2026 during the lunch meal service observation. The Chief Dietitian confirmed the foods looked too thin and were spread on the plate and further stated she was not aware they were not straining foods and used all the water from cooking foods. The Chief Dietitian stated she would not want the kitchen staff to serve foods when they are not the appropriate consistency. The Chief Dietitian further stated, they've been implementing the International Dysphagia Diet Standardization Initiative, IDDSI. The Chief Dietitian stated the cooks do not understand what they should be doing and the foods are not passing the IDDSI standards and she would expect them to use the fork and spoon tests to determine if they are the appropriate consistency but they have been working more on a minced and moist diet than puree. During a review of the facility's document titled, Clinical Nutrition Department Diet Manual, (undated), page 9 indicated, the facility's modified diets are modeled after the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines. The Clinical Nutrition Department Diet Manual also indicated the facility's Full Puree food in the same level as IDDSI Diets Puree (Level 4).Review of the facility's Policy and Procedure (P&P) titled Food Production Performance Expectations, 1.97, effective date 11/15, indicated, Purpose: To establish appropriate standards of performance for all food production areas so that each production employee knows his/her role in producing high quality, consistent products. Procedure: All recipes will be followed exactly, and any excess ingredients will be returned to the appropriate storage areas. 2. All ingredients for each recipe will be weighed and measured exactly as specified on the recipe.All cooks must taste and test temperature of their products before it is sent to the tray service area.Review of the facility's P&P titled, Standardized Recipes, 1.92, effective date 08/14, indicated, Purpose: To maintain the consistency and quality of food products. To provide guidelines of how a food product should be prepared. Procedure: 3. Each cook is responsible for using the appropriate recipe. The cook must follow the recipe completely and use proper weights in recipes to ensure that the desired results will be achieved.Review of the Complete IDDSI Framework Detailed Definitions 2.2, dated 2026, indicated, Level 4 Pureed and 4 Extremely Thick descriptions/characteristics as Usually eaten with a spoon (a fork is possible) Cannot be drunk from a cup because it does not flow easily Cannot be sucked through a straw Does not require chewing Can be piped, layered or molded because it retains its shape, but should not require chewing if presented in this form Shows some very slow movement under gravity but cannot be poured Falls off spoon in a single spoonful when tilted and continues to hold shape on a plate No lumps Not sticky Liquid must not separate from solid. It also indicated how to test pureed food by doing the Fork Drip Test and Spoon Tilt Test. The Fork Drip Test is done When a fork is pressed on the surface of Level 4 Extremely Thick Liquid/Pureed food, the tines/prongs of a fork can make a clear pattern on the surface, and/or the food retains the indentation from the fork. Sample sits in a mound/pile above the fork; a small amount may flow through and form a short tail below the fork tines/prongs, but it does not flow or drip continuously through the prongs of a fork. In the Spoon Tilt Test, a full spoonful must plop off the spoon if the spoon is titled or turned sideways; a very gentle flick (using only fingers and wrist) may be necessary to dislodge the sample from the spoon, but the sample should slide off easily with very little food left on the spoon. A thin film remaining on the spoon after the Spoon Tilt Test is acceptable, however, you should still be able to see the spoon through the thin film. the sample should not be firm and sticky May spread out slightly or slump very slowly on a flat plate.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed in accordance with professional standards and facility policy when:1. Hand hygiene was not performed during medication pass for one of three nurses observed (Licensed Vocational Nurse (LVN 2)). Hand hygiene is the process of cleaning hands to physically remove or chemically inactivate pathogens (germs). It is achieved by handwashing, using an alcohol-based hand rub or surgical hand antisepsis to break the chain of infection from bacteria, viruses, and fungi that cause illness. 2. A multi dose bottle of testing strips, used for multiple residents for blood sugar testing, was brought into a resident's room during medication pass for one of three nurses observed (LVN 2).3. [NAME] 1 did not wear the required personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when cleaning the room of Resident 6 and Resident 277, who were on enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs-a bacteria or germ that has developed resistance to multiple classes of antibiotics) in nursing homes). These failures may result in cross contamination of infection that may jeopardize the health and safety of the residents and staff.Findings: 1. On 7/14/26 at 9:01 a.m., LVN 2 was observed preparing morning medications for Resident 214 on the 6th Floor South Tower Unit. The preparation included nine oral tablets, one liquid medication, and one eye drop medication. At 9:08 a.m., LVN 2 sanitized his hands and donned gloves. In Resident 214's room, LVN 2 then scanned the medications, opened their packaging, placed the oral tablets into a medicine cup, and poured the liquid medication into a separate medicine cup. During the same observation, at 9:17 a.m., LVN 2 adjusted Resident 214's bed and administered the oral medications without performing hand hygiene. LVN 2 then repositioned the resident's bed again without performing hand hygiene and administered the eye drop medication to Resident 214's right eye, again without performing hand hygiene. During an interview on 7/14/26 at 9:28 a.m. outside Resident 214's room, LVN 2 confirmed he operated the bed controls and administered the oral and eye medications without performing hand hygiene. LVN 2 acknowledged the infection risk to the resident associated with not performing hand hygiene between tasks. During an interview on 7/16/26 at 8:08 a.m. with the Infection Prevention and Control Director (IPD), the IPD stated the expectation is for staff to follow the five moments of hand hygiene, which include: before contact with a resident, after contact with a resident, before clean procedures, and after touching the environment. She acknowledged that not performing hand hygiene between touching the environment and administering oral and eye medications is not acceptable practice and places the resident at risk for transmission of infection. During a review of the facility's policy and procedure titled, Hand Hygiene, dated March 2025, indicated, All healthcare workers will follow appropriate hand hygiene guidelines as established by the World Health Organization (WHO) [global health agency, provides guidance to prevent diseases] and further indicated: 1. The facility follows the WHO 5 moments of Hand Hygiene which focus on the concept of hand hygiene before, after or during interaction with the patient/resident zone (room, by or pod) and health-care zone (areas external to patient/resident's zone) During a review of the World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care, published May 2009, Your 5 Moments for Hand Hygiene indicated: Moment 1 – Before Touching a Patient When: .before touching a patient when approaching him/her Why: To protect the patient against harmful germs carried on your hands. Moment 2 – Before a Clean/Aseptic Procedure When: .immediately before performing a clean or aseptic procedure Why: To protect the patient against harmful germs, including the patient's own from entering his/her body. Moment 3 – After Body Fluid Exposure Risk When: . immediately after an exposure risk to body fluids (and after glove removal) Why: To protect yourself and the health care environment from harmful patient germs. Moment 4 – After Touching a Patient When: .after touching a patient and her/his immediate surroundings, when leaving the patient's side. Why: To protect yourself and the health care environment from harmful patient germs. Moment 5 – After Touching Patient Surroundings When: .after touching any object or furniture in the patient's immediate surroundings. even if the patient was not touched. Why: To protect yourself and the health care environment from harmful patient germs. 2. On 7/14/26 at 9:01 a.m., during a medication pass observation, LVN 2 was observed testing Resident 214's blood sugar level using a glucometer (a small portable device that analyzes blood sugar; a small amount of blood is placed on a test strip that is then read by the glucometer). LVN 2 brought a multi dose bottle of glucose test strips, used for multiple residents, into Resident 214's room and placed it on the resident's nightstand. At approximately 9:08 a.m., LVN 2 was observed cleaning the glucometer and placing it in its storage box; however, the test strip container was not cleaned. During an interview on 7/14/26 at 9:28 a.m. outside Resident 214's room, LVN 2 confirmed he placed the multi dose bottle of glucose test strips on the resident's bedside and acknowledged the infection risk, stating the container should remain in the glucometer storage box. During an interview with the IPD on 7/16/26 at 8:14 a.m., the IPD stated nurses should not bring the whole bottle of glucose test strips into a resident's room because the bottle is used for multiple residents. She acknowledged the risk of infection transmission since the bottle had been placed in the resident's room. During a review of the American Journal of Infection Control, titled, Safe injection, Infusion, Medication Vial and Point-of-Care Testing Practices in Healthcare volume 53, Issue 9, dated September 2025, indicated, Don't' store multidose vials in the patient care environment (for example (eg) at bedside.) 3. During an observation on 07/13/26 at 11:18 AM, a sign posted on the door of Resident 6 and Resident 277's shared room indicated both residents were on Enhanced Barrier Precautions (EBP). The sign indicated, Anyone participating in any of the 6 Moments must also don gown and gloves . cleaning & disinfecting the environment. During an observation on 7/13/26 at 11:20 AM, [NAME] 1 was observed mopping the floor inside Resident 6 and Resident 277's room without wearing a gown and gloves, despite the posted EBP requirements. During an interview on 7/13/26 at 11:23 AM, [NAME] 1 was asked regarding the posted EBP sign on Resident 6 and Resident 277's door. [NAME] 1 reviewed the sign and stated, Oh, I'm sorry. My mistake. I forgot. I should wear the gown and gloves. Review of Resident 6's active orders for July 2026 indicated, Patient Isolation Status – Resident with the following indwelling device: G-Tube, Tracheostomy tube. Resident should be placed in Enhanced Barrier Precautions (EBP) while indwelling device is present. Review of Resident 277's active orders for July 2026 indicated, Patient Isolation Status – Resident with the following: Sacral, Multiple leg wounds. Resident should be placed in Enhanced Barrier Precautions (EBP) while wound is present and excretions are able to be contained and/or covered. Review of the facility's policy and procedure titled, Transmission-Based Precautions and Patient/Resident Room Placement, 72-01 B5, revised 01/2026, indicated, . Procedure . 7. ENHANCED Barrier Precautions (EBP) are for Long Term Care residents with wounds, indwelling medical devices, and/or infected or colonized with a SFDPH-targeted MDRO where contact precautions do not otherwise apply. EBP should be used during specific high-contact resident care activities commonly associated with MDRO transmission . b. Wear gowns and gloves while performing high-risk tasks: . iv. Cleaning and disinfecting the environment.

Based on observation, interview, and record review, the facility failed to ensure tube feeding (enteral nutrition - delivers liquid formula directly to the stomach or small intestine) was administered in accordance with the physician's orders for one (1) of 5 sampled residents (Resident 21) when a licensed nurse adjusted the tube-feeding rate without verifying the current physician's order.This failure resulted in Resident 21 receiving an incorrect tube feeding rate and had the potential to result in inadequate nutrition and underfeeding complications to Resident 21 and other tube-fed residents.Review of Resident 21's admission record indicated, was readmitted to the facility on [DATE] with diagnoses including major neurocognitive disorder (decreased mental function and loss of ability to do daily tasks), gastrostomy status (refers to having a surgically created opening for a feeding tube), dysphagia (difficulty swallowing), and Huntington's disease (an inherited disorder that causes nerve cells in the brain to gradually break down and die).During an observation on 7/13/26 at 12:06 PM, in resident's room, a female nurse who identified herself as the rounding nurse, was observed at the bedside inspecting Resident 21's feeding pump, which was set at 50 milliliters per hour (ml/hr), before leaving the room. Subsequently, Licensed Vocational Nurse (LVN) 1 entered the room and manually adjusted the tube-feeding rate to 46 ml/hr.During a concurrent observation and interview on 7/13/26 at 12:09 PM, in Resident 21's room, the tube feeding pump displayed 46 ml/hr with 241 ml infused as of 12:09 PM. LVN 1 checked the sticker label on the feeding bottle and stated the rate should be 46 ml/hr and that the feeding began at 7:00 AM.Review of the sticker label on the tube feeding bottle indicated:Vital 1.2 Cal RTH (Ready-To-Hang - a specialized, peptide-based medical nutrition formula providing 1.2 calories per milliliter for patients who require tube feeding)Rate: 46 ml/hrRun time: 22 hours/dayRun from 7:00 AM to 5:00 AMExpiration: 07/14/2026 at 7:00 AMDuring a concurrent interview and record review on 7/15/26 at 10:05 AM, Registered Nurse (RN) 1 reviewed Resident 21's current physician orders. The physician's orders indicated the current tube feeding order was Vital 1.2 Cal RTH at 50 ml/hr for 20 hours, hold from 5:00 AM to 7:00 AM. RN 1 confirmed and stated that the rate had been increased from 46 ml/hr to 50 ml/hr on 7/6/26.During an interview on 7/15/26 at 10:12 AM, Director of Nursing (DON) 1 stated that a rounding nurse had checked the resident's tube feeding and verified the rate was correctly set at 50 ml/hr per current orders. DON 1 stated that LVN 1 lowered the rate back to 46 ml/hr because the bottle label reflected a previous tube feeding order. DON 1 further stated that LVN 1 did not verify the current physician's order before adjusting the tube feeding rate.Review of the facility's policy and procedure titled, Enteral Tube Feeding Management, E 5.0, revised 04/2025, indicated, Policy. 4. The Licensed Nurse (LN) checks the feeding pump at the beginning of the shift to verify that the pump is functional and programmed per the order . Procedures . C. Administration of Formula Feeding . 2. Enteral Tube and Site Care . n. Notify the Nutrition Services diet office for any new enteral diet orders or changes in formula or calories.

Based on observation, interview, and record review, the facility failed to administer medications in accordance with professional standards of practice and facility policy when personal protective equipment (PPE) was not donned during the administration of a hazardous medication for one of four sampled residents observed during medication pass (Resident 214), and when eye drop medication was not administered correctly during medication pass observation for one of four sampled residents (Resident 214).These failures had the potential to result in staff exposure to a hazardous medication and for Resident 214 to receive an ineffective or sub therapeutic dose of eye medication.Findings:A review of the resident's clinical record on 7/14/26 indicated the following active physician medication orders: Valproic Acid (medication to slow, calm electrical activity in the brain) 250 mg (milligrams, unit of strength) per 5 mL (milliliters, unit of volume) oral solution. Ordered dose: 500 mg (10 mL), to be administered three times daily for seizure disorder (uncontrolled electrical activity in the brain, causing changes in consciousness, body shaking, and muscle stiffening). Order start date, after last modification: 11/23/25.Administration Instructions: Hazardous. Wear two pairs of gloves, gown, and eye protection. Dispose of properly. Dorzolamide timolol (combination ophthalmic (eye) solution to reduce elevated pressure inside the eye (intraocular pressure)) administer one drop to the right eye twice a day for glaucoma (eye disease caused by too much pressure in the eye). Order start date, after last modification: 6/15/26.LVN 2 was observed not pressing the inner corner of Resident 214's right eye after administering the eye drop.During a medication pass observation on 7/14/26 at 9:01 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 was observed preparing Resident 214's morning medications in the resident's room, which included two unit dose cups of valproic acid oral solution (5 mL each) and the resident's dorzolamide timolol eye drop medication. At 9:12 a.m., LVN 2 was observed opening one cup of the valproic acid solution and pouring the red liquid into a medicine cup and then repeating the process with the second cup. LVN 2 was wearing gloves during medication preparation but was observed not wearing any other PPE. At approximately 9:17 a.m., LVN 2 administered the oral medication by bringing the medicine cup to Resident 214's mouth.Following the administration of the oral medications, LVN 2 was observed administering one drop of the dorzolamide timolol ophthalmic medication to Resident 214's right eye. LVN 2 was observed not pressing the inner corner of Resident 214's right eye after administering the eye drop.During an interview on 7/14/26 at 9:28 a.m. with LVN 2 outside the resident's room, LVN 2 confirmed he did not hold the inner corner of Resident 214's eye after administering the eye medication. LVN 2 acknowledged that not performing this step could result in less medication remaining in the eye.During a follow up interview and clinical record review on 7/14/26 at 12:52 p.m., LVN 2 stated that when administering valproic acid, gloves need to be worn because it is a toxic medication. LVN 2 reviewed the resident's valproic acid order within the electronic health record, which indicated, Hazardous. Wear two pairs of gloves, gown and eye protection. LVN 2 acknowledged he did not wear a gown or eye protection when preparing and administering the medication. During an interview on 7/15/26 at 1:16 p.m. with the Director of Pharmacy (DOP), the DOP stated nurses are expected, after administering eye drops, to hold the inner corner of the eye. He stated this process ensures the medication remains in the eye, reaches the intended area, and does not drain out or cause systemic effects.During an interview and record review on 7/15/26 at approximately 1:30 p.m. in the pharmacy department with the Director of Pharmacy (DOP), Pharmacy Supervisor (PS 1), and Pharmacist (PH 3), PH 3 reviewed the valproic acid liquid administration requirements in the electronic health record, which stated, Hazardous. Wear two pairs of gloves, gown and eye protection. The DOP stated that the facility maintains a hazardous medication list, and that required PPE and handling instructions automatically populate the Medication Administration Record (MAR) to guide nurses in using the appropriate PPE. The DOP stated valproic acid liquid requires double gloving, a gown, and eye protection because the medication could spill during preparation or administration, and PPE reduces the nurse's risk of exposure.During a review of the facility's policy and procedure titled, Medication Administration, dated, May 2025, indicated, Administration of Eye Medications 1. Eye Drops .e. Apply pressure to the nasolacrimal duct [known as the tear duct, inner corner of the eye] after each prescription medication after 30 seconds to prevent possible systemic effects.

Based on interviews and record review, the facility failed to transmit Resident 569's assessment to Center for Medicare and Medicate Services (CMS) within 14 days of the final completion date. This delay in submission resulted in noncompliance with regulatory standards for timely reporting, potentially impacting on the accuracy and availability of resident information.During a concurrent interview on [DATE] at 3:05 PM with Director of Regulatory Affairs (DRA), and a review of a facility document titled Minimum Data Set (MDS) Assessment, MDS Overview, Death in Facility Tracking Record in their electronic health record data system, dated [DATE], the MDS Assessment indicated that the assessment for Resident 569 was completed on [DATE]. Moreover, the MDS Assessment showed a submission status of In Progress. DRA stated, the resident died on [DATE] and the MDS assessment is marked as In Progress means it was not transmitted.During an interview on [DATE] at 10:28 AM, with MDS Coordinator, MDSC stated, Although the assessment was completed on time, the submission status was not updated from In Progress to Ready for Export. Because the resident was deceased , the chart was closed and the alert for submission was not acknowledged. The system is designed to alert staff when an assessment is due for submission. However, the MDS assessment for Resident 569 was not transmitted as required, the MDSC confirmed the submission only occurred on [DATE].

Based on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents (Resident 281) was treated with dignity and respect when the Social Worker entered the resident's room without knocking or introducing themself. The Social Worker abruptly tossed the resident's mail onto the overbed table, without engaging the resident or acknowledging them in a respectful manner.As a result, Resident 281 felt upset and disrespected; this failure also had the potential to affect the psychosocial well-being (including mental, emotional, social, and spiritual effects) of other residents.Review of Resident 281's admission record indicated, was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), rheumatoid arthritis (an ongoing autoimmune disease that causes pain, swelling and stiffness in the lining of your joints), chronic obstructive pulmonary disease (COPD is an ongoing lung condition caused by damage to the lungs), and osteoarthritis of bilateral hips (pain and stiffness in your hip joint, related to the soft tissues in the joint).Review of Resident 281's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/5/26 that Resident 281 has no cognitive impairment. The MDS assessment also indicated that mood and behavioral symptoms were not exhibited.During a concurrent observation and interview on 7/13/26 at 11:31 AM, in Resident 281's room, a female staff entered the resident's room without knocking or introducing herself. Then, the female staff simply said here and abruptly tossed the white envelope onto the overbed table without interacting or acknowledging the Resident 281. During a concurrent interview, the female staff identified herself as Social Worker (SW) 1 assigned in the unit. SW 1 stated she was just delivering the resident's mail and left the room.During an interview on 7/13/26 at 11:33 AM, Resident 281 stated she did not even know the female staff was SW 1. Resident 281 stated, that's a social worker with no social skills. Furthermore, Resident 281 verbalized feeling upset and disrespected.During an interview on 7/15/26 at 11:58 AM, Director of Nursing (DON) 1 stated that any staff should treat residents with respect and dignity.Review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, 24-02, revised 10/2023, indicated, .Procedure: 1. All LHH staff members who are involved in providing care to residents shall promote and maintain resident dignity and respect resident rights .

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 508) was free from unnecessary medications when nursing staff administered oxycodone (a strong controlled medication, used for moderate to severe pain, associated with high abuse and addiction potential) on four occasions in July 2026 without adequate clinical indications. This occurred when duplicate, overlapping as needed (PRN) oxycodone orders for pain were active, allowing staff to administer opioid doses not supported by the physician's parameters.This failure resulted in Resident 508 receiving opioid medication inconsistent with physician orders and the facility's policies, increasing the potential risk for unnecessary medication administration, dosing errors, and adverse drug effects such as over sedation and respiratory depression.Findings:Record review indicated Resident 508 was admitted on [DATE] with chronic pain, primary osteoarthritis of both knees and hips (joint stiffness and pain), type 2 diabetes with neurological complications (uncontrolled blood sugar with nerve damage from high blood sugar), chronic obstructive pulmonary disease (difficulty breathing, cough, wheezing), and moderate persistent asthma with acute exacerbations daily airway inflammation with episodic worsening).A review of physician orders indicated the following active PRN opioid orders from July 1, 2016, through July 17, 2026: Oxycodone, immediate release (IR) 10 mg, one tablet every 4 hours PRN for severe pain ([numeric pain scale] score 7-10, started 7/1/26. Oxycodone IR 15 mg, one tablet every 4 hours PRN for breakthrough pain, [sudden flare up of pain when taking regular, long acting pain medicine], started 7/8/26.The Numeric Pain Rating Scale (NRS), which directs PRN opioid administration, is a standardized tool in which the resident reports a pain level from 0 to 10. A score of 0 indicates no pain; 1-3 indicates mild pain; 4-6 indicates moderate pain; and 7-10 indicates severe pain, with 10 being the worst pain possible.During a concurrent interview and clinical record review on 7/17/26 at 9:39 a.m., Registered Nurse (RN 2) stated Resident 508 could verbalize her pain score and the location of her pain. RN 2 confirmed the resident had two PRN oxycodone orders and stated she would administer the 10 mg dose first, then the 15 mg dose if the 10 mg was ineffective. She further acknowledged that the 15 mg oxycodone could be given for any pain score as the breakthrough pain order did not include a defined pain scale.Further record review during the same interview with RN 2 indicated Resident 508 received 15 mg oxycodone at 5:43 a.m. on 7/17/26 for a pain score of 7 for breakthrough pain, although the previous 10 mg dose had been administered on 7/16/26 at 12:55 p.m. (over 16 hours prior). RN 2 stated she was not sure why staff administered the 15 mg dose first.During an interview with Nurse Manager (NM 1) on 7/17/26 at 9:56 a.m. in the 3 South charting room, NM 1 reviewed Resident 508's July MAR, medication orders, and pain documentation. She stated PRN pain medication orders should include a pain severity scale to guide when the medication is to be administered. NM 1 confirmed the severe pain PRN order (10 mg dose) included a defined pain scale, while the breakthrough pain order (15 mg dose) did not, making the order unclear. NM 1 stated staff offer the resident the 10 mg or 15 mg dose, and the resident tells staff which one she wants, and acknowledged this practice was not consistent with physician orders.During the concurrent interview and record review, NM 1 confirmed Resident 508 received the following PRN oxycodone doses with the associated documented pain scores: On 7/11/26 at 5:36 a.m., 10 mg was administered for a pain score of 4, although the severe pain order required a pain score of 7-10. On 7/14/26 at 6:58 a.m., 15 mg was administered for a pain score of 4 under the breakthrough pain order. The previous 10 mg dose had been given more than 17 hours earlier, indicating use without adequate indications. On 7/14/26 at 10:43 p.m., 15 mg was administered for a pain score of 7 under the breakthrough pain order. The previous 10 mg dose had been given more than 11 hours earlier, again indicating use without adequate indications. On 7/17/26 at 5:43 a.m., 15 mg was administered for a pain score of 7 under the breakthrough pain order. The previous 10 mg dose had been given more than 16 hours earlier, indicating use without adequate indications. NM 1 acknowledged nursing staff did not clarify the duplicative and unclear oxycodone PRN orders before administering these opioid doses. As a result, three doses of oxycodone 15 mg were given under the breakthrough pain order-two for pain scores of 4 and one for a pain score of 7 (when the 10 mg severe pain dose should have been given)-and one dose of oxycodone 10 mg was given for a pain score of 4, despite the severe pain order requiring a pain score of 7-10.On 7/17/26 at 11:26 a.m., during an interview and concurrent record review with the Director of Pharmacy (DOP) and Pharmacist (PH 1), PH 1 stated breakthrough pain medications are used in combination with long acting pain medications and require criteria for administration. PH 1 acknowledged Resident 508 had two PRN oxycodone orders, but only one included a defined pain scale, which left nurses to interpret when the breakthrough dose should be given. PH 1 confirmed both PRN oxycodone orders were active from 7/8/26 through 7/17/26.The DOP and PH 1 confirmed Resident 508 received 15 mg oxycodone on 7/14/26 for a documented pain score of 4 under the breakthrough pain PRN order. They acknowledged the lack of administration criteria for the breakthrough pain dose created the potential for opioid stacking increasing the risk of adverse medication effectsDuring a review of the facility's policy and procedure titled, Pain Recognition, Assessment, and Management, dated, December 2022, indicated, the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice. and the facility will use a pain assessment tool which is appropriate for the residents. cognitive status to assist staff in consistent assessment. of the residents pain. The policy further indicated, the LN [licensed nurse will assess the resident/patient for. pain. And administer pharmacologic treatment per physician order.During a review of the facility's policy and procedure titled, Safe Medication Orders, dated January 2023, indicated, To ensure resident safety by reducing the potential for error or misinterpretation when orders are communicated. Medications are administered only upon the clear, complete and signed order. The policy further indicated, orders that are incomplete or unclear shall not be transcribed or processed by nursing or pharmacy. The prescribing practitioner shall be contacted for clarification. Multiple PRN medications written for the same indication: The parameters for use of each medication must be clearly written to specify when it shall be used.

Based on observation, interview, and record review, the facility failed to ensure that one out of two sampled residents (Resident 1) had a safe and clean environment. This deficient practice resulted in placing Resident 1 at risk for accidents and unsafe conditions.During a review of MD Assessment for Resident 1, dated 02/27/2026, the MD Assessment indicated Resident 1 has the following active diagnoses that requires a clean, safe and hazard-free environment that is calm and predictable for Resident 1: blindness, schizoaffective disorder, bipolar type, and human immunodeficiency virus (HIV) infection.During an observation conducted on 04/22/2026 at 2:47 PM, Resident 1's room was found to be cluttered with excessive items stored on surfaces, furniture, and the floor.The bedside table to the left of Resident 1's bed was completely covered with numerous items, including but not limited to two dented cans of pineapple juice, multiple spray bottles, seven bottles of lotion, clothing items, plastic food containers, mouthwash, used paper and medication cups, an opened shipping package, a large bottle of mouthwash, and several other unidentified items.A large open clear trash bag was observed on the floor in front of the table. The bag contained various items that were spilling onto the floor, including non skid socks, a bottle of moisturizer cream, clothing, a box of fruit snacks, used tissue paper, and other unidentified items. Next to the bag, an oatmeal cracker package was observed on the floor.A bookshelf with two bottom drawers located to the right of the resident's bed was cluttered, with a large stack of facility linens, multiple open brown paper bags, two lotion bottles, two open plastic bags, a box of large gloves, and other items spilling from the shelves and drawers. In front of the drawers was a large box with a stack of facility linens and an open shipping package placed on top.A chair next to the box was covered with a urinal, unfolded sheets, a blue tarp, and a clear plastic bag filled with items. Beneath the chair was an orange mesh bag containing items. To the right of the chair were an empty gray mesh bag, empty soda cans, used purple gloves, a clear plastic bag with items, non skid socks, a blue tarp covering a stack of items, and clothing placed on top.This failure resulted in an environment that did not promote cleanliness, orderliness, or infection control for Resident 1 and has the potential to affect the health, safety, and well being of the resident.During an interview conducted on 04/22/2026 at 2:48 PM with Patient Care Assistant (PCA 1), PCA 1 stated that Resident 1's room has consistently appeared cluttered and acknowledged that the condition of the room is a problem, despite ongoing efforts by the infection control team and the facility management to address the issue. PCA 1 reported that the clutter in Resident 1's room has worsened since PCA 1 began working on the unit in August 2025. PCA 1 further stated having observed occasional fruit flies in Resident 1's room as a result of the room's condition. PCA 1 also reported that other residents on the unit have commented that Resident 1's room appears messy.During an interview on 04/22/2026 at 3:01 PM with the Nurse Manager (NM) for Resident 1's unit, the NM stated that Resident 1 frequently declines room cleanings and that the current condition of the room is, in the NM's opinion, improved compared to how it had been previously. The NM stated it has been a significant challenge to manage the clutter in Resident 1's room, reporting that Resident 1 deliberately creates a mess after staff cleans the room. The NM stated the facility has made repeated efforts to clean and organize Resident 1's room; however, Resident 1 becomes very upset when staff intervene. During an interview on 04/23/2026 at 10:30 AM with Certified Nursing Assistant (CNA 1), CNA 1 stated that approximately two to three years ago Resident 1 began refusing to allow staff to clean Resident 1's room, and that the condition of the room had progressively worsened since that time. CNA 1 reported that the Environmental Services (EVS) team attempted to clean Resident 1's room prior to the time this interview took place. CNA 1 stated that Resident 1 previously had a specific EVS staff member assigned, and that staff must request permission from Resident 1 before cleaning the room. During an interview conducted on 04/23/2026 at 11:11 AM with the Environmental Services Director (EVSD) and the Environmental Services Supervisor (EVSS), the EVSD stated that the facility has experienced longstanding environmental concerns in Resident 1's room since approximately 2024. The EVSS reported that prior to 2025, Resident 1 would throw feces in the room, and that the current issue primarily involves hoarding behaviors. The EVSD stated that Resident 1 began refusing to allow staff to clean the room approximately two to three years ago. The EVSD explained that Environmental Services (EVS) began maintaining a log in 2024 to document Resident 1's refusals of room cleaning, but this documentation was discontinued in May 2025 because Resident 1 appeared more willing to allow cleaning. The EVSS stated they believe Resident 1 is improving rather than worsening. The EVSS stated that Resident 1 selects specific EVS staff members to clean the room and at times continues to refuse staff entry; however, in the past Resident 1 would yell and scream at porters, and this behavior has decreased. EVSS stated that Resident 1 has become more receptive to having the room cleaned. The EVSD stated that in 2024, the EVS team participated in Interdisciplinary Team (IDT) meetings together with nursing, social work, and the medical team to address the clutter in Resident 1's room; however, such meetings have not continued. The EVSD reported that interventions were attempted, including gradually removing items and incentivizing Resident 1 with laundry pods to promote a cleaner environment.During a review of the Resident Care Team Meeting Note for Resident 1, dated 10/01/2024, the Resident Care Team Meeting Note indicated Resident sometimes allows EVS to clean Resident 1's room. The Resident Care Team Meeting Note also indicated that Resident 1 declines to have the room cleaned and states that Resident 1 will clean the room themself. The Care Plan further indicated that Resident 1 continues to postpone room cleaning by telling staff to come back later.During a review of EVS Daily Resident Room Cleaning Issue Log for Resident 1, dated 12/06/2024 to 03/04/2025, the EVS Daily Resident Room Cleaning Issue Log indicated the dates that Resident 1 refused room cleaning, the staff name and their initials. Between the dates of 12/06/2024 and 03/04/2025, Resident 1 refused room cleaning for 58 days. During a review of Cleaning Log for Resident 1's room, dated 12/01/2024 to 05/31/2025, the Cleaning Log for Resident 1's room indicated three columns that included a column for the date, a column for noting Cleaned by, and a third column noting a check box for Denied Access. The Denied Access column was not checked off 57 times between 12/01/2024 and 05/31/2025, which meant Resident 1 allowed EVS staff to clean Resident 1's room.During a review of the Nursing Weekly Summary for Resident 1 dated 04/17/2026, the Nursing Weekly Summary notes that Resident 1 has a history of refusal and rejection of care. The Nursing Weekly Summary also indicated that Resident 1 declines to have the room cleaned, states they will clean the room themself, and repeatedly postpones room cleaning by telling staff to come back later. The Nursing Weekly Summary further notes the unsanitary room and environmental conditions, including litter throughout the bed and floor such as empty juice cans and plastic cups, empty nutrition shake bottles, gloves, tissue, dried hand wipes, plastic bags, absorbent under pads, adult briefs and pull ups, straws, plastic and metal utensils, blue cups, empty mouthwash or lotion bottles, shampoo containers, food and candy wrappers, used blankets, linens, towels, pillows, and dirty clothing. The summary also noted that Resident 1 does not allow staff to enter the room to assess the room's condition.Based on a review of the facility's policy titled EVS Standard Cleaning Procedure (dated April 2025), the procedure establishes that daily cleaning tasks are required in all resident, staff, and public areas of the facility. These tasks include:Trash removal and restocking of suppliesHigh dusting of items above shoulder levelCleaning and disinfecting high and low touch surfacesFloor cleaning (sweeping, mopping, vacuuming, and carpet/floor care as needed)A second round to ensure trash removal, supply restocking, and spot cleaningHowever, observation of Resident 1's room revealed clutter that prevented staff from performing required environmental cleaning tasks, including:Removing trash as required by the facility's procedureAccessing surfaces necessary to perform high dustingCleaning and disinfecting high and low touch surfacesAccessing the floor area for required floor cleaningCompleting the second round ( policing) of the room as outlined in the procedure

Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from physical abuse by a resident for one of three sampled residents (Resident 11) when Resident 12 struck Resident 11 on the left side of her face. This failure resulted in Resident 11 sustaining a left Zygomatic Arch (cheek bone area) fracture , Left Orbital (bone area around eye) wall fracture, and contusion (swelling) on the left side of her face. Findings: A record review of Resident 11's History and Physical (H & P, an assessment completed by a medical provider) dated 5/7/25 indicated, Resident 11 was admitted with multiple diagnoses including Vascular dementia (A usually progressive condition marked by the development of multiple cognitive deficits with abrupt or gradual onset that is caused by cerebrovascular disease), Dementia related behaviors, Cerebrovascular Accident (Stroke) in 2016, history of Panic Attacks (a sudden feeling or episode of panic), history of Possible Anxiety Disorder (any of various disorders in which anxiety is a predominant feature).During a concurrent observation and interview on 7/22/25 at 3:40 PM, in Resident 11's room, Resident 11 was observed lying in bed yelling loudly Who are you?! I don't want to be here! I don't want to be here! while attempting to climb out of her bed. COACH 1 (a person assigned to a resident for close supervision) was sitting at bedside and reassured Resident 11 she was in her room and it was time to rest. COACH 1 reported throughout the day, she assists Resident 11 with eating, dressing, incontinence (inability of the body to control the evacuative functions of urination or defecation) care, and preventing falls. At 3:46 PM, the Activity Therapist (ACT1) entered the room and introduced himself to Resident 11. Resident 11 yelled loudly Who are you? I'm scared! while holding on to his hand. ACT1 reassured resident she was safe and asked if she was in pain. Resident 11 stated, Yes! I hurt! My back, my leg, my face!. A review of the Resident 11's Minimum Data Set (MDS, a standard assessment tool) dated 5/20/25, indicated a Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function [includes thinking, learning, and decision making ability] score of 4 out of 15 (scores of 0-7 suggests severe cognitive impairment). A further review of Resident 11's MDS indicates Resident 11 has verbal behavioral symptoms not directed towards others that include rummaging, verbal/vocal symptoms like screaming, and disruptive sounds that occurred 1 to 3 days of the week. During a concurrent interview and record review on 7/24/25 at 2:09 PM with the Social Worker (MSW1), LHH MSW Resident Encounter Note dated 6/18/25 was reviewed. The resident encounter note indicated Resident 12 was transferred from a secured psych unit (this unit serves a psych population that requires. locked, psychiatric emergency, violent, self-harm, harm to others) from [Hospital A] with past behavioral history that included assault, wandering (a going about from place to place), suicidal ideation (the act of considering or planning suicide), and homicidal ideation (of, relating to, or tending toward homicide. Resident 12 always required a COACH at bedside and two personnel for direct care, due to assault risk at [Hospital A] and his history of violence (aggressive, assault, and combative), requiring wrist and vest restraints (a device that restricts movement) due to assault risk and history of endangerment or harm to others. Resident 12's former case manager reported Resident 12 had one episode of attacking someone with a pipe at a community clinic five years ago and he made occasional verbal threats. Recommendations from the [Hospital A] Registered nurse included providing space, when he is observed pacing or hyperventilating which provides relief. MSW1 stated resident encounter note was a brief summary of Resident 12's overall background, used to make recommendations for his care. During an interview on 7/23/25 at 3:01PM with Nursing Supervisor (SUP1), SUP1 stated the general practice for residents admitted with prior history of physical violence towards others requires a committee review and acceptance process. SUP1 stated Resident 12's preadmission screening (assessment to determine residents appropriateness prior to admission) was completed by the Clinical Nurse Specialist (an advanced practice registered nurse that provides consultation services for complex patient care needs) and Neuropsychologist (a doctor that is concerned with the integration of psychological observations on behavior and the mind). During an interview on 7/23/25 at 9:01 AM with the Clinical Nurse Specialist (CNS), the CNS stated Resident 12's behavior trigger (to cause an intense and usually negative emotional reaction in someone) was documented as Too much stimulation. The CNS stated Resident 12's identified triggers included, Too much stimulation, does not do well in groups, females were a trigger .and loud noises. He does well in a peaceful non stimulating environment. When asked what the patient population on the unit where both residents 11 and 12 resided, the CNS reported many residents have disruptive behaviors due to dementia with a wide range of functional abilities. The CNS added Resident 12 had a COACH for close monitoring/supervision but was stopped on 7/7/25, due to increased irritability and agitation.During a concurrent interview and record review on 7/24/25 at 4:13 PM with a Registered Nurse (RN1), a document titled Change of Condition Nursing Note dated 7/15/25 was reviewed. The Change of Condition Nursing Note indicated, Resident 12 had a recent change of condition (COC) involving physical aggression towards a visitor, when Resident 12 went after the visitor in anger causing a minor injury to the visitor. RN1 stated, A coach was assigned to him, but he became aggressive and was combative to the coach. The coach was stopped because he was angry due to the coach. He would be okay then instantly become violent and aggressive. During an interview on 7/24/25 at 2:09 PM with MSW1, MSW1 stated she was made aware of Resident 12's COC (physical aggression towards a visitor) on 7/15/25 via voicemail left by a licensed nurse. When asked if any updates were made to Resident 12's care plan, MSW1 stated I was not really clear on what actually happened, so I could not follow up. MSW1 stated no attempts were made to contact the reporting licensed nurse to gain further details of the COC. MSW1 acknowledged, updates to Resident 12's psychosocial care plan would have been made if it pertained to his level of wellbeing and adjustment. During an interview on 7/29/25 at 1:12 PM with Nurse Manager (NM), NM stated staff were made aware of Resident's 12's past aggressive physical behaviors, but due to his dementia he no longer was violent. NM defined triggers as Anything that will make somebody to behave in an abnormal way and recalled Resident 12's triggers included loud noise, women and hunger. NM confirmed he was made aware of the COC reported on 7/15/25 and verified the COC was discussed in daily huddle the next morning, but no resident care team meeting was coordinated in the daily huddle because MSW1 was still trying to follow up with the individual. When asked if there were any interventions implemented that decreased the likelihood of violent behaviors towards others, NM stated, If he (Resident 12) is exhibiting physical aggression then you leave him alone and go back later. which was communicated to the staff that provided care for Resident 12. During an interview on 7/24/25 at 3:43 PM with a personal care attendant (PCA, a person who provides resident's care), the PCA stated she was made aware of Resident 12's identified triggers with loud noises and bright lights. He becomes overwhelmed right away and wants to be left alone. The PCA stated Resident 11' s daily behaviors included yelling and making loud noises when awake. Prior to the incident, the PCA reported Resident 11 was sitting in the Great Room (dining area) yelling loudly, then PCA heard screaming and commotion. During an interview on 7/24/25 at 4:13 PM with a Registered Nurse (RN1) , RN1 stated prior to the incident Resident 11 was yelling loudly non- stop while sitting in the great room. When asked if Resident 12 was triggered by other residents with loud disruptive behaviors, RN1 stated Yes. During an interview on 7/24/25 at 2:25 PM with a Registered Nurse (RN2), RN2 stated they were familiar with Resident 12's care and prior to the assault, witnessed Resident 12 mumbling to himself I'm tired and I'm sick and pacing back and forth in the great room, while resident 11 was yelling loudly. RN2 stated, He (Resident 12) was telling me I'm tired and sick of this noise, then he suddenly ran over to her (Resident 11) then he just hit her on the left side of face. RN2 stated she was aware of resident 12's identified triggers including loud noises and disruptive behaviors. RN2 stated, He (Resident 12) does not like noise. If he hears noise, he becomes easily agitated. RN2 stated both Resident 11 and 12 were in great room for approximately 30 minutes prior to the incident. When asked if she believes Resident 11's loud yelling triggered Resident 12's aggressive behavior, RN2 replied Yes. During an interview on 7/24/25 at 3:43 PM with the PCA, the PCA stated she took Resident 11 to her room and provided first aid care after the incident. The PCA stated, She was in so much pain, she was crying, and saying how do I look? She said she was so scared. During an interview on 7/24/25 at 2:25 PM with RN2, RN2 stated Resident 11 reported feeling scared following incident and had visible injuries that included a swollen left eye, purple discoloration to left side of her face, and bleeding from left eyebrow. During an interview with Resident 11's RP on 7/23/25 at 1:36 PM, RP stated, After Resident 11 was assaulted she still remembers a lot of things (from the assault), and she is scared and terrified since she has walked back in the door, she has lost all of her fire. It's so sad. The RP provided additional details regarding Resident 11's multiple facial fractures and her permanent facial damage, based on the report given from the plastic surgeon consult while in the hospital. Due to her (Resident 11) age and stuff, they said it would not be good to do surgery. RP further stated, Resident 11 was able to walk around with minimal assistance, feed herself, and able to use phone to call family. Now they said she cannot do anything. She has lost all independence since the incident. During a review of Resident's 11 ED (Emergency Department) Provider Notes dated 7/17/25, ED Provider note indicated. CT (computed tomography scan, a non-invasive medical imaging procedure that uses x-rays and computer technology to create detailed images of the body) trauma brain face and cervical spine (!) IMPRESSION.3. Left ZMC fracture (zygomaticomaxillary complex, break in the left cheekbone) pattern with comminuted (a type of fracture where the bone is broken into more than two pieces) fractures of the zygoma/zygomatic arch (bones around eye), lateral orbital wall (side wall of the bony socket that contains the eyeball), inferior orbital wall (bony surface that forms the bottom of the eye socket), anterior maxillary wall (bone that forms the upper jaw), posterior maxillary wall (rear border of the maxilla bone in the skull), additional fractures of the left medial orbital and maxillary walls (bones that form the cheek area and part of the nasal cavity) .5. Significant subcutaneous edema (soft tissue swelling)A review of Resident 11's Resident Care Team MDS Assessment Note dated 7/18/25, MDS Assessment note indicated. Compared from previous comprehensive assessment (Dated: 5/20/25), resident (Resident 11) declined in areas of ADL Self Care: Eating- from partial/moderate assistance to substantial/maximal assistance to dependent. Oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene- from substantial/maximal assistance to dependent with 1-2 person assist.Resident also declined in Mobility: Roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer- from supervision or touching assistance to substantial/maximal to dependent with 1-2 person assist.Resident also declined in bladder incontinence from occ (occasional) to freq (frequent) incontinent. A review of the facility policy titled ABUSE AND NEGLECT PREVENTION, IDENTIFICATION, INVESTIGATION, PROTECTION, REPORTING AND RESPONSE, last revised on 4/14/25, indicated that physical abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The policy also indicated that, In cases of allegations of abuse.of resident-to- resident or visitor- to resident altercation, the nurse manager or the charge nurse, with input from the RCT [Resident Care Team, a collaborative group of people involved in a resident's care] and the resident (s) themselves shall take the lead in assessing and updating the resident's care plan (s). Considerations for care planning may include the following.staff action and/or inaction that may have contributed to the resident's behavior.Ability to modify the environment.Likelihood of repeat incident.Interventions to minimize the risk of reoccurrence.

Based on interview and record review, the facility failed to report four allegations of abuse, within two hours, to the California Department of Public Health (the Department). This failure had the potential to leave residents vulnerable to further abuse. Findings: A review of Form SOC 341 Report of Suspected Dependent Adult/Elder Abuse, dated 5/27/25, submitted by the facility to the Department on 5/27/25, at 17:53, indicated Residents 1 and 2 had been involved in a resident-to-resident sexual abuse. The report indicated Resident 2 was standing at bedside of Resident 1. Resident 2 attempting to open Resident 1's brief with his right hand, his left hand in his pants. When redirected, Resident 2 became physically aggressive towards the staff. The incident happened on 5/25/25 at 12:30 AM. Review of Resident 1's admission record, indicated, Resident 1 had a had stroke, with right sided weakness, Dysphagia, (difficulty swallowing), Aphasia, (difficulty with talking) and Neurocognitive disorder. Has a BIMS (Brief Interview for Mental Status) score of 0, daughter is decisionmaker. Review of Resident 2's admission record, indicated, Resident 2 has a diagnosis of Dementia associated with alcoholism with behavioral disturbance, non-intractable epileptic spasms (severe form of epilepsy that is resistant to antiepileptic drugs) and age related macular degeneration (causes loss of vision) of both eyes. During an interview and record review on 6/5/25, at 1:42PM, with Registered Nurse Manager, RNM1, per RNM 1, the incident happened in the middle of the night, when Resident 2 was observed by staff wandering and standing by his roommate's bedside. When charge nurse came, Resident 2 was trying to open his roommate's' brief. Resident 2 stated, this is my wife. Staff separated them, Resident 2 got physically aggressive. They moved Resident 1 to Isolation room temporary, till next day we placed him in a room where he is now. Both did not remember anything. Resident 2 has a new roommate who has a coach all the time. Both residents have a BIMS score of 0, cognitively impaired. Per RNM 1, the incident was reported by AM charge nurse, and reported to the team, but the team decided it was not reportable, MD decided it should be reported so the report was done late. During an observation on 6/5/25 at 1:45 PM, Resident 2 observed in the great room sitting, by himself, no activity, introduced myself, no response then got up used his walker. Observed Resident 1 in bed, smiling when introduced myself, no other response. During an interview on 6/5/25 at 3:35 PM, with Assistant Nursing Home Administrator (NHAA), NHAA stated, as the covering Abuse Coordinator, all staff are mandated reporter, they receive annually training on abuse and reporting. If they see an abuse, they need to report. They need to report within 2 hours of incident, as indicated in policy and procedure. CDPH phone number are posted all over the station, they can all anytime. During a phone interview on 6/6/25 at 9:16AM, with Registered Nurse (RN) 1, RN 1 stated they were the charge nurse that shift, got a call from staff, Resident 2 was wandering, he opened the blanket of roommate, his hand trying to open his roommate's brief, we separated them and Resident 2 became aggressive and was threatening. Called supervisor and Resident 1 was moved to another room, while Resident 2 was monitored that night. He was able to sleep, would get up to bathroom. This incident was reported to the team, but per the team it was not reportable. I documented what happened and reported to the team. Review of facility Policy and Procedure, abuse and Neglect Prevention, Identification, Investigation, Protection, Reporting and Response, dated, 4/25, indicated, Policy:2. All LHH employees, contractors and volunteers are mandated reporters of alleged incidents of abuse and/or suspicion of incidents of abuse. 4. LHH employees, contractors, and volunteers shall report alleged violations to the California Department of Public Health (CDPH), the Ombudsman and Nursing Operations within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is mmade,if the events that cause the allegation involve abuse or result in serious bodily injury. Findings: During an interview on 6/4/2025 at 2:14PM with Patient Care Assistant 1( PCA1), PCA1 stated, I've been working as Resident 3's PCA since he was admitted , I've known him for a long time. I was working last 5/27/2025 from 7am to 3:30pm. I saw Resident 3 and Resident 4 sitting in front of the TV at the dining area, when suddenly Resident 4 went beside Resident 3 and started rubbing her hands to his face, to his neck then to his chest going down inside his pants. I asked what are you doing Resident 4! then she stopped and said that she was only kissing his hands. I reported to our team leader, RN2 but she replied to me that it's okay to touch because they are friends. When we had our huddle last 5/28/2025 I told the team about the incident, I know that I am a mandated reporter of abuse, but I don't know if this is reportable or not. During an interview on 6/5/2025 at 10:21AM with Social Worker (MSW) 1, MSW 1 stated, Resident 3 and Resident 4 have a long friendship. The incident was reported by one PCA seeing Resident 4 doing inappropriate touching to Resident 3 happened last 5/27/2025. It was reported during our morning huddle last 5/28/2025 and she did not know if it is reportable or not. As a mandated reporter of abuse we need to report it in 2 hours, but it took time to report. During Interview on 6/5/2025 at 10:23AM with Social Worker (MSW)2, MSW 2 stated, that as per PCA the incident happened last 5/27/2025 and it was reported to us during our morning huddle on 5/28/2025, but it was only last 5/30/2025 that I reported to CDPH and other agencies. There's a delay of reporting because we tried to reach out to the family of Resident 3, they live out of state. The family has been very happy what was happening with the friendship between Resident 3 and Resident 4, however I know it's my mistake not to report it right away. A review of Clinical Progress note dated 5/29/2025 at 10:13am, the Clinical Progress Note indicated Discussed with Family 1and Family 2 wanted to set up boundaries and report only if boundaries were not respected. I and others expressed to team that although family did not think this was reportable/not abuse, since these issues were raised and we were made aware, it should be reported. Addendum: S2 nurse manager reported to me that she discussed the situation that came to light today with abuse officer at LHH ( also LHH CEO) and they did not deem information learned today as reportable after reviewing situation and CMS guidelines. No report being made at this time. A review of Clinical Progress Note dated 5/30/2025 at 4PM, The Clinical Progress Note indicated an allegation of abuse was reported on 5/30/2025. On 5/27/2025 at 12:45PM a staff observed that a co-resident inappropriately touched Resident 3. Staff intervened when this was observed and both resident were kept separated. A resident to resident abuse investigation was initiated. Incident was reported to the following: CPDH at 2:47PM, Ombudsman at 2:05PM, Nursing Operations at 2:42PM, DON at 2:32pm, Abuse coordinator at 2:32PM, SFSD at 2:37pm, SOC 341 faxed to CDPH at 4:16pm.

Based on observation, interview, and facility document review, the facility failed to ensure one, full, outside refuse (garbage) container lid was closed, and that outside recycle and compost bins were cleaned. This failure had the potential to attract pests such as rodents and insects resulting in the spread of disease to all residents for a facility census of 506. Findings: During a concurrent observation and interview with Food Service Director (FSD) on 4/29/25 at 10:21 AM, showed two black garbage bins stored against a building across from the kitchen loading dock area. One garbage bin was filled to the top and the lid was open. Contents of the open garbage bin included used food containers. During a concurrent observation outside behind the kitchen across from the loading dock area and interview on 4/30/25 at 10:21 AM, the Director of Emergency Management (DEM) confirmed the full garbage bin lid was opened and stated the lid should be closed. During a concurrent observation and interview on 4/30/25 at 10:23 AM, with DEM and the Executive Director of Facility Services (EDFS), showed compost and recycle bins stored on the grounds behind and off to the side of the back kitchen, loading dock area. There were over 60 bins (blue and green). Flies were flying around the bins. The majority of the bins had black residue on the outside surface. Three blue recycle bins lids were opened to observe the contents. Two blue bins were filled with empty food containers. There was black residue on the inside surface of the bins, including the inside surface of the bin lid. One of the blue bins was mostly empty with some garbage and empty food containers at the bottom. The inside surface of the bin was covered in black residue. Four green bins were opened to view the contents. All of the bins were mostly empty with what appeared to be food residue and pieces of garbage at the bottom and some black residue on the inside surfaces. In addition, the green bins were wet inside. EDFS stated the bins were not clean. The DEM stated the bins were emptied once at the end of the day, and pressure washed once per month. According to the 2022 Federal Food Code, receptacles for outdoor refuse, recyclables, and returnables, are to have tight fitting lids and shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.

Based on observation, interview, and facility document review, the facility failed to ensure the kitchen was free from flies. The failure to ensure the kitchen was free from flies had the potential to contaminate food, equipment, and utensils and result in pest transmitted disease for 467 residents who received food from the kitchen out of a census of 506. Findings: An observation during the initial tour of the kitchen on 4/28/25 at 9:12 AM, showed small flies were on the ceiling and walls in the dish machine room, mainly around the area where bins were located for items such as shredded paper, refuse, and recycling. An observation and interview in the kitchen on 4/29/25 at 10:00 AM., showed at least 15 small flies on the ceiling above refuse, recycling bin area. In addition, there were also at least four flies on the ceiling in the food production/trayline area. The Food Service Director (FSD) confirmed there were flies on the ceiling and stated he was not aware of the flies in the kitchen. FSD stated the pest company serviced the kitchen three times a week. FSD stated if staff noticed flies, the staff placed a work order to Facilities and Facilities notified the pest company. FSD stated it had been a while since a work order was placed for flies in the kitchen. During an interview with Food Service Supervisor (FSS) 2 on 5/2/25 at 9:34 AM, FSS 2 stated whenever she observed flies in the kitchen, she documented on a checklist and placed a workorder. During consecutive document review and interview with FSS 2 on 5/2/25 at 9:35 AM, the Kitchen & Cafe Inspection Checklist dated 4/15/25, and 4/25/25 showed flies were identified by FSS 2. Checklists dated 4/11/25 and 4/25/25 showed a work order was placed for flies. FSS 2 confirmed she identified flies in the kitchen on 4/11/25, 4/15/25 and 4/25/25 but she was not sure if a work order was placed on 4/15/25. FSS 2 stated she often noticed flies in the meat chopper food production area. Review of Web Request Work Order dated 4/11/25 (work order number 20795), and 4/26/25 (work order 20967) showed the work orders were created by FSS 2 for fruit flies at pot washer area ceiling and meat chopper ceiling (20795) and at shredder bin area around (20967). Documentation for work order 20794, showed the work order was placed on 4/11/25 and on 4/14/25, the pest company inspected and vacuumed 25 fruit flies around the chopper area. Documentation for work order 20967 showed the work order was placed on 4/26/25 and on 4/28/25 the pest company inspected and vacuumed fruit flies. During an interview with FSD on 5/2/25 at 10:05 AM, FSD stated while the pest company was notified of fly activity in April 2025 and the pest company conducted their regular pest service in the kitchen, specific action to eliminate flies was not taken. According to the 2022 Federal Food Code, premises (physical facility) shall be maintained free from insects and other pests.

Based on observation, interview and record review, the facility failed to accurately dispose of and record disposal of controlled drugs for one of one sampled resident reviewed for safe and secure disposal and recording methods for controlled medications (Resident 332). This failure could result in Resident 332 receiving an inaccurate dose or diversion of the controlled medication. Findings: During an observation of Medication Room on 04/30/2025 at 10:31 AM revealed an Omnicell receipt dated 04/30/2025 with time 10:03 AM for Methadone Concentrate 50 mg/ 5mL Cup, with the names of RN3 and RN4 noted on the receipt for Resident 332, and with an administration amount noted as 90 mg and a waste amount noted as 10 mg. Methadone is classified as a Schedule II controlled substance, which means it is recognized for its medical use but has a high potential for abuse and addiction. This classification indicates that even though methadone can be prescribed for certain conditions, such as for pain management, it must be carefully regulated to prevent misuse (UpToDate 2025). Interview of NS2 on 04/30/2025 at 10:31 AM revealed that all Omnicell receipts are reviewed by the Licensed Nurses (LN) at the end of the day and then discarded. NS2 confirmed RN3 was the witness for RN4 regarding the 10 mg waste amount noted on the Omnicell receipt dated 04/30/2025 with time 10:03 AM for Methadone Concentrate 50 mg/ 5mL Cup for Resident 332. Interview of RN3 on 04/30/2025, shortly after interviewing NS2, confirmed RN3 was the witness for the disposal of Methadone Concentrate 50 mg/ 5mL Cup for Resident 332 on 04/30/2025 with time 10:03 AM. RN3 was asked to verbalize the process of disposing 10 mg of the Methadone Concentrate 50 mg/ 5mL. RN3 noted that 10 mg of Methadone Concentrate 50 mg/5 mL was first measured using a measuring cup. RN3 noted that both the 10 mg liquid of Methadone Concentrate 50 mg/ 5mL Cup and the measuring cup that the liquid was in, was then disposed of together in the black container with signage attached to the front of the container that indicates PHARMACEUTICAL WASTE/DISPOSAL FOR ALL NON-CONTROLLED SUBSTANCE WASTE, because it did not fit in the PRO SERIES RX Destroyer with signage attached to the front of the container that indicates FOR CONTROLLEDSUBSTANCE WASTE/DISPOSAL. Interview of NS2 on 04/30/2025, immediately after interview of RN3, confirmed correct process for disposal of 10 mg of Methadone Concentrate 50 mg/5 mL that should start with pouring the liquid into the PRO SERIES RX Destroyer FOR CONTROLLED SUBSTANCE WASTE/DISPOSAL and disposal of the cup into the black container for PHARMACEUTICAL WASTE/DISPOSAL FOR ALL NON-CONTROLLED SUBSTANCE WASTE. NS2 confirmed RN3 did not verbalize the correct process for disposal of 10 mg of Methadone Concentrate 50 mg/5 mL. Record review of Laguna [NAME] Hospital-wide Policies and Procedures 25-15 Medication Administration last revised on 02/03/2025 notes in item 16 that controlled substances shall be disposed of in the RxDestroyer located in the medication rooms.

Based on observation, interview, and facility document review, the facility failed to ensure that food stored in a resident refrigerator located in a great room (great room is the large resident dining area on each unit/floor) were stored according to professional standards for food service safety when: 1. Lunch meat was not discarded according to manufacturer's instructions; and 2. Food items intended to be stored frozen were not stored frozen. The failure to store food according to the manufacturer's instructions for two residents (Resident 1 and Resident 420) out of 506 residents had the potential to result in food borne illness his practice poses a risk to residents' health and safety by potentially compromising food quality and safety. Findings: 1. Durng an observation on 4/30/25 at 1:15 PM on North 1's great room, showed two refrigerators used to store food belonging to residents located in the great room dining area. One refrigerator contained an opened package of sliced ham. A facility placed date label showed Date today: 4/20/25 Expiration date:6/27/25. Manufacturer expiration date printed on the package was 6/27/25. The package also showed to use within seven days of opening. During an interview on 4/30/25 at 1:15 PM with Registered Nurse 1 (RN1) and Registered Nurse 2 (RN2), RN1 confirmed the open package of deli meat. RN2 stated facility uses the manufacturer expiration date for lunch meat. RN2 stated the Food Service Director (FSD) was called when they had questions about food storage for residents but did not call FSD about the storage date for the lunch meal. RN 2 confirmed the facility placed date label did not indicate when the package was opened. During an interview on 4/30/25 at 2:25 PM with Food Service Director (FSD), FSD confirmed the ham lunch meat package showed to use within 7 days of opening and nursing should be following manufacturer's instructions on the package. FSD also stated he referred to the Federal Drug Administration (FDA) guidelines for food storage which showed to store processed, packed deli meat for up to three to five days after opening. 2. An observation on 4/30/25 at 1:15 PM on North 1's great room showed a turkey pot pie stored in the same refrigerator as the lunch meat. The pot pie had a facility placed label that showed Date today: 3/22/25 Expiration date: 4/5/26. The manufacturer's instruction on the packaging showed to keep frozen, do not thaw. It was noted the instructions did not show the pot pie was to be thawed prior to cooking. A concurrent observation on 4/30/25 at 1:15 PM., showed a box of Uncrustables Thaw and Eat Chocolate Filled Hazelnut Spread Sandwich with a facility placed label Date Today: 4/19/25 Expiration Date: 10/13/25. The manufacturer's instruction on the package showed to keep frozen until ready to eat, thaw 30-60 minutes at room temperature. During an interview on 4/30/25 at 1:15 PM with Registered Nurse 1 (RN1) and Registered Nurse 2 (RN2), RN1 and RN2 confirmed the great rooms have only refrigerators, no freezers, and that the freezers in the galley kitchens (compact kitchens on individual units/floors with a smaller layout utilized for food storage and simple preparation) were used only for ice cream and other frozen foods from the facility's main kitchen. During an interview on 4/30/25 at 2:25 PM with FSD, FSD stated he did not know where resident's personal frozen food brought in from the outside should be stored. FSD stated he made recommendations to the nursing staff to get tabletop freezers for the great rooms for frozen foods brought in by outsiders (family, friends, visitors). FSD stated he did not want resident's personal food brought in from the outside stored in the galley kitchens due to cross-contamination. Review of the facility's policy and procedure (P & P) titled, 1.1 Food From Home or Outside Sources Served Directly to Residents, dated Revised: 7/2024, showed , Food intended for resident consumption from outside sources shall be held to the same high levels of food safety and sanitation, storage, handling, and consumption as properly applied in the Food and Nutrition Services Department . Procedure: 3. Food brought in by family or visitors shall be stored separately or easily distinguishable from facility food. Perishable food is labeled with the resident's name, date received and expiration date, and kept in the designated resident refrigerator. 4. Food from home is discarded after 3 days or per manufacturer recommendation. Review of the facility's P&P titled Food Supply/Food Storage dated 7/2024, showed food that is outdated, spoiled, or contaminated will be removed from the general storage area. The maximum period perishable products will be retained under refrigeration will be 72 hours or per manufacturer's recommendation. According to the 2022 Federal Food Code, frozen food shall remain frozen.

Based on interview and record review, the facility failed to ensure the baseline care plan was developed within 48 hours of admission for one of 35 sampled residents (Resident 879) on ADL (Activities of Daily Living) for oral care. This failure had the potential to result in inadequate care and services rendered to Resident 879. Findings: Review of Resident 879 admission record indicated, Resident 879 was admitted on [DATE] , indicated during admission, diagnoses including Stroke, Dysphagia (trouble swallowing), Heart Failure, Aphasia (unable to speak), Systemic lupus erythematosus (a chronic condition where the body's immune system attacks its own tissues). During an interview on 04/30/25 at 9:48 AM with Nurse Manager 2 (NM 2). NM 2 stated baseline assessment is usually done during admission and within 48 hours. NM 2 confirmed baseline care plan was not developed within 48 hours after admission. During an interview on 04/30/25 9:50 AM with Patient Care Assistant1 (PCA 1), PCA 1 stated for a new admit resident we have to check the basic care plan for the patient on ADL on what to do and what the resident do every day. If it's not on the care plan we won't do it A review of Resident 879's Clinical record review Care Plan, dated 4/23/2025, indicated Resident 879, Dental Care Plan start on 4/23/2025 expected end 7/23/2025. Goal will maintain oral and dental health daily. A review on facility's policy and procedure titled, Resident Care Plan (RCP) Resident care team (RCT) and resident care conference (RCC), revised 9/12/2023 .Baseline Care Plan. 1. Shall be initiated by nursing within eight hours on the day of admission 2. Shall be completed and implemented within 48 hours of a resident's admission.

Based on observation, interview, and record review, the facility failed to appropriately administer medication when one of 35 sampled residents (Resident 414) was self-administering medication without being appropriately assessed and approved for self-administration. This failure had the potential for Resident 414 to aspirate (choking, the accidental inhalation of food, liquid, or other material into the lungs) from improperly administered medication. Findings: Review of Resident 414's History and Physical (H&P), dated 6/8/22, indicated Resident 414 had diagnoses including impaired mobility, impaired activities of daily living, left hemiparesis (weakness or the inability to move on one side of the body) and dysphagia (difficulty of swallowing). During a concurrent observation and interview on 4/29/25 at 11:02 AM with Resident 414, a half full cup of thick, dark orange colored liquid was seen on top of Resident 414's bedside table. Resident 414 drank it and stated, It's orange juice that tastes like Metamucil (a medication for constipation), when asked what it was. During an interview on 4/29/25 at 11:22 AM in Resident 414's room, Licensed Vocational Nurse (LVN) 4 acknowledged the thick, dark orange colored liquid found on Resident 414's bedside table was Metamucil mixed with orange juice. During a concurrent interview and record review on 4/29/25 at 11:25 AM with LVN 4, Resident 414's electronic medical record was reviewed. The record indicated on 4/29/25 at 8:25 AM, Resident 414's prescribed and scheduled Metamucil was administered. LVN 4 acknowledged Resident 414 was not observed taking the medication in full amount since the resident prefers to consume the Metamucil at his own pace. LVN 4 further stated, nursing staff to stay and observe the resident and to ensure the resident has taken the medication in whole amount when asked regarding the expectation during medication administration. During an interview on 4/30/25 at 10:27 AM, LVN 4 stated, Resident 414 couldn't open the packet (medication) on his own and does not consume the Metamucil in a timely manner, LVN 4 further stated, Resident 414 is not capable to self-administer medication. During an interview on 4/30/25 at 11:40 AM, Nurse Manager (NM)1 acknowledged she was made aware of Resident 414 not consuming his Metamucil in a timely manner and medication was left at bedside without the resident taking the full dose. NM 1 stated, I just found out yesterday after the nurse was asked about it. NM 1 further added, self-administration assessment was done after that and the resident failed. During a concurrent interview and record review on 4/30/25 at 11:45 AM with NM 1, Resident 414's electronic health record was reviewed. The record indicated the facility had not conducted an assessment to determine whether Resident 414 was capable and appropriate for self-administration. There was no physician's order authorizing Resident 414 to self-administer Metamucil. Additionally, there was no care plan addressing self-administration, nor were there interdisciplinary team (IDT) notes indicating Resident 414 can safely self-administer Metamucil on the day the resident was observed in doing so. When asked about the risk of Resident 414 self-administering Metamucil at the bedside, NM 1 stated, it can cause aspiration (choking, the accidental inhalation of food, liquid, or other material into the lungs). Review of the facility's policy and procedure (P&P), titled, BEDSIDE STORAGE OF MEDICATIONS, revised in December 2022, indicated .Prior to placing medications at the bedside, the interdisciplinary team shall determine that the resident can safely self-administer medications, and an appropriate plan of care shall be written . The P&P further indicated .No other medications or herbal supplements shall be kept at bedside .

Based on observation, interviews, and record review the facility failed to ensure resident rights to choose treatment options was honored for one of three residents (Resident 290) when, urine sample was sent for urine toxicology (also known as drug screen, a test that analyzes a urine sample to detect the presence of drugs or other chemicals) and completed on 4/16/25, which the resident refused. This deficient practice violated residents' rights to make medical decisions. Findings: Record review of Resident 290's Face Sheet, dated 5/1/25 indicated, Resident 290 was admitted to the facility on [DATE] at 11:30 AM. Record review of Resident 290's BIMS (Brief Interview for Mental Status - an assessment tool used to screen cognitive impairment), dated 2/1/25 indicated, a score of 15 (cognitively intact). Record review of Resident 290's Physician Progress Notes, dated 4/18/25 indicated, diagnoses including, quadriplegia (medical condition characterized by the partial or total loss of function in all four limbs and the torso) due to history of gunshot wound in 2017, stimulant disorder (substance use disorder where there is continued use of stimulants despite harm to the person using them), chronic stimulant disorder with metamphetamine (also known as meth or crystal meth, is a very addictive illicit drug) during his time at the facility, and chronic pain syndrome Record review of Resident 290's Physician's Order, dated 4/14/25 indicated, Toxicology screen, urine, electronically (e)-signed by the Physician on 4/14/25 at 11:53 AM. During a concurrent record review and interview on 4/30/25, at 1:25 PM, with the Registered Nurse (RN 8), the urine toxicology screening result, dated 4/16/25, was reviewed. RN 8 stated, the urine toxicology result on 4/16/25 was positive for metamphetamine. RN 8 stated resident was quadriplegic and staff would perform routine intermittent catheter procedure (ICP, method in which a thin, flexible tube is inserted into the urethra and then removed several times a day to empty the bladder), and bowel regimen (a structured plan or routine aimed at helping individuals manage their bowel movements, often to address conditions like constipation or fecal incontinence) to assist the resident. Record review of Resident 290's Nursing Notes, dated 4/14 /25 indicated, Resident refused urine tox screen Record review of the Urine Toxicology Screen, Status: Final result, dated 4/16/25 indicated, POSITIVE; for Amphetamine (a central nervous system (CNS) stimulant drug including metamphetamine). In a concurrent record review and interview, on 04/30/25 at 2:21 PM, with the Charge Nurse (CN 2), the Nursing Notes (NN) dated 4/14/25 was reviewed. CN 2 stated, staff don't usually check urine toxicology but, Even if the doctor orders it [urine tox] we still have to ask. When asked if the resident had given verbal permission, the CN 2 searched the Electronic Health Record and stated Resident 290 refused the toxicology test. CN 2 further stated the facility collected a urine sample on 4/16/25 and sent the specimens to the laboratory. During a concurrent observation and interview, on 4/29/25, at 1:15 PM, Resident 290 was in his room, in bed, awake, alert and oriented x 3 (aware of their person, place, and time). Resident 290 denied using illicit drugs. When asked if urine toxicology was done on 4/16/25, the resident stated, I refused it. Record review of the facility's Policy and Procedure titled, Resident/Patient Rights, with the last revise date of 9/2/23 indicated, POLICY: 1. Resident's/Patient rights are honored . 2. The resident /patient has a right to a dignified existence, . a. The facility shall treat each resident/patient with respect and dignity . b. The facility shall protect and promote the rights of the residents/patient.

Based on observations, interviews, and record reviews, the facility failed to meet professional standards of quality when: 1.One out of two sampled residents (Resident 183) received oxygen therapy outside the prescriber's order. This failure could potentially result in negative outcomes for Resident 183 like shortness of breath, fatigue and confusion. 2.Two residents out of 42 sampled residents reviewed for medication administration (Resident 44 and Resident 155) received medication outside the prescriber's order and parameters. These failures resulted in Resident 44 receiving prescription medication Glipizide (a medication to treat high blood sugar) 10 mg tablet for type 2 diabetes mellitus (high blood sugar) outside prescribing parameters and Resident 155 receiving incorrect application of Lidocaine 5% patch for pain outside the prescriber's order. These failures have the potential for Resident 183, Resident 44, and Resident 155 to receive inadequate care. Findings: 1.Review of Resident 183's MDS (minimum data set - a federally mandated resident assessment tool), dated 4/7/25, indicated Resident 183 was readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that makes breathing hard) and had a Brief Interview for Mental Status (BIMS, MDS tool that measures resident cognition) score of 15, indicating intact cognitive function. During an observation on 4/29/25 at 10:26 AM, Resident 183 was observed breathing through his mouth while receiving oxygen (O2) at 1 liter per minute (lpm, unit that express flow rate) via nasal cannula (a medical device that provides supplemental oxygen to a resident through the nose) connected to the wall oxygen. During a concurrent observation and interview on 4/29/25 at 10:46 AM with Registered Nurse (RN) 5 in Resident 183's room, Resident 183 was receiving oxygen at 1 lpm via nasal cannula connected to the wall oxygen. RN 5 increased the oxygen to 2 lpm and stated, It should be at 2 lpm, as ordered by the doctor. During a concurrent interview and record review on 4/29/25 at 10:50 AM with RN 5, Resident 183's electronic health record was reviewed. The physician's order, in the record, dated 12/20/23, indicated oxygen at 2 1pm via nasal cannula to maintain an oxygen saturation level (O2 sat, a measurement of how much oxygen the blood is carrying as a percentage) above 92% as needed (PRN) for COPD/ history of obstructive sleep apnea (OSA, a condition when breathing stops and starts during sleep due to a blockage in the throat). When asked about the oxygen saturation of Resident 183 for that day, RN5 stated, No oxygen saturation was charted this morning. The last recorded oxygen saturation was on 4/27/25 at 10:13AM, two days ago. During an interview on 4/30/25 at 11:08 AM, Nurse Manager (NM)1 acknowledged being aware of Resident 183's physician order for PRN oxygen at 2 lpm, which was not followed. NM 1 also confirmed the oxygen saturation was taken but not documented in the electronic health record. NM1 stated, Resident 183's oxygen saturation was 95% the previous morning. NM 1 further stated, Resident 183 did not require PRN oxygen based on the reading. During a concurrent interview and record review on 5/1/25 at 1:04 PM with NM1, Resident 183's electronic health record was reviewed. The record indicated on 4/29/25 at 8:31 AM, Resident 183's oxygen saturation was 95%. However, it was not documented whether the resident was on oxygen or room air at the time of the reading. NM1 stated, staff are expected to check oxygen saturation while the resident is on room air especially when a PRN oxygen order is in place to determine whether supplemental oxygen is needed. Review of Resident 183's care plan titled Problem: Respiratory-Adult, dated 3/23/22, indicated .On PRN supplemental oxygen via nasal cannula at 2 liters per minute to keep O2% (oxygen percentage) saturation above 92% . Review of the facility's policy and procedure (P&P) titled, Resident Care Plan (RCP), Resident Care Team (RCT) & Resident Care Conference (RCC), last updated on 9/12/23, indicated .Policy .Care problems require various professional disciplines working together in planning, implementing and evaluating goals and interventions . Review of the facility's P&P titled, Oxygen Administration last updated in September 2006, indicated .Nasal Cannula .Adjust liter flow according to physician order . 51444 2. During concurrent observation, interview, and record review, the observation of Medication Administration on 04/30/2025 showed RN6 gave Resident 44 Glipizide 10 mg tablet at 10:16 AM. Record review of the electronic health record (EHR), for Resident 44 revealed Glipizide 10 mg tablet was ordered for every morning before breakfast. Interview of RN6 provided confirmation that Glipizide 10 mg tablet was administered after breakfast instead of before breakfast, at the incorrect time. RN6 confirmed breakfast for Resident 44 was completed at 8:30 AM. RN6 confirmed order for Glipizide 10 mg tablet requires administration every morning before breakfast. During a concurrent interview and record review on 4/30/25 at 10:16 AM, RN 6 acknowledged Resident 44 did not receive Glipizide 10 mg tablet before breakfast according to the prescriber's order. During concurrent observation, interview, and record review, the observation of Medication Administration on 04/29/25 at 10:06 AM showed that LVN3 gave Resident 155 an application of two Lidocaine 5% patches to the mid-lower back area and to the area over the right lower ribs. Record review of the EPIC EHR for Resident 155 revealed the order parameters for the two Lidocaine 5% patches requires application of the Lidocaine 5% patches to the right shoulder and to the right rib area for pain. Interview of LVN3 provided confirmation that one Lidocaine 5% patch was incorrectly applied to the mid-lower back area, instead of the right shoulder. LVN3 confirmed that the order parameters for Lidocaine 5% patch requires administration of the two Lidocaine 5% patches to the right shoulder and to the right rib area for pain. LVN3 confirmed applying one of the Lidocaine 5% patches incorrectly to the mid-lower back area. After acknowledging the error, LVN3 corrected the error by removing the Lidocaine patch on the mid-lower back and placing it on the right shoulder of Resident 155. Resident 155 did not receive the correct application of one Lidocaine 5% patch to the correct location of the right shoulder according to the order parameters. Record review of Laguna [NAME] Hospital-wide Policies and Procedures entitled Medication Administration notes that the Licensed Nurses (LN) will follow the 6 Rights of medication administration listed as: Right resident, Right drug, Right dose, Right time, Right route, Right documentation.

Based on observation, interview, and facility document review, the facility failed to ensure that one out of one kitchen staff was competent when testing sanitizer (a substance or product that reduces or eliminates microorganisms such as bacteria on surfaces to a safe level) strength used to sanitize food contact surfaces. This failure had the potential to result in compromising infection control and resident safety. Findings: During an observation and interview on 4/28/25 at 1:45 PM with Food Service Supervisor (FSS)1, FSS1 stated he was responsible for testing the sanitizer strength for the sanitizer used in the red buckets (sanitizer used to test food contact surfaces). FSS1 demonstrated how he tested the sanitizer strength. FSS1 held a sanitizer test strip in the sanitizer solution inside a red bucket for 20-21 seconds then immediately compared the color of the strip to the color chart on the test strip packaging to determine the concentration. When FSS1 was asked how many seconds the test strip was to be held in the solution, FSS1 stated for about 10 seconds. Review of the manufacturer's label on the test strip container showed to immerse the strip in solution for 5 seconds, then evaluate the color 10 seconds after removing the test strip from the sample. Match the center of the test strip pad to the color chart to determine concentration. During a facility document review of Food & Nutrition Services Department In-Service: Three Bucket Sanitizing Method, dated December 2024, the Department In-Service indicated FSS1 was in attendance. Furthermore, included in the Department In-Service documents of December 2024, titled Policies & Procedures: 1.165 General Cleaning and Sanitizing work Surfaces and Kitchen or Galley Equipment 16) It is important to follow the policy and procedure on testing the concentration of Sink & Surface Cleaner Sanitizer. This will be done by Chef, Supervisor or team-Leader twice daily to ensure that the chemical is being effective. During an interview on 5/1/25 at 11:15 AM, the Food Service Manager (FSM) stated she conducted the In-Service training for the Three Bucket Sanitizing Method on December 2024, but the training did not include how long to immerse the test strip in the solution. Review of the facility's policy and procedure (P & P) titled, 1.80 Testing of correct titration for Sanitizer, revised 8/24, was to ensure that the department approved chemical used for sanitizing food service work equipment and surfaces are at the correct titration . Procedure: 1. Twice a day (AM and PM) the Supervisor, Chef, or designee will test titration with proper testing strips to ensure that it's at appropriate Parts Per Million (PPM) for sanitizing the work surface area and food service equipment.

Based on observation, interview, and facility document review, the facility failed to ensure standards of practice for storing, preparing, and serving food were met when: 1. The kitchen floor in the steam jacket kettle area was not maintained resulting in cracked tiles and missing grout; 2. The ceiling above the manual dish washing area was not maintained free of dust build-up; 3. Steam jacket kettles were not sanitized as part of the cleaning process; 4. Frozen food items were not covered when stored in the freezer; and 5. An egg-salad sandwich available for a resident (Resident 569) at bedside, was not discarded within an appropriate time frame. These failures had the potential to result in contamination of food, utensils, and equipment; and/or promote the harborage of pests for at least 385 residents who received food from the kitchen out of a census of 417. Findings: 1. It would be the standard of practice to ensure the materials for indoor floor, wall, and ceiling surfaces under conditions of normal use are maintained to ensure they are smooth, durable, and easily cleanable. Additionally, pooling of liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens. (US Food Code, 2022). During the Initial Tour of the kitchen on 11/04/24 at 10:45 a.m., an observation showed the floor in the steam jacketed kettle (a large, deep pot mounted on legs to stand on the floor. The pot uses steam to cook food) area was wet and had several cracked tiles. When pressure was placed on the cracked tiles, water came out from beneath the tiles. In addition, there was missing grout which created long divots between several tiles. During a concurrent interview with the Food Service Director (FSD) on 11/4/24 at 10:45 a.m., FSD stated a work order was placed two to three weeks ago to fix the cracked tiles and missing grout. FSD stated Facilities was in the kitchen since the work order was placed to fix floor tiles in the kettle area. A document review showed two work orders were created on 10/18/24 for Broken tile in front of Steamer # [number] 4; and Broken tile and missing grouts in between kettle #1 and #2. During an interview and concurrent observation in the kitchen on 11/6/24 at 3:35 p.m., the Director of Facilities (DOF) confirmed broken tiles and missing grout under the steam jacket kettles. DOF stated he resurfaced the tile floor under the steam jacket kettles on 10/20/24. DOF stated it was a very wet area and the grout was disrupted easily. DOS stated the area needed to be resurfaced with a better material that did not degrade so quickly when wet. 2. It would be the standard of practice to ensure the materials for indoor ceiling surfaces under conditions of normal use are maintained to ensure they are easily cleanable. Additionally, the presence dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. (US Food Code, 2022). On observation and concurrent interview with FSD on 11/4/24 at 1:00 p.m., showed a significant amount of a gray, fuzzy substance on the ceiling in the warewashing room, mainly in the area of the manual warewashing sinks. FSD stated the substance was likely dust. FSD stated the dust build-up on the ceiling was likely due to moisture in that area. FSD stated a cleaned the ceiling about once a year, but it could be cleaned more often by facility staff. FSD stated he thought the ceiling was last cleaned by the company in April. Review of the facility Kitchen Registers & Oven Cleaning Project Report for service dates 5/28 - 5/31/2024, showed HVAC (heating, ventilation, and air conditioning) registers (vents) and adjacent ceiling tiles were cleaned. 3. Review of the facility Policy and Procedure (P&P) titled General Cleaning and Sanitizing work Surfaces and Kitchen or Galley Equipment revised 7/2024, showed cleaning is the process in which a food service worker is removing food and other types of soil from a surface. Sanitizing is the process in which a food service worker uses a sanitizer on the same surface that was previously cleaned, to reduce the number of micro-organisms to a safe level. To be effective, the food service worker must conduct a two-step process, cleaning and sanitizing. Surfaces must be first cleaned and rinsed before sanitizing. All food-contact surfaces must be washed, rinsed, and sanitized. For sanitizing the surface, use a clean cloth with sanitizer and allow the surface to air dry. Review of the undated facility document titled Nutrition Services Department Job Description, showed a responsibility for Job Number 15 was to ensure food service machinery was clean and sanitized. For large pieces of equipment, wash, rinse, sanitize, and airdry. An observation in the kitchen and interview with a Food Service Worker (FSW) and FSD on 11/4/24 at 10:50 a.m., showed an area with six steam jacket kettles (two 50-gallon, and four 100-gallon) ad some were in use for cooking food. Food Service Worker (FSW) stated she was position number 15 and was responsible for cleaning the kettles. FSW stated she was about to clean a kettle filled with food residue. FSW stated the cleaning process included draining the kettle, then scrubbing the inside surface with a brush, soap, and hot water, and lastly rinsing the inside surface with water. FSD confirmed there should be a sanitizing step. Then FSW stated if she used a sanitizer, she would drain the kettle, scrub the inside surface with soap and water, wipe the inside surface with a sanitizing solution, and lastly rinse the inside surface again. FSD stated the kettle should not be rinsed after sanitizing. 4. It would be the standard of practice to ensure food is be protected from cross contamination by storing the food in packages, covered containers, or wrappings. (US Food Code, 2022). During the Initial Tour of the kitchen on 11/4/24 at 10:30 a.m., an observation of food stored in walk-in freezer number one was conducted. Due to boxes from the morning food delivery stacked in the middle of the freezer, the majority of the freezer was inaccessible. A spot check was done for food stored on racks close to the freezer entrance The spot check revealed multiple foods stored on the racks were not covered including plant based chicken breast, pureed carrots, plant based vegan (no animal product ingredients) patties, and plant based sausage patties. These foods were in opened boxes and the plastic wrapping around the food within the boxes did not cover the food. During a concurrent interview with FSD on 11/4/24 at 10:30 a.m., FSD confirmed multiple frozen foods were stored and not covered. FSD stated we can do a better job. when asked how the frozen foods should be stored. 38066 5. During an observation on 11/4/24 at 10:18 AM, in Resident 569's room, an egg salad sandwich was on the overbed table. The label on the sandwich indicated, 11/3/24 Dinner. During a concurrent interview, Resident 569 confirmed the sandwich was served for dinner on 11/3/24. Resident 569 stated, Yes, it was for last night's dinner. During an interview on 11/4/24 at 10:43 AM, Nurse Supervisor (NS) 1 validated the sandwich was served for dinner on 11/3/24. NS 1 stated, He can have food poisoning. According to the 2022 Federal Food Code, a Time Temperature Control for Safety (TCS; foods designated to maintain specific temperature ranges within designated time frames to prevent the growth of harmful bacteria) food is to be discarded when within four hours from the point in time when the food is removed from temperature control.

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from sexual abuse when Resident 2 climbed into Resident 1's bed and kissed him on the lips. This failure resulted in Resident 1 not being able to sleep well due to feeling unsafe at the facility. Findings: A review of the facility policy titled ABUSE AND NEGLECT PREVENTION, IDENTIFICATION, INVESTIGATION, PROTECTION, REPORTING AND RESPONSE, last revised on 11/14/23, indicated that sexual abuse is defined as non-consensual sexual contact of any type with a resident. One of the stated purposes of the policy is to provide clinical interventions to prevent and minimize abuse or neglect . The policy further indicated that In cases of allegations of abuse . or resident-to-resident or visitor-to-resident altercation, the nurse manager or charge nurse, with input from the RCT [Resident Care Team, a collaborative group of people involved in a resident's care] and the resident(s) themselves (If possible) shall take the lead in assessing and updating the residents care plan(s). Considerations for care planning may include the following .staff action and/or inaction that may have contributed to the resident's behavior . Ability to modify environment . Likelihood of repeat incident . Interventions to minimize the risk of recurrence. A review of the facility policy titled COACH [a person assigned to a resident for close supervision] USE FOR CLOSE OBSERVATION, last revised in 10/10/23, indicated that Resident behaviors that may require close observation include but are not limited to the following: harm to self or others . Other extenuating needs as determined by the Resident Care Team (RCT) and with the approval of Nursing Director/Nursing Operations. The facility policy further indicated that the RCT (at a minimum, the MD and RN) shall review the resident's condition, the specific behaviors that need intervention, and the close observation measures needed to ensure resident safety . if no progress is made, resident case may be referred to clinical leadership for long term placement. A review of Resident 1's history and physical (a formal and complete assessment of someone done by a medical provider), dated 03/09/21, indicated that Resident 1 doesn't have capacity to make medical decisions. Patient has a probate conservator [someone appointed by a court to act on behalf of someone that is no longer able to handle their own financial and/or personal affairs] A review of Resident 1's annual Minimum Data Set (MDS, a resident assessment tool), dated 02/14/24, indicated that Resident 1 was admitted in 2020 with diagnoses including stroke (when blood flow to the brain is stopped due to bleeding or a blockage in blood flow) and aphasia (difficulty in communicating). The MDS also indicated that the Brief Interview for Mental Status (BIMS, a cognitive screening tool) was unable to be completed by Resident 1. In turn, a staff assessment for mental status was done for Resident 1 and his Cognitive skills [brain functions] for daily decision making was assessed as moderately impaired. A review of Resident 2's quarterly MDS, dated [DATE], indicated that Resident 2 was admitted in 2016 with diagnoses including stroke and hypertension (high pressure in the vessels that carry blood). The MDS further indicated that Resident 2 has a BIMS score of 15 (scores of 0-7 suggest severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggest that cognition is intact). A review of Resident 2's RCT note, finalized on 08/07/19, indicated that Resident 2 is assigned a coach for multiple incidents of inappropriately touching vulnerable residents . However most recent incident Occurred in the unit and was deemed by RCT to assign resident his own COACH 24h [hours]. A review of Resident 2's RCT note, finalized on 08/04/20, indicated that Resident 2 is assigned a coach for multiple incidents of inappropriately touching vulnerable residents .Resident [2] has also demonstrated intentionally trying to shake off his coach or leave assigned staff behind in order to approach other male residents. For these reasons we will continue with 24 hours COACH supervision at this time. A review of Resident 2's history and physical, dated 09/13/21, indicated that Resident 2 has repeated history of inappropriate verbal and physical behaviors, including intrusiveness [violating someone's personal space or privacy], sexual misconduct (touching others without consent, public masturbation, sex acts with others), verbal aggression . Due to repeated behaviors, starting in July 2018, [Resident 2] must be accompanied with a coach whenever he goes off unit. Then in August 2019 he was assigned a 24 hr [hour] coach. A review of a nursing note for Resident 2 written by Registered Nurse (RN) 1, dated 09/20/21, indicated that This writer reminded [Resident2] of the reasons why he has coach . This writer explained to him [Resident 2] that he has not demonstrated that other residents are safe around [him] and that's why we are continuing with a COACH at this timet [sic]. A review of Resident 2's RCT note, finalized 08/25/22, indicated that resident continues to requires [sic] 1:1 [one-to-one, someone is assigned to supervise only one person] supervision across 3 shift due to multiple history [sic] of sexually inappropriate behavior towards vulnerable residents in and out of the unit. Resident continues to not realize why his action [sic] are wrong and still tries to find opportunities to approach residents that he had history of inappropriate contact with. A review of Resident 2's RCT note, finalized 06/24/23, indicated that Resident [2] is provided 24/7 days/week [sic] coach due to multiple history [sic] of sexually abusing vulnerable residents in the past. He continues to present this risk and 24 hour supervision is necessary. During a concurrent interview and record review on 05/01/24 at 12:11 PM with Charge Nurse (CN) 1, Resident 2's nursing note written by RN 3, dated 04/16/24, was reviewed. CN 1 stated they are the charge nurse for the Behavioral Response Team (BRT) and RN 3 is a BRT nurse. CN 1 explained that the BRT is part of the therapeutic care team which supports the resident and staff member to create a therapeutic care environment. CN 1 stated that the BRT often works with residents with agitation [a state of nervous anxiety or excitement] and residents with verbal or physically aggressive behavior. The nursing note indicated that RN 3 checked in with unit charge nurse . who reported resident's verbally inappropriate behavior towards co-residents has declined due to the 1:1 assist staff interventions for redirecting and setting boundaries with resident. Based on this note, CN 1 stated that the one-to-one supervision is helping control his [Resident 2's] behavior. CN 1 further stated that the BRT does not decide if someone should have a coach because the RCT should decide. She stated that the RCT knows the resident better and the BRT is not in the unit all the time. A review of Resident 2's RCT note, finalized on 04/23/24, indicated that Resident remains on 1:1 staff supervision due to continued behaviors of impulsivity [tendency to act without thinking] and inappropriate behavior. A review of Resident 2's Care Plan Addendum (update or correction to a care plan), dated 04/25/24, indicated that care plan updated to reflect reduction of 1:1 staff supervision. The care plan further indicated that Resident 2 has episodes of verbally aggressive behavior .cursing at staff when he is prevented from doing things that may be deemed harmful to his peers (such as sexually explicit acts or conversations, teasing) or himself . Has history of sexually inappropriate behaviors which include physical sexual contact such as kissing another resident, inappropriate conversations, exposing himself in a public place. The care plan further indicated an intervention of Continue 1:1 coach 16 hours a day (DAY [7:00 AM to 3:00 PM], PM [3:00 PM to 11:00 PM]). A review of a nursing note for Resident 2 written by Registered Nurse Manager (RNM) 1, dated 04/25/24, indicated that Resident 2's 1:1 staff supervision was reduced to Day and PM shift. Resident will no longer have a 1:1 staff during the AM [11:00 PM to 7:00 AM] shift. A review of nursing note for Resident 2 written by RN 4, dated 04/26/24 at 7:04 AM, indicated that Resident 2 continues with 1:1 supervision for safety. Continues to propelled [sic] (move) self via [through use of] wheelchair in and out of his room to the great room. A review of Resident 2's RCT note, finalized 04/26/24 at 1:21 PM, indicated that Resident started on 04/26/24 AM with the reduction and will remain with 1:1 staff on DAY and PM shift. A review of a nursing note for Resident 2 written by RN 4, dated 04/29/24, indicated that At 0510 [5:10 AM] resident [Resident 2] observed not in his room. Staff immediately searched [for] resident and was found sitting on resident [Resident 1's] bed kissing each other. Both residents had clothes on and smiling . Separated both resident right away . Assigned 1:1 supervision [to Resident 2] for safety due to inappropriate sexual behavior. A review of a Social Worker [a professional trained to help people enhance social functioning and cope with problems of everyday living] note for Resident 2 written by Social Worker (SW) 1, dated 04/29/24, indicated that He [Resident 2] stated that he is physically attracted to his peer . 'I need to focus to do something that interest me. (Name of the peer) is my target. A review of a facility report sent to the California Department of Public Health titled, REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE, dated 04/29/24, indicated that When asked if he [Resident 1] felt safe, [Resident 1] shook his head, 'no'. When asked why he did not feel safe, res [resident] shrugged his shoulders as if to say he didn't know. During an interview on 04/30/24 at 10:49 AM with RN 4, RN 4 stated that she was the nurse that witnessed Resident 2 kissing Resident 1 on Resident 1's bed on 04/29/24. RN 4 stated that Resident 2 did not have a coach at the time of the incident because it was stopped for her shift. RN 4 stated that the presence of the coach has been effective . he hasn't had any inappropriate sexual behavior, when the coach is present. RN 4 further stated that the coach was important because Resident 2 is very smart . he knows when nobody is there and will act inappropriately when staff is not present. RN 4 also stated that she was not included in the decision to discontinue the coach for Resident 2 on her shift. During an interview on 04/30/24 at 11:11 AM with Resident 1, Resident 1 was asked if someone was bothering him; Resident 1 responded, Yeah. When asked if it was another resident, Resident 1 stated, Yeah. When asked if another resident is hurting him, Resident 1 stated, Yeah and proceeded to point to his lips. When asked if this touch bothered him, Resident 1 stated, Yeah. When asked if he saw that resident today, Resident 1 stated, No. When asked if he saw the resident yesterday (04/29/24), Resident 1 stated, Yeah. When asked if Resident 1 feels safe, resident shook his head left-to-right. When asked if the reason he doesn't feel safe is because of the person that touched him, Resident 1 stated, Yes. When asked if he is able to sleep okay, Resident 1 stated, No. When asked if the reason he is unable to sleep is because of his safety concern, Resident 1 stated, Yeah. During an interview on 04/30/24 at 1:40 PM with Resident 2, Resident 2 was asked about Resident 1. Resident 2 stated I am physically attracted to him [Resident 1] . I go to him. Resident 2 stated that he recalled kissing Resident 1 early in the morning yesterday [04/29/24]. Resident 2 further stated that the incident occurred about 5 o'clock in the morning. During an interview on 04/30/24 at 2:17 PM with Patient Care Assistant (PCA) 1, PCA 1 stated that she works as a PCA for Resident 2. PCA 1 also stated she has been working on this unit for about a year and is familiar with Resident 2's care. When asked about the importance of the coach for Resident 2, PCA 1 stated, He knows . he's very smart . he knows that somebody is watching him . If there is no coach he can go everywhere. Even at night . He is up and down in bed . you think he's sleeping and then he's up. PCA 1 further stated that once he [Resident 2] knows he has a coach, he will not go, to other residents' rooms. When PCA 1 was asked if she was aware of any other intervention that has been helpful in preventing Resident 2's sexually inappropriate behavior, PCA 1 stated, Only that one [a one-to-one coach] because he's smart. During an interview on 04/30/24 at 2:49 PM with RNM 1, RNM 1 stated that Resident 2 had a coach for inappropriate sexual behavior. When asked who was part of the decision to reduce Resident 2's coach time, RNM 1 stated the instruction came from leadership. RNM 1 stated that the decision did not come from Resident 2's RCT. During an interview on 04/30/24 at 2:52 PM with Nursing Supervisor (NS) 1, NS 1 stated that the decision to reduce the coach for Resident 2 was made by a committee that looked to verify if coaches are needed for every shift. NS 1 verified that no clinical staff from Resident 2's unit was consulted about coach reduction. NS 1 stated he was just notified by the committee about the reduction in coaching hours and stated, I was made aware that was what had to happen. NS 1 further added, If it were up to us on the unit, we would not have reduced it [Resident 2's coach]. NS 1 stated that from his understanding, the basis for discontinuation was that about 90% of the time it showed that [Resident 2] was sleeping over the night. When asked what interventions have been shown to be effective in preventing Resident 2's sexually inappropriate behavior, NS 1 stated, we moved his household [moved to a different hallway of the unit] and the round the clock coach. Those worked. As outlined in the findings, Resident 1 was assessed as having moderately impaired cognitive skills and therefore the state agency has applied the reasonable person concept in determining the psychosocial outcome for this deficiency.

Based on observation, interview, and record review, the facility failed to protect one of one sampled Resident (Resident 1) from abuse when Resident 1 was verbally abused by a Security Guard (SG). The facility's failure resulted in Resident 1 1. thinking and reliving the incident, 2. feeling sad 3. having low self-esteem 4. having no self-respect Findings: Resident 1 was admitted with multiple diagnoses including paraplegia (loss of inability to move the legs) and chronic pain (long-term pain). Review of Resident 1's record, titled Minimum Data Set (MDS is a standard assessment tool), dated 12/1/24, indicated his memory, reasoning abilities were intact. This was reflected in his Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function [includes thinking, learning, and decision-making abilities]). Resident 1 scored 15 out of 15 indicating he had no cognitive impairment. Under functional abilities, Resident 1 was dependent (helper does all the effort, the resident does none of the effort to complete activity) to requiring substantia/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). A review of the recorded video sent from Resident 1's personal cellular phone, showed Security Guard 1 (SG 1) seated on the left facing Resident 1. SG 1 was heard saying disparaging remarks towards Resident 1, You can't wipe your ass, telling him to jump, laughing at him, and saying you're gonna die here . Security Guard 2 seated on the right side, facing Resident 1 was observed laughing at some point during the phone recorded incident. The incident occurred in the unit lobby in front of the nurses' station and the unit elevator. During an interview on 4/18/24, at 10:02 AM, Resident 1 stated, It happened on 4/13/24. It's like a slap in the face. I feel saddened. I have low self-esteem. They have no respect. I felt I need to take the video to take it seriously. I didn't say anything to staff. I kept thinking about it all day if I should say something. I don't want them not passing because of me. During an interview on 4/18/24, at 10:49 AM, Medical Doctor (MD) 1 stated that the video was horrible. During an interview on 4/18/24, at 11:49 AM, Licensed Social Worker 1 stated, [Resident 1 named] showed me the video. I felt it was abuse. A lot of abuse of language, a lot of laughing at him. It was abusive. [Resident 1] was not happy with the security guard's presence, he does not like people in uniform, it reminded [Resident 1] of initial incident that landed him in the wheelchair. During an interview on 4/18/24, at 2:07 PM, the Nursing Director 1 stated, Security guards are placed for the safety of the residents and staff. The security guards are another set of eyes. During an interview on 4/18/24, at 12:09 PM, Security Guard 3 stated that they were there to maintain a safe place, treat resident with respect, not to put a hand on any resident even if they get aggressive, and not to scream or say bad words towards the residents. A review of the facility Incident Interview Report dated 4/15/24, completed by Quality Management RN 2, indicated, Resident 1 stated, .Honestly, it made me sad. I was like man, is that how people see me. A review of the facility Incident Interview Report dated 4/15/24, completed by RN 2 indicated a Patient Care Assistant (PCA) 1 stated that Resident 1 showed the video and stated, . (SG 1) should not have interacted with (Resident 1) being so insulting. That's abuse. It was hard to watch. She was really provoking him .He feels so insulted . A review of the Licensed Social Worker notes dated 4/15/24, indicated, . [Resident 1] expressed that the incident was very upsetting to him. There was a verbal exchange that he took a video of. In the exchange, [SG 1] laughed at him, called him names, made fun of his family and disability .he kept closing his eyes and having difficulty focusing . A review of the facility Incident Interview Report dated 4/16/24, completed by QM RN 2 indicated, SG 2 stated, .I told her (SG 1) to stop. I told her to walk away and stop talking to [Resident 1]. Everyone is adult and I do not know what else I can say . When Resident 1 was asked, .Do you have any emotional distress or mental anguish? [Resident 1] did not reply but started crying . A review of the facility Investigation of Alleged Abuse dated 4/17/24 completed by Nurse Manager (NM) 1, indicated, .both security (SG) told the resident [Resident 1] that is why you can no longer wipe your ass; nobody gives a fuck about you; you are about to join your mother soon and that is why you are in a wheelchair. Both security guard were laughing and giggling . A review of the facility document, Department of Education and Training (DET) Checklist for evidence of contractor training of [facility name] Abuse and Neglect prevention program provided to SG 1 on 10/4/23, indicated, .persons working in [name of facility] under a contract .are obligated under the law to refrain from acts of abuse . The following summarizes what constitutes as abuse .verbal (that is [i.e.] .staff using inappropriate words towards a resident) . A review of the facility Policy and Procedure titled, Abuse and Neglect Prevention, Identification, Investigation, Protection, Reporting and Response dated 11/14/23, indicated, [Facility name] shall promote an environment that enhances resident well-being and protects residents from abuse .The employees, contractors, and volunteers shall provide a safe environment and protect residents from abuse .Purpose: To protect resident from abuse .Definition: .verbal abuse means the use of oral .or gestured communication that willfully includes disparaging and derogatory terms to residents .

Based on interview and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) when Resident 1 was ambulating (walking) in the facility independently without any assistive devices (objects used to help stabilize someone for safer movement). This failure resulted in Resident 1 sustaining a left femoral neck fracture (a break in the long upper leg bone near where it touches the hip bone) requiring a left hemiarthroplasty (surgery necessary to replace part of the hip joint). Findings: A review of a Resident 1's Quarterly Minimum Data Set (MDS, a resident assessment tool), dated 12/29/23, indicated that Resident 1 has multiple diagnoses including Alzheimer's disease (a brain disorder that slowly impairs memory and thinking skills) and a history of a subarachnoid hemorrhage (bleeding in the space around the brain). The MDS also indicated that the staff assessment for mental status was done for Resident 1 and her Cognitive skills [brain functions] for daily decision making was moderately impaired. A review of the policy titled COACH [a person assigned to a resident for close supervision] USE FOR CLOSE OBSERVATION, last revised 10/10/23, indicated that a coach's responsibilities include . close monitoring of assigned resident(s) to prevent resident(s) from injury to self or injury to others. The policy also indicated that resident behaviors that may require close observation include but are not limited to the following . high risk for falls . elopement risk [when someone leaves a healthcare facility against medical advice even if doing risks their own health or safety] . intrusive behaviors [actions that are disruptive to other's space, belongings, and care]. The policy indicated that the Coaches shall not leave residents unattended under any circumstances. The policy further indicated that the Resident Care Team (RCT, a collaborative group of people involved in a resident's care) is responsible for the initial assessment and ongoing evaluation/need for close observation measures. A review of the policy titled FALLS, last revised 07/09/19, indicated that Supervision/Adequate Supervision is defined as an intervention and means of mitigating [decrease] the risk of an accident . Adequacy is determined by assessing the appropriate level of and number of staff required . and the frequency of supervision needed The determination is based on the individual resident's assessed needs. In addition, the policy indicated that a nurse should complete the [NAME] Fall Assessment (a specific type of scoring tool to assess someone's risk for falling) quarterly for a resident. A review of Resident 1's RCT meeting note, finalized on 09/05/23, indicated that the RCT recommended Resident 1 be provided with a 24 hour safety coach related to her medical decline/condition until physical therapy (PT, a health care provider specialized in helping improve or maintain how bodies perform physical movements) and occupational therapy (OT, a healthcare provider who helps improve or maintain someone's ability to perform daily tasks) evaluation. During a concurrent interview and record review on 02/28/24 at 11:43 AM with Physical Therapist 1 (PT 1), PT 1's note titled, Physical Therapy Evaluation and Care Plan, dated 09/07/23 was reviewed. The note indicated that a reason for Resident 1's PT evaluation was consecutive falls. PT 1 stated that at time of this evaluation, Resident 1 scored a 12 out of 28 on the Tinetti Score. PT 1 stated that the Tinetti score is a measure that tests gait [how someone walks] and balance. PT 1 stated that the resident's score of 12 out of 28 means that they are at high risk for fall. A review of Resident 1's care plan (a health assessment tool used to determine care and services a resident receives) completed by PT 1, dated 09/07/23, indicated that Patient [Resident 1] continues to be high falls risk and currently has a coach to assist. During a concurrent interview and record review on 02/28/24 at 11:48 AM with PT 1, PT 1's progress note titled, Physical Therapy Discharge Summary (Short Form), dated 09/21/23 was reviewed. The note indicated that after PT spoke to Resident 1's Patient Care Assistant (PCA, someone that helps residents with activities of daily living), the PCA confirms patient can ambulate with assistance with hand hold assistance. PT 1 stated that hand-held assistance means that someone is right by [Resident 1's] side when they are walking. This progress note further indicated that Resident 1 is to be discharged from PT services with recommendations to continue coach to assist with out of bed and daily ambulation on unit. During a concurrent interview and record review on 02/28/24 at 11:48 AM with PT 1, PT 1's progress note titled, PHYSICAL THERAPY NON-BILLED VISIT NOTE, dated 10/05/23 was reviewed. The note indicated that PT 1 reassessed patient's ambulation after discussion with Resident 1's PCA and Registered Nurse (RN) at the time. The note indicated that due to pt's [patient's] inability to follow instructions to use FWW [front wheel walker] safely pt should ambulate with staff vs [instead of] FWW. PT 1 stated that based on this assessment, Resident 1 should have continued with hand-held assistance while walking. A review of Resident 1's RCT meeting note, finalized on 10/10/23, indicated under recommendations that 1:1 [one to one, someone is assigned to supervise only one person] coach 4 hours day shift to monitor increased to 24 hr [hour] for a few days. A review of Resident 1's RCT meeting note, finalized on 11/16/23, indicated under recommendations that Resident 1 continues with 1-1 [one to one, someone is assigned to supervise only one person] coach. Under an assessment of activities, the RCT note further indicated that [Resident 1] benefits from having a coach in her daily activities to assist, keep her safe from wondering, program encouragement, supervision and redirection as needed. During a concurrent interview and record review on 02/28/24 at 11:54 AM with PT 1, a physical therapist progress note titled, Quarterly Rehab Screen Form/PHYSICAL THERAPY NON-BILLED VISIT NOTE, dated 11/21/23, was reviewed. The screening indicated that there was no decrease in Resident 1's ability to walk with or without an assistive device. PT 1 stated that since Resident 1 was discharged from PT services, this screening tool would help assess if there was a change in function since the last full PT assessment. PT 1 stated that there is not a change from baseline walking ability according to the screening and she would therefore refer to the previous PT assessment she completed with Resident 1 on 10/05/23 which indicated that Resident 1 should have continued with hand-held assistance while walking. PT 1 verified that at the time of this screening, the resident would continue to need hand-held assistance while walking. During a concurrent interview and record review on 02/28/24 at 3:40 PM with the Director of Regulatory Affairs (DRA), an RN, Resident 1's fall risk assessment, dated 12/05/23, was reviewed. The fall risk assessment indicated a [NAME] Fall score of three. DRA stated that this score means that Resident 1 is at risk for fall. During a concurrent interview and record review on 02/28/24 at 10:09 AM with the Charge Nurse (RN 1), Resident 1's nursing weekly summary (a snapshot of the resident's assessment and care plan), dated 12/08/23, was reviewed. The nursing weekly summary indicated that Resident 1 needed one-person Supervision assistance during Locomotion [walking] on Unit. RN 1 stated that Supervision assistance means that someone is watching the resident and keeping an eye on [Resident 1] while walking on the unit. During a concurrent interview and record review on 02/28/24 at 10:27 AM, with Nursing Supervisor 1 (RNS 1), a nursing note, dated 12/13/23, was reviewed. The note indicated that Resident 1 continues with 1:1 coach for poor safety awareness, risk for injury, and high risk for fall. RNS 1 stated that Resident 1's coach is for safety and that safety is an umbrella term that covers many types of risks and behaviors. RNS 1 further stated that we don't coach for falls [using a coach to prevent a fall]. During a concurrent interview and record review on 02/28/24 at 10:23 AM with RN 1, a nursing note dated 12/13/23 was reviewed. The nursing note indicated that RCT decided to DC [discontinue] resident's coach. Resident has a slow medical decline and has been noted to be less intrusive lately. RN 1 stated that this note means the RCT met and agreed that Resident 1 no longer needed a coach. A review of Resident 1's care plan addendum (update or correction to a care plan), dated 12/13/23, indicated a problem of Safety Adult - Fall with a goal of [Resident 1] will remain safe despite discontinuation of her coach. During a concurrent interview and record review on 02/28/24 at 10:09 AM with RN 1, Resident 1's nursing weekly summary, dated 12/15/23, was reviewed. The nursing weekly summary indicated that Resident 1 needed one-person extensive assistance during Locomotion on Unit. RN 1 stated that extensive assistance means that someone is walking right beside the resident. A review of Resident 1's nursing weekly summary, dated 12/15/23, indicated that there were multiple active care plans with interventions related to the use of a coach. Regarding the goal of Skin integrity is maintained or improved, a listed intervention was that Resident 1 continues 24 hrs [hours] coach to monitor/safety. In addition, regarding the goal of Patient will be free from physical and verbal abusive behavior, a listed intervention was that Resident 1 is with coach for safety r/t [related to] intrusive behavior, wandering around the unit and into other resident's rooms, continue with 24 hours coach to keep free from injury. During a concurrent interview and record review on 02/28/24 at 12:24 PM with the DRA, Resident 1's mobility flowsheet (a document summarizing assessments and routine care tasks over time), dated 12/17/23 at 12:20 AM, was reviewed. The mobility flowsheet indicated that Resident 1 needed extensive assistance with mobility. The DRA stated that extensive means that someone is right next to Resident 1 when walking. A review of a Change of Condition nursing note for Resident 1, dated 12/17/23, indicated that at 15:07 (3:07 PM), Resident 1 was walking towards great room [large gathering space where meetings, activities, or meals can occur] from her room while walking patient lost her balance and landed on the floor and hit her head on the floor. The note further indicated that this was a witnessed fall. During an interview on 02/27/24 at 3:28 PM with RN 2, RN 2 stated that she had witnessed Resident 1's fall on 12/17/23. RN 2 stated that Resident 1 was walking independently in the great room and was not using any assistive devices before Resident 1 fell. A review of Resident 1's abdominal and hip Computerized Tomography scan (CT Scan, a specialized machine used to take detailed pictures inside someone's body to help determine injury), dated 12/17/23, indicated that Resident 1 had a minimally impacted left femoral neck fracture. A review of Resident 1's history and physical (a formal and complete assessment of someone done by a medical provider), dated 12/21/23, indicated that Resident 1 obtained a left hemiarthroplasty of the hip: Post [after] mechanical fall on 12/17/23. During a concurrent interview and record review on 02/28/24 at 12:17 PM with the DRA, Resident 1's nursing weekly summary, dated 02/23/24, was reviewed. The nursing weekly summary indicated that Resident 1 is now totally dependent with locomotion on unit. The DRA stated that total dependence means that the Resident 1 is unable to help and will need staff to move around the unit.

Based on interview and record review, the facility failed to ensure Resident 1's fall care plan interventions were updated and implemented to prevent or minimize fall-related injuries for one of 20 sampled residents (Resident 1) when Resident 1 was assessed as total dependent with activities of daily living, including repositioning when in bed. The care plan interventions did not reflect the two person physical assist required by Resident 1 when repositioning and the facility did not implement effective interventions to prevent falls after identifying Resident 1 with limited Range of Motion (ROM) on bilateral upper and lower extremities, diagnosis of Seizure Disorder (a medical condition that can cause sudden, uncontrollable movements and change in level of consciousness) and poor safety awareness due to diagnosis of Dementia (impaired ability to remember, think, or make decisions). This failure resulted in Resident 1 to have an avoidable fall from her bed during personal care by Patient Care Assistant (PCA) 1 on [DATE], resulting in Resident 1 sustaining a laceration of 1.5 centimeter (cm - unit of measurement) and bleeding on left forehead. Resident 1 expired two hours and ten minutes after the fall. Findings: During a review of Resident 1's admission Record (AR - document containing resident demographic information and medical diagnosis), undated, the admission record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included Seizure Disorder, Dementia, Hypertension (high blood pressure), Congestive Heart Failure (CHF, the heart cannot pump blood or fill adequately), Hypoxemia (low concentration of oxygen in the blood), Atrial Fibrillation (Afib- irregular heart rate), and Left Hip Arthroplasty (joint replacement). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's cognitive (memory) skills for daily decision making was severely impaired. The MDS mobility assessment indicated Resident 1 was dependent to staff when repositioning from lying on back to left and right side and return to lying on back on the bed. During a review of Resident 1's [NAME] Fall Risk (FR, a fall risk assessment tool) assessment dated [DATE], Resident 1's FR assessment indicated Resident 1's fall score was 3 (a score of 3 or more means that patient is at risk for falls and fall prevention interventions should be implemented). During a review of Resident 1' s Progress Note (PN), dated [DATE], the PN indicated, . 8:00 p.m. Change of Condition Nursing Note . ASSESSMENT: Resident fell from low bed to floor mat during care. Remained alert and verbal. 1.5 cm laceration with slight bleeding noted on the left forehead . 10:10 p.m. On call MD (physician) was notified again after resident was observed to have stopped breathing. Resident 1 expired and pronounced at 2210 [10:10 p.m.] . During a review of Resident 1's Care Plan (CP), dated [DATE], the CP indicated, . Problem: Safety Adult - Fall . Goal: Free from fall injury . At risk for fall due to: poor safety awareness, cognition impaired, impaired physical function [Mechanical] lift 2 persons assist during transfer, impaired vision . Interventions: Institute fall precautions as indicated by assessment . 2 Person assist for all mechanical lift transfers . Problem: ADL maintenance . Resident is total dependent with ADLs . Interventions: 1. Total dependent, uses [mechanical] lift for transfers with size medium of sling, 2 person assist with transfer . Maintain environment for safety during ADL/mobility activities . During an interview on [DATE], at 2:35 p.m., with PCA 1, PCA 1 stated he was the assigned PCA to care for Resident 1 on [DATE]. PCA 1 stated Resident 1 was dependent on staff for personal care, including feeding, transfer, and repositioning. PCA 1 stated he first saw Resident 1 at approximately 3:30 p.m. to check her disposable brief for soilage and repositioned Resident 1. PCA 1 stated at approximately 6:30 p.m., he fed Resident 1, and she consumed 50% of her dinner. PCA 1 stated one hour after dinner, he returned to Resident 1's room to change her disposable brief. PCA 1 stated he gathered the incontinent care supplies, placed on top of the bed, and he raised the bed below his waistline, approximately 27 inches in height from the floor. PCA 1 stated Resident 1 was not in any distress or agitated. PCA 1 stated he was on the right side of the bed and repositioned Resident 1 facing the left side of the bed. PCA 1 stated, [Resident 1] was using an air loss mattress ( is a mattress designed to prevent and treat pressure wounds) for pressure ulcer (are localized skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body, typically bony prominences) prevention and her bed does not have side rails. She used to have it before, but it was removed. I pulled [Resident 1] closer to me before turning her body facing the window [left side of the bed]. She was almost in the middle of the bed. I placed [Resident 1]'s right hand under her body and her left hand on top of her body. She was wearing a gown. While performing peri care to [Resident 1], her entire body rolled to the left side of the bed, falling out of the bed, and hit the floor mattress. I don't know what part of her body hit the floor mattress first. I immediately went to the left side of the bed and found her face down and was bleeding on her left forehead. I called the [Charge Nurse, CN 1]. She was assessed by [CN 1] then the two of us carried [Resident 1] back to her bed. Other staff came later, including the doctor. PCA 1 stated the current care plan requires two person assist and one person assist during personal care. PCA 1 stated the unassisted fall will not happen if another staff was helping him during Resident 1's personal care. During an interview on [DATE], at 2:50 p.m., with PCA 1, PCA 1 stated he was not instructed by the CN to obtain Resident 1's vital signs after the fall. PCA 1 stated he was not instructed by the CN to conduct Resident 1's follow-up neuro assessment (an assessment tool to determine a patient's neurologic function) after the fall. PCA 1 stated he was not asked to write a statement about the incident. PCA 1 stated Resident 1 died at 10:10 p.m. and he provided the post-mortem care together with another male CNA (Certified Nursing Assistant). PCA 1 stated he worked and completed his shift and clocked out at 11:30 p.m. During a telephone interview and record review on [DATE], at 8:13 p.m., with Charge Nurse/Registered Nurse (CN) 1, Resident 1's Nursing Note (NN), dated [DATE] was reviewed. The NN indicated, . At around 2000 [8:00 p.m.], PCA reported that resident fell from low bed to floor mattress during care. Neuro check and post fall assessment initiated. On assessment, resident was noted to have a 1.5 [cm] laceration on the left forehead . Notified MD (physician) again after resident was noted to have irregular breathing. Instructed to increase O2 (oxygen) to 5L (Liters, unit of measurement) and administer Acetaminophen (use as pain reliever/fever reducer) and albuterol (use to prevent and treat wheezing and shortness of breath). On call MD was notified again after resident was observed to have stopped breathing. Resident expired and pronounced at 2210 [10:10 p.m.] . CN 1 stated, while at the nurses' station on [DATE] at approximately 8:00 p.m., PCA 1 informed him that Resident 1 fell from the bed to the floor mattress during personal care. CN 1 stated she went to Resident' s 1 room immediately and found her on the floor, on the left side of the bed, with her face down. CN 1 stated he saw [PCA 1] holding a cloth towel on Resident 1's forehead. CN 1 stated, I saw blood on the cloth towel but don't recall the approximate amount of blood saturation on the towel. I noted a 1.5 cm laceration on Resident 1's left forehead. It was bleeding. CN 1 stated he initiated a post-fall neuro check and post-fall assessment, then notified the on-call physician. CN 1 stated, [PCA 1] and I transferred [Resident 1] back to her bed. She was nonverbal. She was comfortable in bed. CN 1 stated he noted blood on the floor mat where the patient fell, approximately the size of 4x4 gauze. CN 1 stated, Resident 1 has a bedside drawer next to the head of the bed and her head probably hit the bedside drawer during the fall that resulted to the 1.5 cm laceration on her left forehead. CN 1 stated there was no documentation stating that he informed the on-call physician on the amount of the blood on the floor and the bedside drawer as the possible reason for the laceration on Resident 1's forehead. During a telephone interview and record review on [DATE], at 8:22 p.m., with CN 1, the facility's policy and procedure (P&P) titled, Falls, dated 7/2019 was reviewed. The P&P indicated, . Purpose: 1. Provide a safe environment for residents . An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary . 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately . b. After the initial assessment . Do not lift the resident by the arms or legs . always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device . i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed . ii. Check vital signs . CN 1 stated he conducted an initial neurological assessment and no further follow-up assessment. CN 1 stated he did not obtain the vital signs or instructed the PCA to collect vital signs after the fall. CN 1 stated Resident 1 was on Palliative Care (is specialized medical care for people living with a serious illness) and with a physician order of no vital signs. CN 1 stated he did not clarify with the physician the frequency of the neurological assessment and if vital signs was needed after the fall. CN 1 stated Resident 1 was not lifted from the floor using a mechanical lift. CN 1 stated Resident 1's nursing care plan indicated two person assist during transfer and the use of mechanical lift. CN 1 stated he failed to follow the facility's falls policy and the nursing care plan. CN 1 stated Resident 1's unassisted fall could have been prevented if another staff was present and assisted PCA 1 during Resident 1's personal care. CN 1 stated the number of direct care staff on his unit when the fall incident happened was less than usual. CN 1 stated Resident expired two hours after the unassisted fall. During an interview on [DATE], at 12:20 p.m., with PCA 2, PCA 2 stated she was the assigned PCA to care for Resident 1 on [DATE], from 7 :00 am to 3:00 p.m. PCA 2 stated Resident 1 was dependent on staff for personal care, including feeding, transfer, and repositioning. PCA 2 stated Resident 1 was at her baseline, sleepy but arousable during her shift. PCA 1 stated she assisted Resident 1 with her meals for breakfast and lunch. PCA 1 stated Resident 1 ate 100% of her breakfast and 25% of her lunch. PCA 2 stated Resident 1 was transferred from her bed to her geri-chair using a hoyer lift with two person assist. PCA 2 stated Resident 1 stayed in her geri-chair from 11 a.m. to 2:00 p.m., then returned to her bed using a hoyer lift with two persons during transfer. PCA 2 stated Resident 1's nursing care plan indicated two-person assist during transfer and the use of mechanical lift. PCA 2 stated she gave a change of shift report to [PCA 1] around 3:00 p.m., including Resident 1's activities and meal intake for breakfast and lunch. During an interview and record review on [DATE], at 3:24 p.m., with Nursing Supervisor (NS) 1, the facility's P&P titled, Falls, dated 7/2019 was reviewed. The P&P indicated, . Purpose: 1. Provide a safe environment for residents . An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary . 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately . b. After the initial assessment . Do not lift the resident by the arms or legs . always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device . i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed . ii. Check vital signs . NS 1 stated Resident 1's unassisted fall with injury was considered a change in condition. NS 1 stated the staff failed to follow the falls policy. NS 1 stated, If we have two person assisting during Resident 1's personal care, the fall could have been prevented. NS 1 stated, I will defer to the physician's assessment on the cause of her [Resident 1] death. During an interview and record review on [DATE], at 3:48 p.m., with Nursing Manager (NM) 1, the facility's P&P titled, Falls, dated 7/2019 was reviewed. The P&P indicated, . Purpose: 1. Provide a safe environment for residents . An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary . 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately . b. After the initial assessment . Do not lift the resident by the arms or legs . always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device . i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed . ii. Check vital signs . NM 1 stated Resident 1's unassisted fall with injury was a change in condition. NM 1 stated she can't find any documentation in Resident 1's record clarifying the physician's order of no vital signs and the facility's Falls P&P. NM 1 stated, We collect vital signs to find out how the resident is doing. With blood pressure, we are looking for high and low. Low BP means internal bleeding, dehydration, infection. Low respiration means the body is shutting down. Without the vital signs, there is no way to determine if the resident condition is changing. When asked if the unassisted fall contributed or caused Resident 1's death, NM 1 stated, I can't say anything. NM 1 stated she conducted a Root Cause Analysis (RCA, a process of determining the possible cause of the incident) on [DATE] and immediately implemented interventions requiring two person assist during personal care to all residents on air loss mattress. During an interview and record review on [DATE], at 4:46 p.m., with the Attending Physician (AP) 1, Resident 1's Progress Note (PN), dated [DATE] was reviewed. The PN indicated, . 8:54 p.m. Patient is [AGE] years old. with Hx [history] Vascular Dementia, Afib, CHF, Seizure Disorder on Keppra (anti-seizure, anti-convulsant medication), who was reported to have a fall from the bed while CNA [Certified Nurse Assistant] was doing the personal care and sustained the laceration on L [left] side of the forehead. Pt [patient] was seen and examined at the bedside along with CNA and CN. Noted the linear cut about 1.5 cm on L side of forehead without active bleeding . Called by the CN again at around 9 pm as the pt was noted to have abnormal breathing, with long pauses, Albuterol prn [as needed] was given and O2 supplementation was increased to 5 L. With the treatment, breathing became more regular . Death Pronouncement . Reported by CN that the pt stopped breathing at around 10 pm. Pt was seen and examined at the bedside . AP 1 stated she was the on-call physician and provided medical care to Resident 1 on [DATE]. AP 1 stated when she arrived in Resident 1's room after the reported fall, Resident 1 was already in bed. AP 1 stated she evaluated the patient and instructed the CN to apply steri-strips on the laceration and apply cold compress. AP 1 stated the report that she received from the CN did not include the amount of blood found on the floor and the possibility of Resident 1's head hitting the bedside drawer when she rolled out of her bed. AP 1 stated the goals of care was comfort care and no escalation of care outside of the unit. AP 1 stated, I can't tell if [Resident 1] sustained a skull fracture from the fall without an x-ray (type of radiation called electromagnetic waves, creates pictures of the inside of your body, the images show the parts of the body in different shades of black and white to check for broken bones). I did not order any procedure. The goals of care was Palliative Care. During a review of the facility's policy and procedure (P&P) titled, Resident Care Plan (RCP), Resident Care Team (RCT), and Resident Care Conference (RCC), dated 9/2023, the P&P indicated, . 4. Comprehensive Care Plan . c. The comprehensive care plan shall include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial (pertains to the influence of social factors on an individual's mind or behavior) needs that were identified in the comprehensive assessment . 7. Developing Interventions . b. Interventions are specific, individualized and describe the team member(s) responsible for carrying it out and the frequency of conducting interventions . c. Interventions reflects standards of current professional practice . During a review of the facility's document titled, Job Description . Registered Nurse, dated 7/2022, the document indicated, . Under general supervision, performs nursing duties in hospitals, clinics, sanitariums, and other institutions . keeps related charts and records in accordance with standard practices . carrying out existing methods and procedures relating to various aspects of patient care . During a review of the facility's document titled, Job Description . Patient Care Assistant / Certified Nursing Assistant, dated 7/2023, the document indicated, . Under general supervision of a licensed nurse, the Certified Nursing Assistant (CNA) performs a variety of routine duties involving care of medically or mentally ill acute or sub-acute patients; performs direct patient care; observes and reports changes in the behavior and physical status of patients . During a review of the Lippincott Manual of Nursing Practice 10th Edition dated 2014, page 16-17 indicated, Standards of practice General Principles .These standards provide patients with a means of measuring the quality of care they receive. Common Departures from the Standards of Nursing Care .failure to adhere to facility policy or procedural guidelines .

Based on interview and record review, the facility failed to ensure one of twenty sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice, comprehensive person-centered care plan to enable residents to maintain their highest practicable level when Resident 1 who was assessed as a high risk for fall, total dependent with activities of daily living, including repositioning when in bed sustained a fall on [DATE]. The care plan interventions did not reflect the two person physical assist required by Resident 1 when repositioning and the facility did not implement effective interventions to prevent falls after identifying Resident 1 with limited Range of Motion (ROM) on bilateral upper and lower extremities, diagnosis of Seizure Disorder (a medical condition that can cause sudden, uncontrollable movements and change in level of consciousness) and poor safety awareness due to diagnosis of Dementia (impaired ability to remember, think, or make decisions). This failure resulted in Resident 1 to have an avoidable fall from her bed during personal care by Patient Care Assistant (PCA) 1 on [DATE], resulting in Resident 1 sustaining a laceration of 1.5 centimeter (cm - unit of measurement) and bleeding on left forehead. Resident 1 expired two hours and ten minutes after the fall on [DATE]. Findings: During a review of Resident 1's admission Record (AR - document containing resident demographic information and medical diagnosis), undated, the admission record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included Seizure Disorder, Dementia, Hypertension (high blood pressure), Congestive Heart Failure (CHF, the heart cannot pump blood or fill adequately), Hypoxemia (low concentration of oxygen in the blood), Atrial Fibrillation (Afib- irregular heart rate), and Left Hip Arthroplasty (joint replacement). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's cognitive (memory) skills for daily decision making was severely impaired. The MDS mobility assessment indicated Resident 1 was dependent to staff when repositioning from lying on back to left and right side and return to lying on back on the bed. During a review of Resident 1's [NAME] Fall Risk (FR, a fall risk assessment tool) assessment dated [DATE], Resident 1's FR assessment indicated Resident 1's fall score was 3 (a score of 3 or more means that patient is at risk for falls and fall prevention interventions should be implemented). During a review of Resident 1' s Progress Note (PN), dated [DATE], the PN indicated, . 8:00 p.m. Change of Condition Nursing Note . ASSESSMENT: Resident fell from low bed to floor mat during care. Remained alert and verbal. 1.5 cm laceration with slight bleeding noted on the left forehead . 10:10 p.m. On call MD (physician) was notified again after resident was observed to have stopped breathing. Resident 1 expired and pronounced at 2210 [10:10 p.m.] . During a review of Resident 1's Care Plan (CP), dated [DATE], the CP indicated, . Problem: Safety Adult - Fall . Goal: Free from fall injury . At risk for fall due to: poor safety awareness, cognition impaired, impaired physical function [Mechanical] lift 2 persons assist during transfer, impaired vision . Interventions: Institute fall precautions as indicated by assessment . 2 Person assist for all mechanical lift transfers . Problem: ADL maintenance . Resident is total dependent with ADLs . Interventions: 1. Total dependent, uses [mechanical] lift for transfers with size medium of sling, 2 person assist with transfer . Maintain environment for safety during ADL/mobility activities . During an interview on [DATE], at 2:35 p.m., with PCA 1, PCA 1 stated he was the assigned PCA to care for Resident 1 on [DATE]. PCA 1 stated Resident 1 was dependent on staff for personal care, including feeding, transfer, and repositioning. PCA 1 stated he first saw Resident 1 at approximately 3:30 p.m. to check her disposable brief for soilage and repositioned Resident 1. PCA 1 stated at approximately 6:30 p.m., he fed Resident 1, and she consumed 50% of her dinner. PCA 1 stated one hour after dinner, he returned to Resident 1's room to change her disposable brief. PCA 1 stated he gathered the incontinent care supplies, placed on top of the bed, and he raised the bed below his waistline, approximately 27 inches in height from the floor. PCA 1 stated Resident 1 was not in any distress or agitated. PCA 1 stated he was on the right side of the bed and repositioned Resident 1 facing the left side of the bed. PCA 1 stated, [Resident 1] was using an air loss mattress ( is a mattress designed to prevent and treat pressure wounds) for pressure ulcer (are localized skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body, typically bony prominences) prevention and her bed does not have side rails. She used to have it before, but it was removed. I pulled [Resident 1] closer to me before turning her body facing the window [left side of the bed]. She was almost in the middle of the bed. I placed [Resident 1]'s right hand under her body and her left hand on top of her body. She was wearing a gown. While performing peri care to [Resident 1], her entire body rolled to the left side of the bed, falling out of the bed, and hit the floor mattress. I don't know what part of her body hit the floor mattress first. I immediately went to the left side of the bed and found her face down and was bleeding on her left forehead. I called the [Charge Nurse, CN 1]. She was assessed by [CN 1] then the two of us carried [Resident 1] back to her bed. Other staff came later, including the doctor. PCA 1 stated the current care plan requires two person assist and one person assist during personal care. PCA 1 stated the unassisted fall will not happen if another staff was helping him during Resident 1's personal care. During an interview on [DATE], at 2:50 p.m., with PCA 1, PCA 1 stated he was not instructed by the CN to obtain Resident 1's vital signs after the fall. PCA 1 stated he was not instructed by the CN to conduct Resident 1's follow-up neuro assessment (an assessment tool to determine a patient's neurologic function) after the fall. PCA 1 stated he was not asked to write a statement about the incident. PCA 1 stated Resident 1 died at 10:10 p.m. and he provided the post-mortem care together with another male CNA (Certified Nursing Assistant). PCA 1 stated he worked and completed his shift and clocked out at 11:30 p.m. During a telephone interview and record review, on [DATE], at 8:13 p.m., with Charge Nurse/Registered Nurse (CN) 1, Resident 1's Nursing Note (NN), dated [DATE] was reviewed. The NN indicated, . At around 2000 [8:00 p.m.], PCA reported that resident fell from low bed to floor mattress during care. Neuro check and post fall assessment initiated. On assessment, resident was noted to have a 1.5 [cm] laceration on the left forehead . Notified MD (physician) again after resident was noted to have irregular breathing. Instructed to increase O2 (oxygen) to 5L (Liters, unit of measurement) and administer Acetaminophen (use as pain reliever/fever reducer) and albuterol (use to prevent and treat wheezing and shortness of breath). On call MD was notified again after resident was observed to have stopped breathing. Resident expired and pronounced at 2210 [10:10 p.m.] . CN 1 stated, while at the nurses' station on [DATE] at approximately 8:00 p.m., PCA 1 informed him that Resident 1 fell from the bed to the floor mattress during personal care. CN 1 stated she went to Resident' s 1 room immediately and found her on the floor, on the left side of the bed, with her face down. CN 1 stated he saw [PCA 1] holding a cloth towel on Resident 1's forehead. CN 1 stated, I saw blood on the cloth towel but don't recall the approximate amount of blood saturation on the towel. I noted a 1.5 cm laceration on Resident 1's left forehead. It was bleeding. CN 1 stated he initiated a post-fall neuro check and post-fall assessment, then notified the on-call physician. CN 1 stated, [PCA 1] and I transferred [Resident 1] back to her bed. She was nonverbal. She was comfortable in bed. CN 1 stated he noted blood on the floor mat where the patient fell, approximately the size of 4x4 gauze. CN 1 stated, Resident 1 has a bedside drawer next to the head of the bed and her head probably hit the bedside drawer during the fall that resulted to the 1.5 cm laceration on her left forehead. CN 1 stated there was no documentation stating that he informed the on-call physician on the amount of the blood on the floor and the bedside drawer as the possible reason for the laceration on Resident 1's forehead. During a telephone interview and record review, on [DATE], at 8:22 p.m., with CN 1, the facility's policy and procedure (P&P) titled, Falls, dated 7/2019 was reviewed. The P&P indicated, . Purpose: 1. Provide a safe environment for residents . An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary . 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately . b. After the initial assessment . Do not lift the resident by the arms or legs . always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device . i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed . ii. Check vital signs . CN 1 stated he conducted an initial neurological assessment and no further follow-up assessment. CN 1 stated he did not obtain the vital signs or instructed the PCA to collect vital signs after the fall. CN 1 stated Resident 1 was on Palliative Care (is specialized medical care for people living with a serious illness) and with a physician order of no vital signs. CN 1 stated he did not clarify with the physician the frequency of the neurological assessment and if vital signs was needed after the fall. CN 1 stated Resident 1 was not lifted from the floor using a mechanical lift. CN 1 stated Resident 1's nursing care plan indicated two person assist during transfer and the use of mechanical lift. CN 1 stated he failed to follow the facility's falls policy and the nursing care plan. CN 1 stated Resident 1's unassisted fall could have been prevented if another staff was present and assisted PCA 1 during Resident 1's personal care. CN 1 stated the number of direct care staff on his unit when the fall incident happened was less than usual. CN 1 stated Resident expired two hours after the unassisted fall. During an interview on [DATE], at 12:20 p.m., with PCA 2, PCA 2 stated she was the assigned PCA to care for Resident 1 on [DATE], from 7:00 am to 3:00 p.m. PCA 2 stated Resident 1 was dependent on staff for personal care, including feeding, transfer, and repositioning. PCA 2 stated Resident 1 was at her baseline, sleepy but arousable during her shift. PCA 1 stated she assisted Resident 1 with her meals for breakfast and lunch. PCA 1 stated Resident 1 ate 100% of her breakfast and 25% of her lunch. PCA 2 stated Resident 1 was transferred from her bed to her geri-chair using a hoyer lift with two person assist. PCA 2 stated Resident 1 stayed in her geri-chair from 11 a.m. to 2:00 p.m., then returned to her bed using a hoyer lift with two persons during transfer. PCA 2 stated Resident 1's nursing care plan indicated two-person assist during transfer and the use of mechanical lift. PCA 2 stated she gave a change of shift report to [PCA 1] around 3:00 p.m., including Resident 1's activities and meal intake for breakfast and lunch. During an interview and record review, on [DATE], at 3:24 p.m., with Nursing Supervisor (NS) 1, the facility's P&P titled, Falls, dated 7/2019 was reviewed. The P&P indicated, . Purpose: 1. Provide a safe environment for residents . An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary . 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately . b. After the initial assessment . Do not lift the resident by the arms or legs . always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device . i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed . ii. Check vital signs . NS 1 stated Resident 1's unassisted fall with injury was considered a change in condition. NS 1 stated the staff failed to follow the falls policy. NS 1 stated, If we have two person assisting during Resident 1's personal care, the fall could have been prevented. NS 1 stated, I will defer to the physician's assessment on the cause of her [Resident 1] death. During an interview and record review, on [DATE], at 3:48 p.m., with Nursing Manager (NM) 1, the facility's P&P titled, Falls, dated 7/2019 was reviewed. The P&P indicated, . Purpose: 1. Provide a safe environment for residents . An on-going evaluation of interventions shall be documented to ensure their proper implementation and efficacy and modified or replaced as necessary . 3. After a fall: a. The RN assess the resident for signs of injury and for changes in condition: i. if a serious injury is suspected do not attempt to move the resident. Notify the physician immediately . b. After the initial assessment . Do not lift the resident by the arms or legs . always use a minimum of 2 person assist. Whenever necessary, use a mechanical lifting device . i. Begin neuro checks if the resident hit their head or if the fall was unwitnessed . ii. Check vital signs . NM 1 stated Resident 1's unassisted fall with injury was a change in condition. NM 1 stated she can't find any documentation in Resident 1's record clarifying the physician's order of no vital signs and the facility's Falls P&P. NM 1 stated, We collect vital signs to find out how the resident is doing. With blood pressure, we are looking for high and low. Low BP means internal bleeding, dehydration, infection. Low respiration means the body is shutting down. Without the vital signs, there is no way to determine if the resident condition is changing. When asked if the unassisted fall contributed or caused Resident 1's death, NM 1 stated, I can't say anything. NM 1 stated she conducted a Root Cause Analysis (RCA, a process of determining the possible cause of the incident) on [DATE] and immediately implemented interventions requiring two person assist during personal care to all residents on air loss mattress. During an interview and record review on [DATE], at 4:46 p.m., with the Attending Physician (AP) 1, Resident 1's Progress Note (PN), dated [DATE] was reviewed. The PN indicated, . 8:54 p.m. Patient is [AGE] years old. with Hx [history] Vascular Dementia, Afib, CHF, Seizure Disorder on Keppra (anti-seizure, anti-convulsant medication), who was reported to have a fall from the bed while CNA [Certified Nurse Assistant] was doing the personal care and sustained the laceration on L [left] side of the forehead. Pt [patient] was seen and examined at the bedside along with CNA and CN. Noted the linear cut about 1.5 cm on L side of forehead without active bleeding . Called by the CN again at around 9 pm as the pt was noted to have abnormal breathing, with long pauses, Albuterol prn [as needed] was given and O2 supplementation was increased to 5 L. With the treatment, breathing became more regular . Death Pronouncement . Reported by CN that the pt stopped breathing at around 10 pm. Pt was seen and examined at the bedside . AP 1 stated she was the on-call physician and provided medical care to Resident 1 on [DATE]. AP 1 stated when she arrived in Resident 1's room after the reported fall, Resident 1 was already in bed. AP 1 stated she evaluated the patient and instructed the CN to apply steri-strips on the laceration and apply cold compress. AP 1 stated the report that she received from the CN did not include the amount of blood found on the floor and the possibility of Resident 1's head hitting the bedside drawer when she rolled out of her bed. AP 1 stated the goals of care was comfort care and no escalation of care outside of the unit. AP 1 stated, I can't tell if [Resident 1] sustained a skull fracture from the fall without an x-ray (type of radiation called electromagnetic waves, creates pictures of the inside of your body, the images show the parts of the body in different shades of black and white to check for broken bones). I did not order any procedure. The goals of care was Palliative Care. During a review of the facility's policy and procedure (P&P) titled, Resident Care Plan (RCP), Resident Care Team (RCT), and Resident Care Conference (RCC), dated 9/2023, the P&P indicated, . 4. Comprehensive Care Plan . c. The comprehensive care plan shall include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial (pertains to the influence of social factors on an individual's mind or behavior) needs that were identified in the comprehensive assessment . 7. Developing Interventions . b. Interventions are specific, individualized and describe the team member(s) responsible for carrying it out and the frequency of conducting interventions . c. Interventions reflects standards of current professional practice . During a review of the facility's document titled, Job Description . Registered Nurse, dated 7/2022, the document indicated, . Under general supervision, performs nursing duties in hospitals, clinics, sanitariums, and other institutions . keeps related charts and records in accordance with standard practices . carrying out existing methods and procedures relating to various aspects of patient care . During a review of the facility's document titled, Job Description . Patient Care Assistant / Certified Nursing Assistant, dated 7/2023, the document indicated, . Under general supervision of a licensed nurse, the Certified Nursing Assistant (CNA) performs a variety of routine duties involving care of medically or mentally ill acute or sub-acute patients; performs direct patient care; observes and reports changes in the behavior and physical status of patients . During a review of the Lippincott Manual of Nursing Practice 10th Edition dated 2014, page 16-17 indicated, Standards of practice General Principles .These standards provide patients with a means of measuring the quality of care they receive. Common Departures from the Standards of Nursing Care .failure to adhere to facility policy or procedural guidelines .