Every finding on record at Las Flores Convalescent Hospital

Based on interview and record review, the facility failed to inform the physician of abnormal laboratory results for one of two sampled residents (Resident 1) when Resident 1's labs were not reviewed until after Resident 1's transfer to a General Acute Care Hospital (GACH).This deficient practice resulted in Resident 1's physician not being aware of Resident 1's labs.Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), chronic kidney disease, stage 4 (severe kidney damage), and pneumonia (an infection/inflammation in the lungs).During a review of Resident 1's History & Physical (H&P) dated 3/6/2026, the H&P indicated Resident 1 could make needs known but could not make medical decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 1's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for eating, oral and personal hygiene, toileting, showering/bathing, and upper and lower body dressing.During a review of Resident 1's Change of Condition Evaluation (COC) dated 3/24/2026, the COC indicated on 3/24/26 at 5:40 a.m., Resident 1 was noted with desaturation (low blood oxygen) and tachycardia (faster than normal heart rate) and transferred to the GACH on 3/24/2026 at 5:45 a.m.During a review of Resident 1's progress notes, dated 3/20/2026 through 3/24/2026, the progress notes indicated on 3/20/2026, the nurse practitioner examined Resident 1, ordered labs, and the labs were carried out. The progress notes indicated between 3/20/2026 through 3/24/2026, there was no documentation if the lab results were reviewed or if the physician was notified of the results.During a concurrent interview and record review on 8/14/2026 at 12:32 p.m. with Registered Nurse 1 (RN 1), Resident 1's Lab Results Report, dated 3/22/2026, was reviewed. The report indicated the labs were collected and received on 3/20/2026 at 4:25 a.m. and reported to the facility on 3/22/2026 at 12:30 a.m. The report indicated the labs were reviewed by the facility on 3/24/2026 at 3:21 pm. The report indicated numerous labs were out of normal range. RN 1 stated lab results come into the facility's computer automatically from the lab. RN 1 stated all lab results, whether within or outside of normal ranges, were to be reported to the ordering physician and documented in the resident's progress notes. RN 1 stated there was no documentation indicating the physician was notified of the results.During a review of the facility's Policy and Procedure (P&P) titled, Change of Condition Notification, dated 2/20/2026, the P&P indicated the attending physician would be notified when there was a need to alter treatment significantly based on lab results.During a review of the facility's P&P titled, Resident Rights - Quality of Life, dated 5/1/2023, the P&P indicated not reporting lab results to the attending physician violated the resident's right to quality care, dignity, and respect.

Based on observation, interview and record review, the facility failed to ensure resident call lights were placed within reach, for three of four sampled residents (Residents 1, 2 and 3). This failure resulted in the residents being unable to reach the call lights and had the potential that residents could not call nurses for help when immediate assistance is needed. This failure had to potential to negatively impact the residents' psychosocial well-being and delay in proving the needed care and services.Findings: a). During a concurrent observation and interview on 7/24/2026 at 9:45 a.m., in Resident 1's room, Resident 1's touch call light (a unit to press when resident need nurse's help) was observed on the floor, on the right side of the bed. Resident 1 was unable to reach the call light and was unable to communicate when asked about it. Licensed Vocational Nurse (LVN) 1 entered the room and observed the call light on the floor. LVN 1 stated that the call light should be within Resident 1's reach so nurses can respond promptly to Resident 1's needs. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the right non-dominant side, muscle weakness (reduction in the strength of muscles) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's History and Physical examination (H&P) dated 12/24/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/15/2026, the MDS indicated Resident 1 had cognitive impairment. The MDS indicated Resident 1 was dependent assistance on staff with Activities of Daily Living (ADLs) such as dressing, toilet use, shower/bathing, transfer and mobility. During a review of Residents 1's care plan titled, ADL self-care performance deficit related to confusion, generalized muscle weakness, dated 4/16/2025, the intervention indicated to encourage the residents to use bells to call for assistance. b). During a concurrent observation and interview on 7/24/2026 at 9:55 a.m., with LVN 1 in Resident 2's room, Resident 2's call light was observed on the left side of her arm, underneath a pillow. When Resident 2 was asked for the call light, she was unable to reach it. Resident 2 stated, My left arm is paralyzed (incapable of movement). Resident 2 stated that she call the nurse when she needs pain medication. Resident 2 stated that the call light should be placed on her right side, on top of her bedside table, so she can easily reach it. LVN 1 placed the call light on top of Resident 2's bedside table and stated that the call light should be placed on Resident 2's functional side. LVN 1 stated that call lights must be kept close to the residents so that they can contact the nurses in case of an emergency. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included contracture of the left elbow (elbow stiff, limiting its range of motion and affecting daily activities). Epilepsy (Epilepsy is a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures), and dementia. During a review of Resident 2's H&P dated 6/8/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Residents 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was dependent on staff with ADLs such as dressing, toilet use, shower/bathing, transfer and mobility. During a review of Residents 2's care plan titled, ADL self-care performance deficit related to generalized muscle weakness, dated 4/16/2025, the intervention indicated to encourage the resident to use bell to call for assistance. c) During a concurrent observation and interview on 7/24/2026 at 10:05 a.m., with Certified Nurse Assistant (CNA 1), in Resident 3's room, Resident 3's call light was observed out of reach and was hanging behind the bed. When Resident 3 was asked about the call light, she pointed toward the wall and was unable to reach it (call light). Resident 3 stated, She needs the call light to call for the nurses. I need assistance from the nurses to change my brief. CNA 1 stated that call lights must be kept close to residents. CNA 1 stated that if Resident 3 needs help, nurses could not attend to the resident's needs promptly. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included metabolic encephalopathy (is a reversible brain dysfunction caused by an underlying metabolic disturbance), epilepsy and muscle weakness. During a review of Resident 3's H&P dated 3/22/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions but is capable to make decisions for activities of daily living. During a review of Residents 3's MDS dated [DATE], the MDS indicated Resident 3 had moderate cognitive impairment. The MDS indicated Resident 3 was dependent assistance on staff with ADLs such as dressing, toilet use, shower/bathing, transfer and mobility. During a review of Residents 3's care plan titled, Resident has a functional abilities deficit, dated 9/22/2023, the intervention indicated keep call system within reach and answer promptly. During an interview on 7/24/2026 at 2:00 p.m. with the Director of Nursing (DON), the DON stated that call lights must be placed close to the residents and within reach. The DON explained that if a resident has weakness in one extremity, the call light should be positioned on the unaffected side. In an emergency, residents must be able to reach the call light to request assistance. The DON emphasized that all nurses are responsible for checking the placement of call lights. During a review of facility's policy and procedures (P&P) titled, Call System, dated 10/24/2022, the P&P indicated the call system should be accessible to a resident lying on the bed, in toileting and bathing facilities. Call cords will be placed within the resident's reach in the resident's room.

Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan for one of four sampled residents' (Resident 4) refusal of nicotine patch (transdermal patches that deliver a steady dose of nicotine through the skin to help reduce cravings and withdrawal symptoms such as restlessness, low mood, irritability, and poor concentration). This deficient practice resulted in no further interventions provided and had the potential to delay the resident's goal to quit smoking.Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4 diagnoses included anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome) insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep) and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). During a review of Resident 4's History and Physical examination (H&P) dated 10/20/2025, the H&P indicated Resident 4 had the capacity to understand and make medical decisions. During a review of Residents 4's Minimum Data Set (MDS - a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 4 had intact cognition. Resident 4 required supervision or touching assistance with staff on Activities of Daily Living (ADLs) such as dressing, toilet use, transfer and mobility. Resident 4 was independent of toileting hygiene, shower/ bathing self. During a review of Resident 4's Physicians Orders dated 7/1/2025, the physician's orders indicated an order of Nicotine Transdermal Patch 24 hours 21 milligrams (mg), one time a day for smoking cessation for 1 week and removed per schedule. During a review of Resident 4's Physicians Orders dated 7/10/2025, the physician's orders indicated Nicotine Transdermal Patch 24 hours 14 mg, transdermal (on the skin) one time a day for smoking cessation for 1 week and removed per schedule. During a review of Resident 4's Medications Administration Record (MAR) for the month of 7/2026, the MAR indicated Resident 4 refused the Nicotine transdermal patch on the following dates:1). Nicotine transdermal patch 21mg, on 7/3/2026, 7/4/2026, 7/5/2026, 7/7/2026 and 7/8/2026.2). Nicotine transdermal patch 14 mg, on 7/10/2026, 7/11/2026 and 7/12/2026. During a review of Resident 3's Care Plan, there was no care plan created for Resident 3's refusal of nicotine transdermal patches. During a concurrent interview and record review on 7/24/2026 at 1:17 p.m., with Licensed Vocational Nurse (LVN) 2, the MAR for 7/2026 was reviewed. LVN 2 stated that, based on the MAR, Resident 4 refused the 21 mg nicotine patches for the entire week and refused the 14 mg patches for three days. LVN 2 stated that when residents refuse medications for consecutive days, it is the nurse's responsibility to inform the physician and create a care plan addressing the refusal. LVN 2 explained that developing a care plan for refusal was important to identify interventions and ensure proper care was provided to Resident 4. During an interview on 7/24/2026 at 2:00 p.m. with the Director of Nursing (DON), the DON stated that when residents continue to refuse medications, nurses must notify the physician. The DON stated that nurses must create a care plan addressing the refusal. The DON explained that addressing the refusal of the nicotine patches was important because the facility needs to determine the reason why Resident 4 refused the medications. During a review of the facility's policy and procedures (P&P) titled, Care Planning, dated 10/24/2022, the P&P indicated the care plan should describe the services to be furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being and any services that would be required but were not provided due to the resident's exercise of rights, which included the right to refuse treatment.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4), received the nicotine transdermal patch (which delivers nicotine through the skin to help reduce smoking cravings) as ordered and notify the physician when the resident refused the medications. These failures placed the resident at risk for withdrawal symptoms such as restlessness, low mood, irritability, and poor concentration, which can affect the Resident 4's ability to maintain their highest practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome) insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep) and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). During a review of Resident 4's History and Physical (H&P) dated 10/20/2025, the H&P indicated Resident 4 had the capacity to understand and make medical decisions. During a review of Residents 4's Minimum Data Set (MDS - a resident assessment tool) dated 5/22/2026, the MDS indicated Resident 4 had intact cognition. The MDS indicated Resident 4 required supervision or touching assistance on staff with Activities of Daily Living (ADLs) such as dressing, toilet use, transfer and mobility. Resident 4 was independent of toileting hygiene, shower/ bathing self. During a review of Resident 4's Physicians Orders dated 7/1/2025, the physician's orders indicated an order for Nicotine Transdermal Patch 24 hours 21 milligrams (mg), one time a day for smoking cessation for 1 week and remove per schedule. During a review of Resident 4's Physicians Orders dated 7/10/2025, the physician's orders indicated an order for Nicotine Transdermal Patch 24 hours 14 mg, one time a day for smoking cessation, for 1 week and remove per schedule. During a review of Resident 4's Physician Orders dated 7/24/2026 the physician's orders indicated Resident 4 had an order for Nicotine Transdermal Patch 24 hours 7 mg apply transdermal one time a day for smoking cessation for 1 week and removed per schedule. During a review of Resident 4's Medications Administration Record (MAR) for the month of 7/2026, the MAR indicated Resident 4 refused Nicotine transdermal patch on the following:a). Nicotine transdermal patch 21mg on 7/3/2026, 7/4/2026, 7/5/2026, 7/7/2026, 7/8/2026.b). Nicotine transdermal patch 14 mg on 7/10/2026, 7/11/2026, 7/12/2026. During an interview on 7/24/2026 at 10:20 a.m., with Resident 4 in Resident 4's room, Resident 4 stated, The doctor told me he would give me nicotine patches to help me quit smoking. I am craving cigarettes; I need the patches. Resident 4 reported receiving only Nicotine patch 7 mg since 7/14/2026 and stated, I have never received the 21 mg or 14 mg patches. Resident 4 stated I do not recall refusing the medications. During a concurrent interview and record review on 7/24/2026 at 2:00 p.m., with the Director of Nursing (DON), Residents 4's progress notes were reviewed. The DON stated Residents 4's progress notes did not indicate the nurses had informed the physician regarding the nicotine patches that were not given to Resident 4. The DON stated it was important to determine the reason why Resident 4 refused the medication. When Resident 4 continued to refuse the medication (Nicotine patch), the nurses should have notified the physician so that alternative medicine can be considered or the medication regimen can be restarted. During a concurrent observation and interview on 7/24/2026 at 3:00 p.m. with Licensed Vocational Nurse (LVN) 2, medication cart station 2 was checked. Resident 4's Nicotine patch 21 mg box had 14 patches. LVN 2 stated that the 21 mg Nicotine patch box was full. LVN 2 stated I do not know why the Nicotine 21 mg box are still full. LVN 2 stated that if medications were no longer in use, they should be discarded. During a review of facility's policy and procedures (P&P) titled Medication Administration dated 5/1/2018, the P&P indicated if resident repeatedly refuse a medication, the Licensed Nurse should contact the physician to discuss alternatives measures for medications administration. During a review of facility's P&P titled, Refusal of treatment, dated 5/1/2023, the P&P indicated when resident refuse a treatment, the charge nurse or Director of Nursing interviews the resident to determine why the resident refused the treatment. The charge nurse or DON will document information relating to the refusal in residents' medical records, including the date and time the Attending Physician was notified and his or her response.

Based on observation and interview, the facility failed to ensure expired and unlabeled food items were not in the kitchen.This deficient practice had the potential to cause foodborne illnesses for residents.Findings:During the initial kitchen tour observation of Freezer 1, on 5/6/2026 at 8:22 a.m., with the Dietary Services Supervisor (DSS), two opened frozen pizzas were observed in the freezer with expiration of 4/30/2026. The DSS stated the pizzas should have been discarded. The DSS stated the risk of having expired food items could result in residents falling ill if food was consumed. During an observation of the Walk-In Fridge 1, on 5/6/2026 at 8:28 a.m., a storage container of lettuce heads was observed with an expiration date of 4/25/2026 and an opened bag of sliced cheese had an expiration date of 5/4/2026. The DSS stated the risk of not discarding expired food could result in foodborne illnesses amongst residents.During an observation of Refrigerator 1, on 5/6/2026 at 8:36 a.m., two opened cartons of 2% reduced fat milk and a 32-ounce-bottle of coffee creamer was observed with no labels. The DSS stated the risk of not labeling food items could result in expired food.During an observation of the spices seasoning rack, on 5/6/2026 at 8:44 a.m., one 5-pound paprika seasoning bottle and one 5-pound garlic seasoning bottle were observed without a label. The DSS stated all opened food items should have a label with an open date and use by date. The DSS stated the risk of not labeling spices used for food could result in expired seasonings.During a review of the facility's policy and procedures (P&P), titled Food Storage, revised 5/1/2018, the P&P indicated to label and date all food items and food items will be stored, thawed, and prepared in accordance with good sanitary practice.

Based on observation and interview, the facility failed to provide dignity and respect for one of four sampled residents (Resident 67) when his indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine) collection bag was not covered with a privacy cover.This deficient practice resulted in Resident 67 feeling embarrassed that people could see his urine.Findings:During a review of Resident 67's admission Record, the admission record indicated Resident 67 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 67's diagnoses included retention of urine (inability to fully empty the bladder), unspecified urethral stricture (a narrowing of the urethra-the tube carrying urine out of the body), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 67's Minimum Data Set (MDS-a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 67 was able to understand and be understood by others. The MDS indicated Resident 67's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 67 was dependent (helper does all of the effort) on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear.During a review of Resident 67's History & Physical (H&P) dated 2/23/2026, the H&P indicated Resident 67 had the capacity to understand and make decisions.During a concurrent observation and interview on 5/5/2026 at 11:30 a.m. with Resident 67 in Resident 67's room, Resident 67's indwelling urinary catheter bag was not covered, which exposed the urine in the bag. Resident 67 stated he would feel embarrassed if people saw the bag of urine.During a concurrent observation and interview on 5/6/2026 at 10:19 a.m. with Certified Nursing Assistant (CNA 2) in Resident 67's room, Resident 67's indwelling urinary catheter bag was not covered. CNA 2 stated the bag should be covered for Resident 67's privacy.During a review of the Policy and Procedure (P&P) titled Privacy and Dignity revised May 01, 2018, the policy indicated residents are afforded a right to privacy and confidentiality.

Based on interview and record review, the facility failed to obtain and document informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five residents (Resident 9) prior to administering treatment with psychoactive medications (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior.)This deficient practice violated Resident 9 and Resident 9's Responsible Party (RP)'s right to make an informed decision regarding the use of psychoactive medications. Findings:During a review of Resident 9's admission Record, the admission record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), anxiety disorder (persistent fear or worry that interferes with daily life), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission record indicated Resident 9's sister was Resident 9's responsible party and Resident 9's daughter was Resident 9's emergency contact.During a review of Resident 9's History and Physical (H&P) dated 1/6/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS-a resident assessment tool) dated 3/20/2026, the MDS indicated Resident 9's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 9 was dependent (helper does all for the effort) on staff for toileting, showering, and mobility.During a review of Resident 9's physician order, dated 1/6/2026, the physician order indicated to administer Escitalopram Oxalate (medication used for major depressive disorder) Oral Tablet 20 milligrams (mg, unit of measurement), 1.5 tablet by mouth daily.During a review of Resident 9's physician order, dated 3/10/2026 the physician order indicated to administer Seroquel (medication used for schizoaffective disorder) Oral Tablet 150 microgram (mcg, unit of measurement) give three 50 mcg tablets by mouth at bedtime.During a review of Resident 9's physician order, dated 3/19/2026, the physician order indicated to administer Duloxetine HCL (medication used for major depressive disorder) Oral Capsule Delayed Release Sprinkle 30 mg give three capsules by mouth dailyDuring a review of Resident 9's physician order, dated 3/20/2026, the physician order indicated to administer Buspirone HCL (medication used to treat anxiety disorder) Oral Tablet 7.5 mg by mouth twice daily.During a review of Resident 9's Medical Administration Record (MAR) dated 5/1/2026 - 5/31/2026, the MAR indicated Buspirone HCL, Duloxetine HCL, Escitalopram Oxalate, and Seroquel were administered as ordered from 5/1/2026 through 5/7/2026.During a concurrent interview and record review on 5/7/2026 at 3:45 p.m. with the Director of Nursing (DON), Resident 9's Psychotherapeutic Drug Informed Consents for duloxetine HCL 90 mg, escitalopram oxalate 20 mg, and Quetiapine (brand name for Seroquel) 100 mg, dated 1/6/2026, were reviewed. The Informed Consents indicated there were no signatures from the Prescriber (physician), Resident 9 or Resident 9's RP. The DON stated there were no signatures on the consents because Resident 9 did not have the capacity to make decisions and Resident 9's family refused to be involved in decision-making. The DON stated the facility should have had an IDT (Inter Disciplinary Team) meeting regarding consent before the medications were administered.During a review of the facility's Policy and Procedure (P&P) titled Informed Consent revised 1/6/2026, the P&P indicated the Attending Physician/LHP (Licensed Healthcare Practitioner) will obtain an informed consent from the resident or authorized representative before administration of a therapy requiring informed consent. The use of an informed consent will be done for but not limited to psychotherapeutic drugs.

Based on interview and record review, the facility failed to ensure an interdisciplinary team ([IDT] team members from different disciplines who come together to discuss resident care) meeting was conducted after a Significant Change in Status Assessment ([SCSA]) - a comprehensive assessment that must be completed when the IDT has determined that a resident meets the significant change guidelines for either improvement or decline) for one of one sampled resident (Resident 10).This deficient practice violated Resident 10's and his representative's rights to be fully informed and had the potential to result in a delay of care and services.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness (a loss of strength throughout most of the body, causing fatigue, and difficulty performing daily tasks).During a review of Resident 10's Census Report, the Census Report indicated Resident 10 was discharged to General Acute Care Hospital (GACH) on 11/15/2025 under medical hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) and readmitted to the facility on [DATE] under Medicare skilled nursing care (daily nursing or rehabilitation services that can only be safely and effectively performed by, or under the supervision of, professional medical personnel).During a review of Resident 10's History and Physical (H&P), dated 11/23/2025, the H&P indicated Resident 10 did not have the capacity to understand and make decisions.During a review of Resident 10's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 10's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor, cues and supervision required). The MDS indicated Resident 10 was dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a concurrent interview and record review on 5/6/2026 at 11:34 a.m., with Minimum Data Set Nurse 1 (MDSN 1), Resident 10's IDT Care Conference Notes, were reviewed. MDSN 1 stated Resident 10 was discontinued from hospice service on 11/15/2025 (the day he was sent to General Acute Care Hospital [GACH]) and readmitted to the facility on [DATE] under skilled care services (daily nursing or rehabilitation services that can only be safely and effectively performed by, or under the supervision of, professional medical personnel) for rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) to improve his physical function. MDSN 1 stated there was no IDT care conference meeting with Resident 10's and his representative after a SCSA from hospice care to skilled care on 11/20/2025. MDSN 1 stated an IDT care conference meeting should be conducted every 3 months, as needed, and if there was a significant change in the resident's status. MDSN 1 stated Resident 10 had a change in care, treatment, and interventions that would warrant an IDT care conference meeting. MDSN 1 stated it was important to conduct an IDT care conference meeting with Resident 10 and his representative so they would know Resident 10's change of plan of care.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 10/24/2022 the P&P indicated, The resident has a right to be informed, in advance, of changes to the plan of care. The P&P also indicated the facility will invite the resident, if capable, and their family to care plan meetings.Cross Reference: F637

Based on interview and record review, the facility failed to accommodate the needs and preferences of one out of three sampled residents (Resident 22) by failing to honor and carry out a physician-ordered therapeutic Out-on-Pass.This deficient practice resulted in Resident 22 not being able to go out on pass when preferred. Findings:During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including acute bronchiolitis (lung infection when the lungs get swollen and filled with mucus), dysphagia (difficulty swallowing), Type II diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypothyroidism (a condition where the thyroid gland does not make enough hormones, causing the body to slow down).During a review of Resident 22's History and Physical (H&P) dated 2/12/2026, the H&P indicated Resident 22 had the capacity to understand and make decisions.During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool) dated 2/22/2026, the MDS indicated Resident 22's cognition (ability to think and process) was intact. The MDS indicated Resident 22 required supervision for mobility and transfers. The MDS indicated Resident 22 utilized a walker and did not have the ability to walk at least ten feet in a room, corridor or similar space.During a concurrent interview and record review on 5/6/2026 at 1:04 p.m. with the Social Services Assistant (SSA), Resident 22's physician order, dated 4/16/2026, was reviewed. The physician order indicated Resident 22 may go out on pass with family. The SSA stated Resident 22 filed a grievance on 4/20/2026 requesting to go out on weekends, however, Resident 22's only family member lived out of state in Arizona. The SSA stated the grievance, documented by the Social Services Director (SSD), indicated the physician agreed to change the order to require someone to go with Resident 22 due to Resident 22's history of multiple falls with fractures. The SSA stated as of 5/6/2026, the physician order had not been changed since 4/20/2026. During a concurrent interview and record review on 5/6/2026 at 3:43 p.m. with Licensed Vocational Nurse (LVN) 5 and LVN 6, LVN 5 stated the physician's out-on-pass order for Resident 22 indicated Resident 22 may go out on pass with a family member. LVN 5 stated if family member was not available, a staff member could escort the resident, or Social Services (SS) or Administration could coordinate Resident 22's request to go out-on-pass. LVN 6 stated Resident 22 could not go out on pass if a family member was not available and there was nothing that could be done for the Resident.During a concurrent interview and record review on 5/7/2026 at 9:35 a.m. with Registered Nurse (RN) 1, RN 1 stated the SSA informed her of Resident 22's grievance on 5/6/2026 at approximately 4:15 p.m. RN 1 stated the SSA asked her to contact the physician to change the out-on-pass order from go-out-on pass with family to go-out-on pass with an escort. RN 1 stated the SSD did not inform her on 4/20/2026 to call the physician to clarify the out-on-pass order.During a concurrent interview and record review on 5/7/2026 at 1:46 p.m. with the Administrator (ADM), the ADM stated she was familiar with Resident 22's grievance dated 4/20/2026. The ADM reviewed the physician's order for Resident 22 written on 5/6/2026 indicated the resident may go out on pass with family. The ADM stated the nurse was responsible for contacting the physician to request an order change. The ADM stated they did not know why the order was not changed on 4/20/2026 and stated the licensed nurse or designee was responsible for updating the order. The ADM stated if a physician's order was not updated timely, residents may experience dissatisfaction with care, and services and accommodations may be delayed which can affect residents' quality of life and care.During a record review of the facility's policy and procedure (P&P), titled Out on Pass, dated 5/1/2023, the P&P indicated, if the resident's use of the out on pass order conflicted with the resident's plan of care or jeopardizes the resident's safety, facility staff would notify the attending physician of the need to review the resident's status prior to permitting the resident to leave the facility on a pass.

Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a federally mandated resident assessment tool) for Significant Change in Status Assessment ([SCSA]) - is a comprehensive assessment that must be completed when the Interdisciplinary Team ([IDT] - team members from different disciplines who come together to discuss resident care) has determined that a resident meets the significant change guidelines for either improvement or decline) was completed for one of one sampled resident (Resident 10).This deficient practice had the potential to result in inaccurate care and services for Resident 10 due to inappropriate MDS care screening and assessment tool practices.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness (a loss of strength throughout most of the body, causing fatigue, and difficulty performing daily tasks).During a review of Resident 10's Census Report, the Census Report indicated, Resident 10 was discharged to General Acute Care Hospital (GACH) on 11/15/2025 under medical hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) and readmitted to the facility on [DATE] under Medicare skilled nursing care (daily nursing or rehabilitation services that can only be safely and effectively performed by, or under the supervision of, professional medical personnel).During a review of Resident 10's History and Physical (H&P), dated 11/23/2025, the H&P indicated Resident 10 did not have the capacity to understand and make decisions.During a concurrent interview and record review on 5/6/2026 at 11:23 a.m., with Minimum Data Set Nurse 1 (MDSN 1), Resident 10's MDS assessment, dated 11/25/2025, was reviewed. MDSN 1 stated Resident 10's MDS completed on 11/25/2025 was for 5-day scheduled assessment for Medicare Part A Stay (Initial Medicare assessment). MDSN 1 stated the facility did not complete a MDS SCSA for Resident 10. MDSN 1 stated there should be a MDS SCSA because Resident 10 had a change of payor from Medical hospice to Medicare and a significant change in resident's status. MDSN 1 stated Resident 10 was discontinued from hospice service on 11/15/2025. MDSN 1 stated MDS SCSA should be completed within 5 to 7 days after Resident 10 was readmitted to the facility. MDSN 1 stated failure to complete an MDS SCSA would lead to inaccurate care plan of resident.During a review of Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/2025, page 46, indicated an SCSA was required to be performed when a resident receiving hospice services and decided to discontinue those services (known as revoking of hospice care).

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 52) had care plans (a personalized document outlining a resident's health needs, goals, and specific interventions) for diagnosis Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication.)This deficient practice had the potential to result in delayed care and services for Resident 52.Findings:During a review of Resident 52's admission Record, the admission record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses that included DM, anemia (a condition where the body does not have enough healthy red blood cells), and anxiety disorder (persistent fear or worry that interferes with daily life.)During a review of Resident 52's Minimum Data Set (MDS-a resident assessment tool) dated 4/20/2026, the MDS indicated Resident 52 would sometimes be able to understand and be understood by others. The MDS indicated Resident 52's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 52 required partial assistance (helper does less than half the effort) for eating and mobility.During a review of Resident 52's History and Physical (H&P) dated 4/19/2025, the H&P indicated Resident 52 did not have the capacity to understand and make decisions.During a review of Resident 52's physician order, dated 4/30/2026, indicated to administer Humalog (fast-acting insulin that is absorbed quickly and starts working within fifteen minutes of administration) Injection Solution 100 UNIT/ML (Insulin Lispro [generic brand of Humalog]) as per sliding scale (progressive increase in the insulin dose based on pre-defined blood sugar ranges.)During a concurrent interview and record review on 5/8/2026 at 10:38 a.m. with Registered Nurse (RN) 1, Resident 52's Care Plan was reviewed. There were no care plans for DM or insulin use. RN 1 stated there should be a care plan for DM and for insulin so the staff would know what interventions and care to give Resident 52. RN 1 stated Resident 52's sugar could be too low or high, or he could go into a diabetic coma (a life-threatening emergency causing unconsciousness in people with diabetes).During a review of the facility's Policy and Procedure (P&P) titled Care Planning revised 10/24/2022, the P&P indicated a comprehensive care-plan would be developed for each resident based on their individual assessed needs to meet a resident's medical, nursing, mental and psychosocial needs.

Based on observation, interview and record review, the facility failed to ensure oxygen was administered as ordered for one out of one sampled resident (Resident 62).This deficient practice had the potential to lead to oxygen toxicity.Findings:During a review of Resident 62's admission record, the admission record indicated Resident 62 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (a sudden, life-threatening syndrome where the respiratory system fails to properly oxygenate the blood or remove carbon dioxide), sepsis (a life-threatening blood infection), pneumonia (an infection/inflammation in the lungs) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 62 history and physical (H&P), dated 4/20/2026, the H&P indicated Resident 62 had the capacity to understand and make medical decisions.During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool), dated 4/25/2026, the MDS indicated Resident 62's cognitive (thinking) skills were intact. The MDS indicated Resident 62 required substantial assistance (helper does more than half the effort) from staff members with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 62's physician orders, dated 4/17/2026, the physician orders indicated to administer continuous oxygen at 2 liters (a unit of measurement) per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen)During an observation on 5/5/2026 at 3:11 p.m., Resident 62 was observed receiving oxygen at 4 liters per minute via nasal cannula.During a concurrent observation and interview on 5/7/2026 at 8:19 a.m., with Registered Nurse 1 (RN 1) in Resident 62's room, Resident 62's oxygen concentrator was set to 4 liters per minute. RN 1 stated Resident 62 had a physician order for oxygen to be administered. RN 1 stated the physician's order indicated to administer continuous oxygen at 2 liters per minute via nasal cannula. RN 1 stated Resident 62 was receiving 4 liters per minute instead of 2 liters per minute as ordered. RN 1 stated Resident 62 should have been receiving 2 liters per minute. RN 1 stated the risk of administering a higher dosage of oxygen than ordered could result in altered carbon dioxide levels and oxygen toxicity.During a review of the facility's policy and procedures (P&P), titled Oxygen Administration, revised 5/1/2018, the P&P indicated a physician's order was required to initiate oxygen therapy, except in an emergency situation, and the order shall include the oxygen flow rate.

Based on interview and record review, the facility failed to provide medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) such as an outside referral for anger management support group therapy (a structured, supportive environment where people learn to recognize triggers and develop healthy coping skills to manage anger, rather than suppressing it) for one of one sampled resident (Resident 12).This deficient practice placed Resident 12 at risk for increased anxiety and ineffective coping ability that would diminish his quality of life.Findings:During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included anxiety disorder (mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing).During a review of Resident 12's Psychiatric Follow-up Note, dated 10/23/2025, the Psychiatric Follow-up Note indicated Resident 12 continued to experience physical symptoms of anxiety, including muscle tension, restlessness, and occasional shortness of breath, which impacted daily functioning. The Psychiatric Follow-up Note indicated a supportive therapy will continue.During a review of Resident 12's History and Physical (H&P), dated 3/13/2026, the H&P indicated Resident 12 had the capacity to understand and make decisions.During a review of Resident 12's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 12 was able to understand and be understood by others. The MDS indicated Resident 12's cognition (ability to think and process) was intact. The MDS indicated Resident 12 was independent (Resident completes the activity with no assistance from the helper) from staff with Activities of Daily Living ([ADLs] - routine tasks/activities) such as oral hygiene, toileting hygiene, and upper body dressing.During an interview on 5/5/2026 at 10:54 a.m. with Resident 12, Resident 12 stated he verbalized to facility staff that he wanted to attend an anger management support group therapy to release his anxiety. Resident 12 stated facility staff told him the facility did not offer services for anger management support group therapy. Resident 12 stated he was seen by a psychiatrist only once and he wanted to have more treatments to address his anger and anxiety.During an interview on 5/6/2026 at 11:00 a.m. with Social Service Assistant 1 (SSA 1), SSA 1 stated Resident 12 was pleasant and anxious. SSA 1 stated the facility's psychiatrist does not provide group therapy, but facility could have referred Resident 12 to outside resources for anger management support group therapy. SSA 1stated Resident 12 was seen by a psychiatrist on 10/23/2025 and there were no further follow-up treatments. SSA 1 stated it was important for Resident 12 to participate in an anger management support group therapy so they could help him manage his anger and relieve his anxiety. SSA 1 stated Resident 12 would benefit from anger management support group therapy so he could express his emotions and show coping skills that would improve his quality of life and psychosocial well-being.During an interview on 5/8/2026 at 8:37 a.m. with Resident 12, Resident 12 stated SSA 1 visited him 2 days ago and did not offer outside resources for anger management support group therapy.During an interview on 5/8/2026 at 9:23 a.m. with Resident 12, as witnessed by SSA 1, Resident 12 verbalized that he was interested in attending anger management support group therapy.During a review of the facility's policy and procedure (P&P) titled Social Service Program, dated 5/19/2025, the P&P indicated Medically related social services are provided to residents in order to maintain and improve resident's wellbeing. The P&P indicated one of the responsibilities of the Social Services Department was to identify individual and social needs of the resident and to research external support groups, as necessary.

Based on interview and record review, the facility failed to ensure:A Narcotic Key Controlled Release Form (a log signed by licensed nurses during shift change endorsing over responsibility for the controlled substances in the cart) was completed accurately.The Controlled Drug (medications that the use and possession of are controlled by the federal government) Record (a log containing the date, time, quantity, and nurse's signature each time a dose is administered) was completed accurately for one of five sampled residents (Resident 113).These deficient practices increased the risk of loss or diversion of controlled medications.Findings:1. During a concurrent interview and record review on 5/6/2026 at 7:27 a.m. with Licensed Vocational Nurse 1 (LVN 1), medication cart 1 Narcotic Key Controlled Release Form, dated April 2026, was reviewed. LVN 1 stated the Narcotic Key Controlled Release Form for April 2026 was not completed accurately. LVN 1 stated there were missing licensed nurses' signatures of licensed nurses on shift changes on 4/1/2026, 4/16/2026, and 4/27/2026. LVN 1 stated Narcotic Key Controlled Release Form should be signed by an incoming and outgoing licensed nurse completely to validate the amount of controlled drugs remaining. LVN 1 stated there would be a risk for theft and drug diversion if the Narcotic Key Controlled Release Form was not completed accurately.2. During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 113's diagnoses included epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), and sepsis (a life-threatening blood infection).During a review of Resident 113's History and Physical (H&P), dated 2/24/2026, the H&P indicated Resident 113 did not have the capacity to understand and make decisions.During a review of Resident 113's physician's order, dated 2/25/2026, the physician's order indicated Resident 113 was prescribed phenobarbital (controlled medication used to treat seizure disorder) 32.4 milligrams (mg, a unit of measurement) twice a day (9:00 a.m. and 5:00 p.m.)During a review of Resident 113's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/28/2026, the MDS indicated Resident 113's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 113 was dependent (helper does all of the effort) on staff for oral hygiene, toileting hygiene, upper and lower body dressing, and mobility.During a concurrent interview and record review on 5/6/2026 at 7:52 a.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 113's Controlled Drug Record was reviewed. LVN 2 stated there were 23 tablets remaining of phenobarbital 32.4 mg in the bubble pack (a secure, organized method of packaging pills in individual, sealed plastic bubbles, mounted on a card). LVN 2 stated the amount of phenobarbital 32.4 mg remaining in the Controlled Drug Record was 24 tablets. LVN 2 stated Resident 113's phenobarbital medication was not properly accounted for. LVN 2 stated she administered Resident 113's phenobarbital 32.4 mg at 7:20 a.m. and she did not sign the Controlled Drug Record form. LVN 2 stated it is a standard of practice to sign the Controlled Drug Record form after the drug was given or administered for resident's safety.During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 5/1/2018, the P&P indicated the licensed nurse would chart the drug, time administered and initial his/her name with each medication administration.During a review of the facility's P&P titled, Receiving Controlled Substances, dated 1/2018, the P&P indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and recordkeeping requirements by the facility. The P&P indicated controlled substance inventory sheets are completed and filed appropriately.

Based on interview and record review, the facility failed to ensure the removal of one of one sampled resident's (Resident 10) indwelling foley catheter (a hollow tube inserted into the bladder to drain or collect urine) was documented in the resident's progress notes. This deficient practice had the potential for miscommunication, not receiving continuity of care and the potential to not receive the appropriate care and services Resident 10 needs.Findings:During a review of Resident 10's admission Record, the admission Record indicated, Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness (a loss of strength throughout most of the body, causing fatigue, and difficulty performing daily tasks).During a review of Resident 10's History and Physical (H&P), dated 11/23/2025, the H&P indicated, Resident 10 did not have the capacity to understand and make decisions.During a review of Resident 10's Minimum Data Set ([MDS] - a resident assessment tool), dated 3/25/2026, the MDS indicated, Resident 10's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor, cues and supervision required). The MDS indicated, Resident 10 was totally dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing. The MDS indicated, Resident 10 had an indwelling catheter.During a review of Resident 10's physician's order, dated 4/23/2026, the physician's order indicated Resident 10's foley catheter was discontinued.During a concurrent interview and record review on 5/6/2026 at 2:40 p.m., with Treatment Nurse 1 (TN 1), Resident 10's Progress Notes, from 4/15/2026 to 4/30/2026, was reviewed. The TN 1 stated there was no documentation in the Progress Notes by nursing staff indicating Resident 10's foley catheter was discontinued. Resident 10's foley catheter was discontinued and removed on 4/23/2026 because his pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) have been resolved. It was important for the facility to document Resident 10's foley catheter removal in the progress notes so the licensed nursing staff could monitor the resident for urinary retention (a condition in which you are unable to empty all the urine from your bladder). Accurate and complete documentation is very important for the resident's plan of care. During an interview on 5/6/2026 at 4:09 p.m., with the Director of Nursing (DON), the DON stated complete documentation is important for the collaboration of resident's care among facility staff.During a review of the facility's policy and procedure (P&P) titled, Indwelling Catheter, dated 2/24/2026, the P&P indicated to document the date and time in the resident's medical records the removal of indwelling catheter, its quantity and color of urine, and pertinent observations including resident response and tolerance of procedure.During a review of the facility's P&P titled, Nursing Documentation, dated 5/1/2018, the P&P indicated, the facility must provide documentation of resident status and care given by nursing staff.

Based on interview and record review, the facility failed to: 1. Ensure Resident 1 was free from physical abuse when Resident 2 punched Resident 1 in the face.As a result, Resident 1 sustained nasal fractures (broken bones), a nosebleed and bump on the forehead which required a transfer to the general acute care hospital (GACH) for evaluation and treatment.Findings: a. During a review of Resident 1's face sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and major depressive disorder (a mental health condition characterized by persistent and intense feeling of sadness or loss of interest that interferes with daily functioning). During a review of Resident 1's history and physical (H& P), dated 2/3/2026, the H&P indicated Resident 1 had the capacity to make all decisions. During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool), dated 2/24/2026, the MDS indicated Resident 1's cognition (ability to think) was intact. The MDS indicated Resident 1 was dependent upon staff for activities of daily living including dressing, bathing and personal hygiene. Resident 1 was dependent upon a wheelchair for mobility. Resident 1 was 66 inches tall and weighed 300 pounds. Resident 1 required a mechanical lift and the assistance of 2 staff to transfer from the wheelchair. During a review of Resident 1's Change of Condition Evaluation (COC) dated 3/4/2026, the COC indicated Resident 1 was in an altercation with Resident 2 on the smoking resulting in Resident 1 being hit in the face. Resident 1's nose was bleeding and a raised area was noted on the forehead. During a review of Resident 1's plan of care (POC), dated 3/4/26, the POC indicated Resident 1 sustained a nasal fracture and was at risk for further nose bleeds, impaired respiratory exchange, nasal facial pain, edema, bruising and psychosocial issues. During a review of Resident 1's Transfer form, dated 3/4/2026, the transfer form indicated Resident 1 was transferred to the acute care hospital on 3/4/2026 at 6:15 p.m., due to a forehead bump and nosebleed after being punched in the head by Resident 2. During an interview on 3/5/2026 at 1:00 p.m., Resident 1 stated he threw coffee on him (Resident 2) because Resident 2 cussed at him and called him fat. During a review of Resident's 1's GACH emergency department (ED) note, dated 3/4/26, the note indicated Resident 1 had an altercation with another resident in which he was punched in the face. The note indicated Resident 1 was punched and had a nosebleed, hematoma in the middle of his forehead and complained of pain, headaches and dizziness. The notes indicated Resident 1 had a computed tomography (CT scan, a non-invasive imaging procedure to create detailed images of the body) of the facial bone, which revealed the resident had an undetermined nasal bone fracture and a left side orbital (eye) wall medial fracture. b. During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included cerebral ischemia (lack of blood flow to the brain causing brain cells to die) and alcohol dependance (excessive alcohol consumption). During a review of Resident 2's MDS dated [DATE] the MDS indicated Resident 2's cognition was intact. Resident 2 was independent with activities of daily living including eating, upper body dressing and personal hygiene. Resident 2 required partial assistance from staff (staff does less than half the effort) with showering, Resident 2 required supervision (verbal cues only from staff with putting on footwear, lower body dressing and toileting hygiene. Resident 2 was able to walk independently but used a wheelchair for mobility. Resident 2 was 65 inches tall and weighed 142 pounds. During a review of Resident 2's H&P, dated 6/20/2025, the H&P indicated Resident 2 had capacity to understand and make all decisions. During a review of Resident 2's change of condition (COC) form, dated 3/4/2026, the COC indicated Resident 2 and Resident 1 were involved in a verbal and physical altercation resulting in Resident 1 throwing coffee on Resident 2's face. Resident 2 then stood from his wheelchair and hit Resident 1 in the face. During an interview on 3/5/2026 at 1:15 p.m., Resident 2 stated he hit Resident 1 in the nose because Resident 1 threw coffee in his face. Resident 1 was blocking the door with his wheelchair, and Resident 2 could not get out. Later, Resident 2 went out to the patio and Resident 1 said if Resident 2 called him names and cussed at him again, he will throw his coffee at Resident 2. Resident 2 stood up from his wheelchair and told Resident 1 to try it. Resident 1 threw his coffee on Resident 2's face, and Resident 2 hit Resident 1 in his face. During interview on 3/5/2026 at 2:15 p.m., with the Director of Nurses (DON), the DON stated she just received notification from the GACH that Resident 1 had a nasal fracture. When asked if a copy of the x-ray report was available the DON stated they did not have a hard copy of the report yet. During a review of the facility's policy and procedure (P&P) dated 8/1/2023 titled, Abuse Prevention and Prohibition Program indicated each resident had the right to be free from abuse, neglect, and mistreatment. Staff must not permit anyone to engage in verbal, mental, or physical abuse.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), did not develop pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence [any point of the body where the bone is immediately below the skin surface]) at the facility. The facility failed to:1). Implement its policy and procedure (P&P) titled, Pressure Ulcer Prevention which indicated, the facility should develop a care plan for residents at risk for pressure ulcers specific to the resident's risk factors (something that increases the chance of developing pressure ulcer).2). Provide care and services to promote the prevention of pressure ulcer development as indicated in its P&P titled, Pressure Ulcer Prevention. 3). Update Resident 1's care plan with additional interventions (actions), including turning and repositioning, offloading pressure, and address Resident 1's tendency to reposition himself back to his left side when Certified Nurse Assistant (CNA) 1 observed Resident 1 removed the pillows from under the right side of his back and throwing the pillow on the floor. 4). Check Resident 1's skin during Activities of Daily Living (ADL- like shower, bed bath) care and document any changes or findings on Resident 1's ADL Log. These failures resulted in Resident 1 acquiring: 1). Dark purple skin discoloration (a sign of various underlying conditions, including bruising or more serious health issues related to blood circulation) on the left heel on 9/5/2025 2). Dark purple skin discoloration on the first (1st) metatarsal head (bone on the 1st toe) of the right foot on 9/16/2025. 3). Deep tissue pressure injury (DTPI, a serious form of pressure injury) on the right lateral (side) foot and the 1st metatarsal head of the left foot on 9/19/2025. 4). Stage III (3) pressure ulcer (serious wounds characterized by full-thickness skin loss, exposing the underlying fatty tissue, and require immediate medical attention for proper treatment and healing) on the left trochanter (hip) on 9/20/2025.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included muscle weakness, affecting left non-dominant side (left side of the body), unspecified protein-calorie malnutrition (a condition that occurs when the body does not receive enough protein and calories to maintain proper health and functioning, leading to muscle loss, and dysphagia (difficulty swallowing [oral phase]). During a review of Resident 1's History and Physical (H&P) dated 7/2/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/4/2025, the MDS indicated Resident 1 had severe (intense) cognitive impairment (problems with the ability to think and reason). The MDS indicated Resident 1 had an impairment (the state of having a physical condition that limits function) on one side in both upper and lower extremities. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform ADLs such as eating. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff with mobility (the ability to move on bed) such as rolling left and right, changing positions from sitting to lying. The MDS indicated Resident 1 was unable to stand due to medical condition and safety concerns. The MDS indicated Resident 1 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident 1 had no wounds. During a review of Resident 1's Braden Scale (a standardized tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers, or bedsores) Evaluation, dated 6/28/2025, the evaluation indicated Resident 1 was at risk of developing pressure ulcers. During a review of Resident 1's care plan titled, Potential for pressure ulcer development, and/ or impaired skin integrity, dated, 6/30/2025, indicated the following interventions:a). Assess the resident's nutritional status, including weight, weight loss, and serum albumin levels (the amount of albumin protein present in the blood. Normal serum albumin level range 3.4 to 5.4 grams (gm- unit of measurement) per deciliter (g/dL). Abnormal levels can indicate various health issues, such as malnutrition [undernourished], or dehydration [a condition caused by the loss of too much fluid from the body]), if indicated.b). Assess the skin over bony prominences (sacrum [bone at the base of the spine], trochanters [bony prominence on the upper thigh bone], scapulae [bones at the shoulder blade], elbows, heels, inner and outer malleolus [bones on either side of the ankle], inner and outer knees, back of the head). These areas are at highest risk for breakdown resulting from tissue ischemia (restriction in blood supply) from compression (squeezed) against a hard surface.c). Encourage good nutrition and hydration (the process of replacing water in the body) to promote healthier skin.d). Keep skin clean and dry.e). Provide incontinence care promptly after resident's incontinent (uncontrolled urination and defecation) episode. During a review of Resident 1's Order Summary Report, Completed, Discontinued for 9/2025, the Order Summary Report indicated Resident 1 was on No Added Salt diet, Mechanical Soft texture (foods that are soft, easy to chew and swallow), thin consistency (liquids like water, flowing easily through a cup or straw without resistance). Resident 1's Order Summary Report did not indicate the resident was on any vitamins or protein supplements prior to 9/20/2025. During a review of Resident 1's skin assessment dated [DATE], the skin assessment indicated Resident 1 had no skin breakdown on admission. During a review of Resident 1's changes of condition ([COC] a clinical deviation from a resident's baseline), the COC indicated the following: 1). On 9/5/2025, Resident 1 had a dark purple skin discoloration on the left heel (no measurement indicated).2). On 9/16/2025, Resident 1 had a dark purple skin discoloration on the right 1st metatarsal head (no measurement indicated). 3). On 9/19/2025, the physician (MD 2) noted Resident 1 had a DTPI on the right lateral foot measuring 1.5 centimeters ([cm] a unit of measurement) in length ([L]- the measurement from the top to the bottom of the wound, at its longest point), 1 cm in width ([W]- the measurement of a wound from side to side, which is crucial for assessing the size and severity of the injury) and was unable to determine (UTD) the depth ([D]- the distance from the skin's surface to the bottom of the wound) of the wound (L x W x D), and left 1st metatarsal head measuring 2.5 cm x 2 cm x UTD. 4). On 9/20/2025, Resident 1 had Stage 3 pressure ulcer injury to the left hip that measured 1.6 cm x 3 cm x 0.1 cm. The COC indicated Resident 1 had a tendency to position himself back to the affected side, after being repositioned. The COC indicated Resident 1 removed offloading devices (equipment to reduce pressure on skin) such as pillows, despite explanation of risks and benefits. During a review of Resident 1's Interdisciplinary Team ([IDT] group of healthcare professionals [Physician, Director of Nurses, Registered Nurses/ Licensed Vocational Nurses], including resident/ resident representative, working together to develop a plan of care for the resident) meeting for the month of 9/2025, the IDT meetings did not indicate IDT skin committee conducted a meeting (as indicated in the facility's P&P titled Pressure Ulcer Prevention) to discuss and address Resident 1's skin breakdowns on 9/5/2025, 9/16/2025, 9/19/2025 and 9/20/2025, by developing a resident-centered care plan specific to the resident's risk factor such as pressure reduction, positioning and bed mobility. During an interview on 11/21/2025 at 3:14 p.m., with CNA 1, CNA 1 stated she (CNA 1) reported Resident 1's left hip pressure ulcer to the Charge Nurse (date unknown). CNA 1 stated the Charge Nurse was notified about Resident 1 removing the pillows and throwing the pillows on the floor, after being turned and repositioned by staff on his right side. CNA 1 stated Resident 1 always repositioned himself by turning back on his left side (pressure area). CNA 1 stated the Charge Nurse instructed (CNA1) to continue using the pillows and to check Resident 1 more frequently, instead of providing a different intervention to resolve the concern (turning back on his left side [pressure area]). During an interview on 11/25/2025 at 1:46 p.m., with the Director of Nursing (DON), the DON stated Resident 1's shower sheets for the month of 9/2025 could not be found in the resident's clinical records. The DON stated Resident 1's shower sheets should be kept or filed in the resident's chart to ensure communication to other staff if there were any new skin issues identified. During a concurrent interview and record review on 11/26/2025 at 11:08 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 1's ADL Skin Observation Log for 7/2025, 8/2025, and 9/2025, were reviewed. LVN 3 stated the skin observation log had missing documentation of skin observations during: 1). The morning shift (7:00 a.m. - 3:00 p.m.) on 7/23/2025, 8/2/2025, 8/6/2025, 8/9/2025, 8/10/2025, 8/17/2025, 8/27/2025, 8/30/2025 and 9/21/2025. 2). The evening shift (3 p.m. - 11 p.m.) on 7/23/2025, 8/25/2025, 8/28/2025, 8/31/2025 and 9/4/2025. 3). The night shift (11 p.m. - 7 a.m.) on 7/6/2025, 7/11/2025, 7/14/2025, 7/31/2025, 8/5/2025, 8/9/2025, 8/10/2025, 8/22/2025, 8/23/2025, 8/28/2025, 8/31/2025, 9/4/2025, 9/8/2025 and 9/20/2025.LVN 3 stated the missing documentation of skin observations every shift meant staff did not check Resident 1's skin. During an interview on 11/26/2025 at 11:38 a.m., with the Treatment LVN, the Treatment LVN stated Resident 1 could have developed the left hip wound due to prolonged pressure. The Treatment LVN stated pressure sores always started as Stage 1 (intact skin with a localized area of redness or changes in sensation, temperature, or firmness) and progresses to Stage 3 pressure ulcer when interventions to prevent skin breakdown were not implemented. The Treatment LVN stated residents who were bony (thin, so that the bones show under the skin) were at risk for skin breakdown because there were no fat or muscles to protect the skin from breakdown. During a concurrent interview and record review on 11/26/2025 at 2:12 p.m., with Registered Nurse (RN) 2, Resident 1's ADL Skin Observation Log for 7/2025, 8/2025, and 9/2025 were reviewed. RN 2 stated some of Resident 1's ADL skin observation log entries were blank and no charting on:1). The morning shift (7:00 a.m. - 3:00 p.m.) on 7/23/2025, 8/2/2025, 8/6/2025, 8/9/2025, 8/10/2025, 8/17/2025, 8/27/2025, 8/30/2025 and 9/21/2025. 2). The evening shift (3 p.m. - 11 p.m.) on 7/23/2025, 8/25/2025, 8/28/2025, 8/31/2025 and 9/4/2025. 3). The night shift (11 p.m. - 7 a.m.) on 7/6/2025, 7/11/2025, 7/14/2025, 7/31/2025, 8/5/2025, 8/9/2025, 8/10/2025, 8/22/2025, 8/23/2025, 8/28/2025, 8/31/2025, 9/4/2025, 9/8/2025 and 9/20/2025.RN 2 stated, if they were not charted, it meant the CNA did not check the resident's skin. RN 2 stated not checking the resident's skin was a problem because if the wound had developed or started, it would not be identified early. RN 2 stated Resident 1 did not have any wounds when admitted to the facility on [DATE]. During concurrent interview and record review on 12/5/2025 at 12:02 p.m., with Treatment LVN, Resident 1's care plan titled, Potential for Pressure Ulcer Development and/or Impaired Skin Integrity, dated 6/30/2025, was reviewed. The Treatment LVN stated interventions should have included repositioning Resident 1 every two (2) hours or more, waffle boots for protection on the feet, pillows between knees, legs, heels, or whatever area Resident 1 was laying on to relieve pressure. The Treatment LVN stated the care plan did not include turning and repositioning, which could mean nursing staff were not repositioning Resident 1. The Treatment LVN stated the facility did not revise Resident 1's care plan when Resident 1 always repositioned himself back on his left side, which was the affected area (with Stage 3 pressure sore). The Treatment LVN stated the facility had no documentation indicating to reposition Resident 1 every 2 hours was done nor was part of Resident 1's care. During a review of facility's P&P titled, Pressure Ulcer Prevention, dated 5/1/2018, the P&P indicated the facility should identify residents at risk for pressure ulcers and provide care and services to promote prevention of pressure ulcer development. The P&P indicated the licensed nurse should develop a care plan specific to the resident's risk factor such as pressure reduction, positioning, mobility and nutrition in consultation with the attending physician, interdisciplinary team- skin committee, Registered Dietitian, Director of Rehab Services. The P&P indicated nursing staff should monitor interventions for effectiveness and resident tolerance. The P&P indicated the care plan should be revised as indicated. The P&P indicated CNAs should inspect the resident's skin during ADL care, complete body checks on resident shower days and report unusual findings to the Licensed Nurse and the Licensed Nurse should document effectiveness of pressure ulcer prevention techniques in the resident's clinical record on a weekly basis. During a review of facility's P&P titled, Care Planning, dated 10/24/2022, the P&P indicated a comprehensive person-centered care plan should be developed for each resident based on their individual assessed needs. The P&P indicated the IDT should develop a comprehensive care plan for each resident based on MDS guidelines. The P&P indicated the care plan should serve as the course of action where the resident and resident's IDT work to address the resident's medical and nursing needs. The P&P indicated the resident's comprehensive care plan should describe the services to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. The P&P indicated, the IDT should revise the Comprehensive Care Plan as needed to address changes in care and as dictated by changes in the resident's condition

Based on interview and record review, the facility failed to prevent one of six sampled residents (Resident 1) from having unplanned severe (greater than 5 percent weight loss in one month) weight loss by failing to:Implement Resident 1's Care Plan titled, Has Potential for Nutrition Problems which indicated to monitor and document Resident 1's meal percentage consumed for each meal. Implement Resident 1's Care Plan titled, Malnourished as evidenced by Nutritional Screening Tool Score of 02, which indicated to offer supplement to Resident 1 if his intake was below 50 percent. Follow the Registered Dietician's (RD) recommendations on 7/14/2025 and 9/3/2025 to provide large-portion meals to Resident 1. 4. Conduct an interdisciplinary Team ([IDT] group of healthcare professionals working together to plan the care needed for each resident) meeting to address Resident 1's unplanned severe weight loss on 9/1/2025 and make recommendations or Care Plan to prevent further weight loss. These failures resulted in Resident 1 having severe weight loss of 12.6 pounds (lbs.) from 8/4/2025 to 9/1/2025 (within 28 days) and 15 pounds from 9/15/2025 to 9/23/2025 (within 8 days). Resident 1 was transferred to the General Acute Care Hospital (GACH) and underwent a Percutaneous Endoscopic Gastrostomy (PEG) tube placement (a feeding tube that is inserted directly into the stomach for administering nutrition, fluids for residents who have difficulty swallowing or cannot get enough nutrition by mouth). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included hemiplegia(total paralysis of the arm, leg and trunk on the same side of the body) and hemiparesis (weakness on one side of the body affecting the arm and/or face) following cerebral infarction (loss of blood flow to a part of the brain) affecting the left non-dominant side, unspecified protein-calorie malnutrition (serious condition from not getting enough protein and calories, causing poor growth, weight loss, weakened immunity and organ dysfunction), and dysphagia (difficulty swallowing). During a review of Resident 1's Nutritional Evaluation dated 6/30/2025, the Evaluation indicated Resident 1 had a score of 0-7 points (reference range 12-14 points, normal nutritional status, 8-11 points at risk of malnutrition, 0-7 points malnourished).During a review of Resident 1's Care Plan titled, Has potential for Nutrition Problems dated 6/30/2025, the Care Plan interventions indicated for RD to evaluate and make diet change recommendations as needed (PRN). The Care Plan interventions indicated the facility would monitor and record the Resident's intake on each meal. During a review of Resident 1's Care Plan titled, Malnourished as evidenced by Nutritional Screening Tool score of 02 dated 6/30/2025, the Care Plan indicated Resident 1 was at risk for increased susceptibility to infections, muscle wasting/weakness, chronic diseases, impaired wound healing, cognitive impairment, dehydration, constipation, weight loss, low Body Mass Index ([BMI - a calculation that uses a person's weight and height to estimate whether someone is at a healthy weight]). The Care Plan goal indicated Resident 1 would receive adequate nutrition and avoid weight loss as much as possible. The Care Plan Interventions included to record meal percentage for every meal and offer supplement to Resident 1 if intake was below 50%.During a review of Resident 1's History and Physical (H&P) dated 7/2/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/4/2025, the MDS indicated Resident 1 had severe cognitive impairment (problems with the ability to think and reason). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to perform Activities of Daily Living (ADLs) such as eating and was dependent (helper does all of the effort) for bed mobility (the ability to move) such as rolling left and right, changing positions from sitting to lying.During a review of Resident 1's Nutritional assessment dated [DATE], the Nutritional Assessment indicated Resident 1 was visually assessed as underweight with low albumin (blood test used to check general health and nutrition) level of 3.3 grams per deciliter ([g/dl] unit of measurement, therapeutic range of 3.5-5.7 g/dl). The Nutritional Assessment indicated Resident 1 was 146 lbs., with an ideal body weight (IBW) of 178 lbs. (32 lbs. under IBW) and BMI of 19.9. The Nutritional Assessment indicated Resident 1 was at risk for weight loss, due to low BMI. The Nutritional Assessment indicated the RD's Nutritional interventions and recommendations included to provide a mechanical (mech) soft diet with large portions to Resident 1. During a review of Resident 1's Physician's Orders dated 7/2025 -8/2025, the Orders did not indicate Resident 1 had Physician's orders for large portions during meals. During a review of Resident 1's Weight Summary dated 8/4/2025, the Summary indicated Resident 1 weighed 148.6 lbs., on 8/4/2025. During a review of Resident 1's COC, dated 9/2/2025, the COC indicated Resident 1 weighed 136 lbs., on 9/2/2025 (8.5% weight loss in one month compared to 8/4/2025). The COC indicated the physician recommended to implement weekly weights and refer to RD. During a review of Resident 1's RD Nutritional/Dietary Note dated 9/3/2025, the Nutritional/Dietary Note indicated Resident's weight was 136 lbs., weight loss of 12.6 lbs. (8.5%) in one month and BMI of 18.4. The Nutritional Dietary/Note indicated to provide large portions at meals for the Resident. During a review of Resident 1's Physician's Orders for the month of 9/2025, the Orders did not indicate Resident 1 had Physician's orders for large portions during meals. During a review of Resident 1's ADL Meal Logs dated 8/2025 and 9/2025, the Logs did not indicate Resident 1's intake percentages were recorded for the following meals: 8/2/2025 for breakfast and lunch 8/6/2025 for breakfast and lunch 8/9/2025 for breakfast and lunch 8/10/2025 for breakfast and lunch 8/17/2025 for breakfast and lunch 8/25/2025 for dinner 8/26/2025 for lunch 8/27/2025 for breakfast and lunch 8/28/2025 for dinner 8/29/2025 for dinner8/30/2025 for breakfast and lunch 8/31/2025 for dinner 9/4/2025 for dinner 9/21/2025 for breakfast and lunch The ADL Meal Log also indicated the following intake percentages for Resident 1: 0-25% on 8/20/2025, 9/11/2025, 9/15/2025-9/16/2025, 9/18/2025-9/19/2025, 9/22/2025-9/23/2025 for breakfast, 9/15/2025, 9/18/2025, 9/22/2025- 9/23/2025 for lunch, 9/5/2025, 9/13/2025-9/14/2025 for dinner 26-50% on 8/2/2025, 8/8/2025, 8/10/2025 and 8/13/2025, 9/15/2025-9/16/2025 and 9/22/2025 for dinner, 9/7/2025, 9/12/2025- 9/14/2025 and 9/20/2025 for breakfast, 9/12/2025-9/14/2025, 9/16/2025, 9/19/2025-9/20/2025 for lunch. During a review of Resident 1's Nutrition-Nourishment and Nurses Notes dated 8/2025 and 9/2025, the Nutrition-Nourishment and Nurses Notes did not indicate Resident 1 was provided supplement for intakes of less than 50% on 8/20/2025, 9/11/2025, 9/15/2025-9/16/2025, 9/18/2025-9/19/2025, 9/22/2025-9/23/2025 for breakfast, 9/15/2025, 9/18/2025, 9/22/2025- 9/23/2025 for lunch, 9/5/2025, 9/13/2025-9/14/2025 for dinner.During a review of Resident 1's active Care Plans dated 9/2025, the Care Plans did not address Resident 1's actual and severe weight loss after it was identified on 9/1/2025.During a review of Resident 1's Weight Summary dated 9/15/2025 and 9/23/2025 sequentially, the Summary indicated Resident 1 weighed 139.2 lbs., on 9/15/2025 and 128.6 lbs., on 9/23/2025 (a total weight loss of 15 lbs. [11%]) During a review of Resident 1's Nurse Note dated 9/24/2025, the Note indicated the Physician ordered to transfer Resident 1 (on 9/24/2024) to the GACH due to Failure to Thrive (state of progressive decline, weight loss, poor nutrition and decreased appetite). During a review of Resident 1's GACH Physician's Notes dated 9/24/2025, the GACH Notes indicated Resident 1 had poor oral intake, unintentional weight loss and generalized weakness. The GACH notes indicated Resident 1 weighed 56 kilograms ([kg] unit of measurement [123.2 lbs.]) and BMI of 16.9. The GACH Notes indicated Resident 1 had diagnoses including Failure to Thrive and poor intake. During a review of Resident 1's GACH Gastrointestinal Physician Progress Note dated 10/4/2025, the Note indicated Resident 1's Assessment and Plan included dysphagia, malnutrition, Failure to Thrive and underwent a PEG placement on 10/2/2025. During a concurrent interview and record review on 11/26/2025 at 9:09 a.m., with the RD, Resident 1's RD evaluations and progress note dated 9/3/2025, were reviewed. RD stated she was informed of Resident 1's weight loss on 9/3/2025 and documented a recommendation of large portions for the Resident. During a concurrent interview and record review on 11/26/2025 at 11:08 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 1's ADL Meal Log, for the month of 8/2025, were reviewed. LVN 3 stated that not all meals were documented for 8/2025. LVN 3 stated this should not happen especially because Resident 1 was at risk of poor nutrition. LVN 3 stated Resident 1 could have lost weight and not received enough nutrients. During a concurrent interview and record review on 11/26/2025 at 2:12 p.m., Registered Nurse (RN) 2, the following Resident 1's records were reviewed: ADL Meal Log, dated 8/2025 Weights Care plan titled, Potential For Nutrition Problems, dated 6/30/2025 Nutritional assessment dated [DATE]. 5. RD's progress note, dated 9/3/2025 All active and discontinued diet orders 7/2025-9/2025. RN 2 stated staff should have documented all of Resident 1's meal intake to ensure Resident 1 did not lose weight. RN 2 also stated Resident 1's Care Plan indicated to monitor the Resident's meal consumption but staff did not follow it. RN 2 stated there should have been an order for large meal portions for Resident 1 per RD's recommendations on 7/14/2025 and 9/3/2025 but was not followed through with the physician. RN 2 stated there were no new orders for large meal portions after 7/14/2025 and 9/3/2025.During a concurrent interviews and record reviews on 11/26/2025 at 4:07 p.m. and 12/10/2025 at 2:54 p.m., with the Director of Nursing (DON), the facility's P&P titled, Assessment and Management of Resident Weights, dated 5/1/2018 and the following Resident 1 records were reviewed: ADL Meal Logs, dated 8/2025 and 9/2025Weights Care plans titled, Potential For Nutrition Problems, and Malnourished as evidenced by Nutritional Screening Tool Score of 02, dated 6/30/2025 COC dated, 9/2/2025 RD's progress note, dated 9/3/2025 Nursing Progress notes dated 7/2025-9/2025 All active and discontinued diet orders dated 7/2025-9/2025 All IDT meetings dated 7/2025-11/2025The DON stated Resident 1's meals were not consistently recorded (for every meal). The DON stated there was no supporting documentation to indicate that the RD's recommendations, to provide large portion meals were endorsed to the physician and provided to Resident 1. The DON stated not following Resident 1's care plans to monitor, record the residents' intake and provide supplement could have caused Resident 1 to lose weight. The DON also stated there was no documentation to support Resident 1 was offered supplements when Resident's intakes were below 50% on 8/20/2025, 9/11/2025, 9/15/2025-9/16/2025, 9/18/2025-9/19/2025, 9/22/2025-9/23/2025 for breakfast, 9/15/2025, 9/18/2025, 9/22/2025- 9/23/2025 for lunch, 9/5/2025, 9/13/2025-9/14/2025 for dinner. The DON stated she could not recall conducting IDT meetings after Resident 1's identified weight loss on 9/1/2025 and did not see documentation to indicate an IDT was conducted to address the Residents' actual weight loss. The DON stated an IDT should have been conducted to address Resident 1's weight loss and update the plan of care to ensure Resident 1 did not further decline. The DON stated staff did not follow the facility's Policy and Procedure (P&P) titled, Assessment and Management of Resident Weights. During a review of facility's P&P titled, Assessment and Management of Resident Weights dated 5/1/2018, the P&P indicated, significant weight changes were weight changes of 5% in one (1) month and the DNS or licensed nurse will notify the physician and dietician of significant weight changes, and document notification in the nurses' notes. The P&P also indicated the licensed nurse will notify the physician of the dietician's recommendations; If the physician does not implement the dietitian's recommendations, the facility will document the rational for non-implementation in the medical record. The P&P indicated the IDT care plan will be updated to reflect individualized goals and approaches for managing the weight change.

Based on interview and record review, the facility failed to provide close supervision for two of seven sampled residents (Resident 1 and Resident 2) reviewed for elopement (the act of leaving a facility unsupervised and without prior authorization) risk, by failing to ensure: 1. One-to-one (1:1- a dedicated nurse assigned to continuously observe and attend to a single resident, providing close supervision and immediate interventions when needed) monitoring every shift as indicated in the care plan. 2. The functionality of the wander guard system (a technology solution designed to detect, track, and alert staff when at high risk for elopement resident attempt to exit a designated area).These deficient practices resulted in Residents 1 and 2 eloping from the facility on 7/19/2025, unsupervised for several hours, placing the residents at risk for serious harm, including injury, exposure to environmental hazards, and death. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN- high blood pressure), and anxiety (a feeling of fear). During a review of Resident 1's History and Physical (H&P), dated 3/2/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 1's cognition (process of thinking) was severely impaired. The MDS indicated Resident 1 required moderate (helper does less than half the effort) assistance from staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's care plan titled Resident is an elopement risk/wanderer., initiated 5/7/2025, the care plan indicated interventions included use a wander guard bracelet and one-to-one staff monitoring on every shift to maintain the resident's safety due to elopement risk. During a review of Resident 1's Change of Condition (COC), dated 7/19/2025, timed at 11:45 a.m., the COC indicated on 7/19/2025 at approximately 10:00 a.m., Resident 1 was observed in the hallway pushing another resident (Resident 2) in a wheelchair. The COC also indicated at 11:00 a.m., during visual check rounds, the staff could not locate Resident 1 anywhere in the facility. Staff also were unable to locate the resident in the surrounding neighborhood. Resident 1 was returned to the facility on 7/19/2025 at approximately 4:45 p.m., by the Administrator (ADM). b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), anxiety, dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). During a review of Resident 2's H&P, dated 1/30/2025, the H&P indicated Resident 2 did not have the capacity to understand and make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 required moderate assistance from staff with ADLs and did not have the ability to walk. The MDS indicated Resident 2 required the use of a wheelchair for mobility. During a review of Resident 2's COC, dated 7/19/2025, timed at 11:45 a.m., the COC indicated on 7/19/2025 at approximately 10:00 a.m., Resident 2 was observed in the hallway in her wheelchair being pushed by another resident (Resident 1). The COC indicated at 11:00 a.m., the staff could not locate Resident 2 in the facility or the surrounding neighborhood. The COC indicated Resident 2 was brought back to the facility on 7/19/2025 at approximately 3:22 p.m., by a local hospital ambulance. During an interview on 7/29/2025 at 12:02 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/19/2025 at approximately 10:00 a.m., Resident 1 was observed in the hallway pushing Resident 2 in her wheelchair towards nurses' station near the front exit door. LVN 1 stated Resident 1 was high risk for elopement and had been issued a wander guard bracelet. LVN 1 stated Resident 1 was not on one-to-one monitoring, and instead was being checked during hourly visual rounds. LVN 1 stated Resident 2 was non-ambulatory (able to walk), used a wheelchair, and required staff assistance for mobility. LVN 1 stated at 11:00 a.m., during scheduled visual rounds check, staff were unable to locate Residents 1 and 2. LVN 1 stated she reported the missing residents to the charge nurse and staff initiated a search. LVN 1 stated she did not observe the residents exiting the facility and did not hear the front door alarm which indicated that staff were not monitoring the exit door as required to prevent residents from exiting the facility unsupervised. LVN 1 stated it was the responsibility of the Director of Staff Development (DSD) to ensure such assignments as exit monitoring were reflected in the daily staff assignment. LVN 1 stated the front exit door should be continuously monitored by staff to prevent residents from leaving the facility unsupervised, especially those at high risk for elopement. LVN 1 stated someone should have been watching the exit. During a telephone interview on 7/29/2025 at 1:06 p.m., with Registered Nurse (RN) 1, RN 1 stated she was the charge nurse on duty the morning of 7/19/2025. RN 1 stated she was made aware by LVN 1 that Residents 1 and 2 were missing during the 11:00 a.m. visual check rounds. RN 1 stated Resident 1 had a wander guard bracelet, but she was unaware if the system was active or functioning. RN 1 stated she was not able to recall if Resident 1 was on one-to-one monitoring at the time of the elopement incident on 7/19/2025. RN 1 stated she did not receive any alerts from the wander guard system. RN 1 stated she did not see or hear the residents exiting the facility. RN 1 stated staff should have been assigned to monitor the front exit to prevent residents from leaving unsupervised, especially those with elopement risk. RN 1 stated she believed a staff member (unable to recall name) had been assigned to monitor the front exit on the morning of 7/19/2025, but she was not able to confirm whether that assigned staff was present at the time of the elopement. RN 1 stated I was busy with other duties, and I honestly don't know if they were at the door. RN 1 stated the facility did not have a written policy for monitoring the exit door, it was an informal expectation, and everyone was responsible for the residents' supervision. During a concurrent interview record review on 7/29/2025 at 4:07 p.m., with the Director of Staff Development (DSD), the facility record titled Nursing Staffing Assignment and Sign-in-Sheet, dated 7/19/2025, was reviewed. The staff assignment record indicated Certified Nursing Assistant (CNA) 1 had initially been assigned to monitor the facility's front exit door and observe for any resident attempting to leave unsupervised. The DSD stated all staff were expected to monitor residents by keeping an eye on them, especially those with documented elopement risks. The DSD stated the facility did not have a formal, written protocol requiring staff to be specially assigned to monitor exit doors. The DSD stated she was responsible for preparing the staff assignment sheet for 7/19/2025. The DSD stated CNA 1 was reassigned to provide care to another resident in room [ROOM NUMBER]. The DSD stated there was no one to replace CNA 1 after his reassignment and staff at the nurses' station (located near the exit) were to assist with watching and monitoring the exit. The DSD stated this oversight resulted in Residents 1 and 2's elopement on the morning of 7/19/2025. During an interview on 7/29/2025 at 4:50 p.m., with the Administrator (ADM), the ADM stated on the morning of 7/19/2025, while Resident 1 pushed Resident 2 in her wheelchair, the residents exited the facility without staff knowledge. The ADM stated both residents were later located off-site and returned to the facility in the afternoon. The ADM stated Resident 1 had a wander guard bracelet, but the system failed to function at the time of the elopement, and no alarm was received by staff. The ADM stated the facility did not have a specific written policy designating which staff member was responsible for monitoring the front exit. The ADM stated it was an informal facility process that available staff were assigned to monitor the exit. The ADM stated it was expected that all staff would be vigilant and visually monitor the front exit and monitor the residents to prevent the residents from leaving the facility unsupervised. The ADM stated current practices were inadequate and that steps would be taken to create a formal front exit monitoring system. During a review of the facility's policy and procedures (P&P) titled Safety-Resident Monitoring, undated, the P&P indicated:1. The facility would ensure the safety and well-being of all residents by establishing guidelines for effective monitoring, supervision, and timely interventions.2. Staff must ensure resident whereabouts, especially for residents at risk of elopement.3. All staff would be informed of residents under 1:1 observation. During a review of the facility's P&P titled Wandering & Elopement, revised 5/1/2023, the P&P indicated the facility would identify and monitor residents at risk for elopement and facility staff would prevent residents from leaving the facility unsupervised. During a review of the facility P&P titled Safety of Residents, revised 5/1/2023, the P&P indicated the facility would provide a safe environment for residents at the facility.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm), for one of two sampled residents (Resident 3) when Resident 4 physically attacked Resident 3.This deficient practice resulted in Resident 3 sustaining welts (raised, red, or skin-colored bumps that appear on the skin) to his left arm, after Resident 4 hit him with a clothes hanger.Findings: During a review of Resident 3's admission Record (face sheet), the face sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a feeling of worry or fear, often about potential future problems), and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance. During a review of Resident 3's Care Plan titled, the resident has been physically aggressive by throwing his food tray at nursing staff, dated 3/19/2024 indicated interventions including anticipate resident's needs, monitor/document observed behavior and attempted interventions in behavior log. The interventions also indicated that when the residents become agitated, staff will intervene before agitation escalates. During a review of Resident 3's History and Physical (H&P) dated 5/23/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make medical decisions. During a review of Resident 3's Minimum Data Set (MDS - a comprehensive quarterly resident assessment) dated 6/4/2025, the MDS indicated Resident 3 had the ability to make self-understood and the ability to understand others. During a review of Resident 3's Change of Condition Evaluation (COC) dated 6/25/2025, the COC indicated Resident 3 exhibited behavioral changes when he pulled on another resident's call light, curtain, and yanked his bed. The COC indicated Resident 3 had a left arm open scratch, with a sad and frightened facial expression. The COC indicated Resident 3 showed facial grimacing when his left arm was touched during assessment. During a review of Resident 3's Skin Check (an assessment of the residents' skin), dated 6/25/2025, the skin check indicated Resident 3 had three welts measuring 8.0 cm, and 0.4 cm (centimeter-a unit of measurement), in length on the left outer forearm after Resident 3 was hit with a hanger by Resident 4. The assessment indicated one of the welts included a scratch. During a review of Resident 3's Order Summary Report dated 6/25/2025, the order summary report indicated cleanse the left arm open scratch and apply Bacitracin ointment (a topical antibiotic used to prevent and treat minor skin infections from cuts, scrapes, and burns) for 14 days, one time a day until finished. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyarthritis (swelling or tenderness in five or more joints causing pain or stiffness that gets worse with age), cardiomegaly (an enlarged heart), left leg above knee amputation (surgical removal of the leg when it is severely damaged). During a review of Resident 4's H&P dated 10/28/2024, the H&P indicated Resident 4 had the capacity to understand and make medical decisions. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had the ability to make self-understood and the ability to understand others. During a review of Resident 4's Change of Condition Evaluation (COC) dated 6/25/2025, the COC indicated Resident 4 alleged hitting another resident (Resident 3) with a hanger. The COC indicated staff will monitor Resident 4 for 72 hours. During a concurrent observation and interview on 6/27/2025 at 4:08 pm in Resident 3's room, Resident 3 was observed lying in bed with a small, dry, scab (a crusty protective covering) on the left arm. Resident 3 stated he was lying in his bed a few days ago, when Resident 4 hit him with a hanger. Resident 3 stated Resident 4 accused him of throwing dirty towels under his bed. Resident 3 stated he sustained a bruise and had pain in his left arm after Resident 4 hit him with a hanger. Resident 3 stated it made him feel scared and afraid. During an interview on 6/27/2025 at 4:23 pm in Resident 4's room, Resident 4 stated a few days ago, he hit Resident 3 because Resident 3 was pulling and pushing his (Resident 4's) bed, pulling on the privacy curtains, and call light. Resident 4 stated Resident 3 had done this several times before and had thrown dirty towels under his bed, but he did not report it to staff. During an interview on 7/2/2025 at 1:40 pm, with LVN (Licensed Vocational Nurse) 1, the LVN stated no resident should be abused. During a review of the facility's Policy & Procedure (P&P) titled, Abuse Prevention and Prohibition Program revised 8/1/2023, indicated Each resident has the right to be free from abuse, neglect, or misappropriation of resident property. The P&P indicated welts and bruises are signs and symptoms of physical abuse. The P&P indicated The Administrator is the Abuse Coordinator. In order to facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the Facility to the proper authorities. During a review of the facility's P&P titled, Behavior - Management revised 5/1/2018, indicated When the resident exhibits behaviors, the Licensed Nurse will document the resident's behavior in the medical record and include the following as indicated: Any precipitating factors, interventions used to redirect behavior, the resident's response to the intervention, notification of attending physician and responsible party as indicated, update the plan of care as indicated. During a review of the facility's P&P titled Resident - Resident Altercations revised 8/1/2023, the P&P indicated Facility staff monitors residents for aggressive or inappropriate behavior toward other residents, family members, visitors, and facility staff.

Based on interview and record review, the facility failed to implement care plan intervention to monitor routinely, one of three residents (Resident 1), to prevent from leaving the facility unsupervised by failing to specify: a. The type of supervision (the act of watching) Resident 1 needed after he eloped (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) from the facility on 6/19/2024 and 8/24/2024. b. How often Resident 1 would be monitored (watched), daily. This failure resulted in Resident 1 eloping from the facility and placed the resident at risk for medical complications, such as hypertensive crisis (dangerously high blood pressure), diabetic coma (loss of consciousness due to uncontrolled blood sugar), stroke (loss of blood flow to a part of the brain), behavioral crisis (inability to control oneself, becoming a danger to themselves or others), embolism (blockage of blood flow in the body), sepsis (a life-threatening blood infection), malnourishment (lack of food), motor vehicle accident, and death. On 10/21/2024, Resident 1 had still not been found. On 10/16/2023 at 5:10 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) and Administrator (Admin) due to the facility ' s failure to implement care plan intervention to monitor Resident 1 routinely, to prevent Resident 1 from leaving the facility unsupervised, for the third (3rd) time. On 10/17/2024 at 4:58 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP implementation through observation, interview, and record review, the IJ was removed onsite on 10/18/2024 at 10:30 a.m., in the presence of the Admin and DON. The IJRP included the following immediate actions: 1). On 10/16/24, the DON contacted the physicians of residents identified for being at risk for wandering (roaming) /elopement to obtain orders to monitor each resident every (q) 2 hours. On 10/17/24, the DON contacted the physicians of the residents identified with history of elopement to obtain orders to monitor each resident q 1 hour. Residents with history of elopement: Resident 1 - monitor q1 hour Resident 4 - monitor q1 hour Resident 5 - monitor q1 hour Resident 9 - monitor q1 hour Residents identified to be at risk for elopement: Resident 2 - monitor q2 hour Resident 3 - monitor q2 hour Resident 6 - monitor q2 hour Resident 7 - monitor q2 hour Resident 8 - monitor q2 hour Orders were noted and carried out. Rounding during change of shift by outgoing and oncoming nursing staff (Licensed Vocational Nurse [LVN], Registered Nurse [RN], and Certified Nurse Assistant [CNA]) will take place to account for all residents with emphasis on identifying the whereabouts of residents that were at risk for elopement. The LVN or RN will record on the Medication Administration Record (MAR) their visual check of the residents and document in the progress note the location of the residents. Medical Records will audit the MAR for compliance of Licensed Staff documenting on residents who has orders to monitor every 2 hours for risk for wandering/elopement and 1 hour for residents with history of elopement. The audits will be daily for one week, weekly for two weeks and monthly for 3 months (x3) thereafter. Medical Records will report to the Administrator/designee the findings of the audit daily for one week, weekly for two weeks, and monthly x3 thereafter. 2). On 10/16/24 and 10/17/24, the Minimum Data Set (MDS) Coordinator reviewed the care plans for the nine (9) residents identified for being at risk for wandering to ensure residents have measurable interventions. Resident interventions were updated to include interventions such as but not limited to monitor residents ' location every 2 hours or 1 hour, Department Managers Monday through Friday and the RN Supervisor on weekends will provide room visits daily to provide orientation for socialization and sensory stimulation and apply wander guard bracelet by Admissions or Licensed Nurse. Resident Specific Monitoring: Resident 1 - had eloped; care plan will be updated when/if resident returns. Resident 2 - activities to provide accessory for her to take care of her babies/dolls to provide a sense of comfort. Resident 3 - redirected and reorientate resident that wife has passed away. Resident 4 - activities and social services to offer escort for shopping throughout the week. Resident 5 - reorient resident he has no friends across the street or nearby; reassure resident that everyone who ' s not here with him is okay; activities to distract resident from wandering by offering pleasant diversions such as listening to oldies on the patio and socializing with peers. Resident 6 - provide Restorative Nurse Assistant (RNA) services as ordered, activities and social services to provide escort when resident goes shopping across the street. Resident 7 - activities and social services to escort resident to gardening patio, nonsmoking, or smoking patio for fresh area. Resident 8 - offer resident to be escorted to store/shopping plaza nearby. Resident 9 - distract resident from wandering, offer pleasant diversions, resident usually prefers to stay in room but at times will do activities involving food. 3). Licensed staff to complete wandering/elopement assessments on admission/readmission, quarterly and when a change of condition occurs. The Quality Assurance (QA) Nurse updates the residents special need binders/postings as residents are identified. The Admissions Coordinator updates the facility wanderguard (a wearable device to help track residents who are at risk of wandering) binder located at each station with resident ' s face sheets who were identified to be at risk to elope/ wander and have wander guards applied as needed. Wander guard binder will be checked by Admissions or QA nurse during the weekday and designated RN/LVN on the weekend. All residents who have been identified to be at risk for elopement/wandering will have identifiable pink color name bands. Residents identified to be at risk, will be discussed with facility staff during daily shift huddle and weekday stand-up meetings. This allows facility staff to be aware of residents identified to be at risk for wandering/elopement. Staff will be informed of the pink color name band, special need binder/posting and wander guard binder through in-services held by the Director of Staff Development, QA nurse and/or Administrator. 4). On 10/14/24 the Administrator, DON, Director of Staff Development (DSD) began in servicing facility staff, which included but not limited to Nursing, Housekeeping, Maintenance, Dietary, Department Managers including front door staff and contracted rehab staff, on residents at risk for wandering/elopement and what behaviors to monitor for each resident. Behaviors to monitor for at risk for wandering/elopement: -Aggressive episodes - Angry outbursts - Sitting near exit doors - Resident being withdrawn, isolative - Attempts to leave unattended - Resident saying they want to leave for fresh air instead of the patio area - Resident attempting to smoke out front instead of designated patio area - Resident saying they miss their family and want to go see them, and attempts to leave to see them. - Resident saying I ' m not a child, I don ' t need an order to go outside - Resident verbalizing, they want to go somewhere else but not details of where they want to go. - Paranoid or suspicious behavior. Example - resident says they don ' t belong there. The in-service also included facility ' s policy and procedure titled, Wandering & Elopement and Wandering Policy. The in-servicing is on-going. The QA nurse will audit the in-service provided to staff daily and report the findings to the Administrator. The Administrator will ensure all staff on assignment and currently working daily are in-serviced by October 21, 2024. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Admission Record indicated Resident 1 had diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-abnormal blood sugar levels), heart failure (a heart disorder which causes the heart not to pump the blood efficiently), chronic (long-term) atrial fibrillation (A-fib, irregular heart beat that increases risk of blood clots), and hypertension (HTN-high blood pressure). The Admission Record indicated Resident 1 had a conservator (a judge-appointed person to act or make decisions for the resident). During a review of Resident 1 ' s care plan titled, Noted with repetitive pacing behaviors; no actual destination or purpose, dated 11/14/2023, the interventions indicated staff will monitor Resident 1 ' s behavior every shift, record and notify the physician if behavioral episodes increased, provide visual checks and frequent (nonstop/constant) monitoring of behavior, remind the resident not to leave the facility unassisted and encourage him to be involved in activities of choice. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 3/22/2024, the MDS indicated Resident 1 had intact cognition (awareness). The MDS indicated Resident 1 did not experience hallucinations (thinking or feeling that something is real, when it is not) or delusions (beliefs that are firmly held and do not align with reality). The MDS indicated Resident 1 was independent with sitting to standing, lying to sitting position, and walking 10 feet. The MDS indicated Resident 1 required supervision with transfer to and from the toilet and with walking 50 feet (a unit of measurement) with two turns and walking 150 feet. During a review of Resident 1 ' s Elopement Evaluation, dated 5/19/2024, the evaluation did not indicate Resident 1 was at risk for elopement or had elopement attempts. During a review of Resident 1 ' s Change in Condition (COC) Evaluation form, dated 6/19/2024 at 6:33 a.m., the COC indicated on 6/19/2024, at night (time not indicated), Resident 1 walked out of the premises with his travelling bag. The COC also indicated Resident 1 was observed walking back and forth the hallway with a travelling bag, stating the facility cannot tell me when and where to smoke, so I walked out the building. The COC indicated the police was notified and 10 minutes later, Resident 1 returned to the building. During a review of Resident 1 ' s Elopement Evaluation, dated 6/19/2024 at 7:33 a.m., (first post elopement evaluation), the evaluation indicated Resident 1 had a history of, or an attempted elopement while at home. The report indicated Resident 1 had a history of leaving the facility without informing staff. The report indicated Resident 1 verbally expressed the desire to go home, packed his belongings and stayed near an exit door. The evaluation report also indicated Resident 1 ' s wandering behavior was likely to affect his safety or wellbeing and that of others. The evaluation ' s clinical suggestions section indicated staff will apply an identification (ID) bracelet on Resident 1, monitor the resident ' s location frequently, use visual barriers such as stop signs, ribbons, and tapes, and notify staff of Resident 1 ' s wandering and elopement risk. During a review of Resident 1 ' s care plan titled Resident left facility this morning without notifying staff, dated 6/19/2024, the interventions indicated the staff will monitor Resident 1 for wandering behavior and provide diversional activities frequently. During a review of Resident 1 ' s Interdisciplinary Team (IDT-group of healthcare professionals, including the resident/ resident representative, working together to provide residents with needed care) meeting notes dated 6/19/2024, the IDT meeting notes indicated Resident 1 stated he eloped so he can smoke cigarettes at his preferred times. The IDT meeting notes indicated Resident 1 was reminded of the facility ' s rules. The IDT meeting notes indicated Resident 1 was offered smoking cessation assistance but refused. During a review of Resident 1 ' s Elopement Evaluation, dated 8/24/2024 (second post elopement evaluation), the evaluation indicated Resident 1 had a history of elopement and attempts to leave the facility. The evaluation indicated Resident 1 verbally expressed a desire to go home, packed his belongings, or stayed near an exit door. The evaluation indicated Resident 1 ' s wandering behavior occurred in a pattern, likely to affect the privacy of others. The clinical suggestions section was left blank with no suggestions on how staff would care for Resident 1 to prevent him from eloping. During a review of Resident 1 ' s care plan titled Resident left the faciity on [DATE] without notifying staff, dated 8/26/2024, the interventions indicated staff will distract Resident 1 from wandering by offering the resident pleasant diversions, structured activities, food, conversation, television, book resident prefers. During a review of Resident 1 ' s care plan titled, Noted with repetitive pacing behaviors, dated 8/26/2024, the interventions indicated the staff will monitor Resident 1 ' s location routinely, monitor the resident for wandering behavior, and provide diversional activities. The care plan indicated the staff will monitor Resident 1 ' s triggers for eloping and de-escalate (calm down) the behaviors. During a review of Resident 1 ' s physician order dated 8/26/2024, the order indicated to apply a wanderguard bracelet (a wearable device to help track residents who are at risk of wandering) to alert staff if Resident 1 attempted to leave the facility. The physician ' s order indicated to check the wanderguard bracelet ' s placement at the left wrist every shift, monitor the number of attempts to leave the facility every shift, weekly check of wanderguard bracelet to ensure it is functioning properly every day shift every 7 days. During a review of Resident 1 ' s IDT meeting notes dated 8/26/2024, the notes indicated on 8/24/2024, at 12:30 a.m., Resident 1 eloped from the facility, and at 1:15a.m., he was accompanied back to the facility by a staff member. The notes indicated Resident 1 was educated on the dangers and risk of going out alone, and a wanderguard was offered to Resident 1 to remind him not to leave the facility unattended. During a review of Resident 1 ' s COC Evaluation form dated 8/30/2024, the COC indicated Resident 1 left the faciity on [DATE] at around 5:45 a.m., through the front door. The COC indicated the door alarm turned on and two (2) staff members went after Resident 1 and brought Resident 1 back inside the facility. During a review of Resident 1 ' s physician orders for October 2024, the physician order indicated the following: 1. Advair Diskus Aerosol Powder Breath Activated 250 50 microgram (mcg- unit of measurement)/ Fluticasone-Salmeterol 1 inhalation orally two times a day for chronic obstructive pulmonary disease (COPD- lung disease). 2. Aspirin Tablet Chewable 81 milligram (mg - a unit of measurement) 1 tablet by mouth daily for cerebral vascular accident (CVA- stroke) prophylaxis (PPX- prevention). 3. Coreg Tablet 6.25 mg 1 tablet by mouth two times a day for hypertension (HTN- high blood pressure). 4. Digoxin (medication for Atrial-fibrillation ([A-fib] irregular heart rate) oral tablet 125 micrograms (mcg- a unit of measurement) 1 tablet by mouth in the morning. 5. Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) glargine (long-acting medication for DM) 100 units (measurement for insulin)/milliliter (mL- a unit of measurement) inject 8 units subcutaneously (under the skin) at bedtime for DM 6. Insulin lispro (fast-acting medication for DM) 100 units/mL injected as per sliding scale (dose adjusted based on current blood sugar) subcutaneously before meals and at bedtime for DM 7. Glyburide (medication for DM) tablet 5 mg by mouth in the morning for DM 8. Tiotropium bromide monohydrate (medication for COPD) 1 capsule inhale orally one time per day for COPD 9. Risperidone (medication for schizophrenia) tablet 2 mg by mouth two times per day for schizophrenia manifested by (m/b) auditory hallucinations (hearing sounds that are not real) 10. Benztropine mesylate (medication for movement disorders) 1 mg by mouth two times per day for extrapyramidal symptoms (EPS - uncontrollable movements due to antipsychotic medications) During a concurrent interview and record review on 10/16/2024 at 8:03 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s care plans dated 11/14/2023, 6/19/2024, and 10/15/2024, Elopement Evaluations dated 6/19/2024 and 8/26/2024, Physician Orders dated 8/26/2024 were reviewed. LVN 1 stated the Elopement Evaluation dated 6/19/2024 and 8/26/2024 indicated Resident 1 was at risk of eloping due to Resident 1 ' s past attempts and successful elopements. LVN 1 stated Resident 1 ' s Elopement Evaluations indicated Resident 1 eloped from the facility two times (on 6/19/2024 and 8/24/2024), prior to the third elopement on 10/13/2024. LVN 1 stated Resident 1 ' s care plan dated 11/14/2023 indicated the staff will visually monitor Resident 1 ' s location, Resident 1 ' s behavior, and remind Resident 1 not to leave the facility unassisted. LVN 1 stated staff did not monitor Resident 1 ' s location or wandering behavior. LVN 1 stated the visual checks were not performed or documented in Resident 1 ' s clinical record. LVN 1 stated the interventions in Resident 1 ' s care plan dated 6/19/2024 which indicated staff will monitor Resident 1 ' s wandering behavior and location, were not documented in Resident 1 ' s clinical record. LVN 1 stated Resident 1 ' s care plan regarding elopement was not individualized and not specific to Resident 1 ' s needs. LVN 1 stated Resident 1 ' s physician ' s order dated 8/26/2024 indicated to apply a wanderguard bracelet on 8/26/2024. LVN 1 stated the wanderguard was on the resident but was not incorporated (added) to the care plan until 10/15/2024, after Resident 1 had eloped 10/13/2024 (third elopement). During an interview on 10/16/2024 at 10:50 a.m. with the Director of Nursing (DON), the DON stated the intervention on Resident 1 ' s care plan to monitor for location routinely was vague (unclear) and not measurable. The DON stated the care plan ' s interventions should have been specific on the type of supervision Resident 1 needed and how often the staff had to monitor Resident 1. The DON stated the facility did not know where or when Resident 1 left the facility, or where Resident 1 was, after last seen on 10/13/2024 at 5:30 am. During an interview on 10/16/2024 at 12:37 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was last seen in the facility on 10/13/2024 at 5:30 a.m. and was discovered missing on 10/13/2024 at 7:30 a.m. CNA 1 stated Resident 1 ' s assigned staff were supposed to always monitor the resident ' s whereabouts and during the change of shift. CNA 1 stated on 10/13/2024 at 7:00 am, no staff monitored Resident 1 during the change of shift. CNA 1 stated Resident 1 had eloped because staff was not monitoring his (Resident 1) location. During a concurrent interview and record review on 10/16/2024 at 2:18 p.m. with Registered Nurse (RN 2), Resident 1 ' s physician orders for October 2024 and MAR for October 2024 were reviewed. RN 2 stated Resident 1 had no physician order to monitor his (Resident 1) location or his wandering behaviors. RN 2 stated the facility did not monitor Resident 1 ' s location or wandering behaviors, which may have been the reason why the facility did not know where Resident 1 was. RN 2 stated there was no documentation in Resident 1 ' s MAR indicating the resident ' s location. RN 2 stated Resident 1 eloped again because staff was not monitoring him. RN 2 stated Resident 1 ' s elopement placed Resident 1 ' s safety in danger. RN 2 stated, because Resident 1 eloped, Resident 1 missed his daily medications like digoxin, carvedilol, aspirin, insulin, insulin lispro, glyburide, tiotropium bromide, advair diskus aerosol, risperidone and benztropine. RN 2 stated without receiving his daily medications, Resident 1 was at risk for hypertensive crisis, diabetic coma, stroke, behavioral crisis, embolism. RN 2 stated Resident 1 could get struck by vehicles, possibly injured himself, resulting to hospitalization and death. During a concurrent interview and record review on 10/15/2024 at 4:47 p.m. with RN 3, Resident 1 ' s care plan titled, Resident left the facility without notifying staff or having escort, dated 8/24/2024, was reviewed. RN 3 stated the care plan interventions included to monitor for fatigue and weight loss, offer diversions, and monitor the resident ' s location routinely. RN 3 stated, the interventions were not individualized according to Resident 1 ' s needs, who attempted to elope many times. RN 3 stated the intervention should have been specified to monitor the resident ' s location every hour. RN 3 stated the interventions listed on the care plan did not have a physician ' s order, therefore, the monitoring of location routinely was not conducted and documented in Resident 1 ' s MAR. During a review of the facility ' s undated policy and procedure (P&P) titled Wandering & Elopement, the P&P indicated its purpose was to enhance safety of residents in the facility. The P&P indicated the license nurse in collaboration with the IDT, will assess residents upon identification of significant change in condition, resident ' s risk for elopement and preventative interventions for elopement will be documented in resident ' s medical record, will be reviewed, and re-evaluated by the IDT upon change in condition. The P&P indicated the license nurse will implement immediate interventions to prevent further wandering/ elopement by the resident. During a review of the facility ' s undated P&P titled, Care Planning, the P&P indicated the facility must ensure care plans were comprehensive person-centered and were developed based on the resident ' s individual assessed needs. The P&P indicated changes may be made to the comprehensive care plan on an ongoing basis for the duration of the resident ' s stay and reflected to the baseline care plan. The P&P indicated residents ' care plans should describe the services to be provided to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure residents had an environment free of accident hazards (risk) for three (3) of 3 sampled residents (Residents 1, 2, and 3) who were smokers by failing to: 1). Ensure Resident 1 did not have a cigarette lighter on his bedside table on 5/29/2024 at 11:24 a.m. 2). Ensure Resident 2 did not have a lighter and two (2) cigarette sticks in her (Resident 2) purse on 5/29/2024 at 2:51 p.m. 3) Ensure Resident 3 did not have a lighter and 2 cigarette sticks while in the hallway, and at the bedside table on 5/30/2024 at 9:07 a.m. 4). Implement its policy and procedure (P&P) titled, Smoking: Nursing Manual-Nursing Administration, which indicated smoking materials such as cigarettes, and lighters should be stored in a secured area (area where access was limited to authorized persons only), and residents who smoked will be assessed for the most appropriate method to securely store smoking materials such as lighters, and cigarettes. These deficient practices had the potential for Residents 1, 2, and 3 to turn on the lighters, cause a fire that could affect the health, safety, and wellbeing of all 118 residents in the facility, staff and visitors and result in serious injuries, hospitalization , and death. On 5/30/2024 at 5:05 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (Admin) and Director of Nursing (DON) due to the facility ' s failure to ensure Residents 1, 2 and 3 ' s lighters were stored in a secured area which had the potential to cause a fire affecting the health, safety and wellbeing of all 118 residents in the facility including staffs and visitors. On 6/1/2024 at 1:59 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] a plan with interventions to correct the deficient practice). After validating the IJRP ' s implementation onsite, the IJ was removed on 6/1/2024 at 5:00 p.m., in the presence of the Admin and DON. The IJRP included the following immediate actions: 1. On 5/30/2024, the DON, Admin, and Registered Nurse (RN) 1 immediately informed all residents, both nonsmokers and smokers, that according to the facility ' s Smoking Policy and Procedure, residents will not keep cigarettes, e-cigarettes, and lighters in their possession, bedside or rooms. Residents were informed all smoking materials were to be kept at the nurses ' Station 1 in a locked drawer and the activity office. 2. On 5/30/2024 and 5/31/2024, the Director of Staff Development (DSD) Assistant and Social Service Designee (SSD) checked bedsides of all residents and ensured there were no cigarettes, e-cigarettes, or lighters at the bedsides. The DSD Assistant and SSD removed any cigarettes, e-cigarettes, and lighters found. 3. Residents ' bedside tables and nightstands were to be checked every shift by the assigned Certified Nursing Assistant (CNA) for 2 weeks, then daily for 2 months. Results of those rounds were to be reported to the charge nurse per shift. A log will be used to record results of rounds and reported to the charge nurse per shift. Residents found with cigarettes, e-cigarettes, and lighters will be removed immediately by the assigned CNA. 4. A daily census will be used by the RN shift Supervisor to record the results of room observations during rounding. Residents found with cigarettes, e-cigarettes, and lighters will be removed immediately by assigned CNA. 5. Of the 27 residents identified to smoke, nine residents were assessed by the shift RN, were unable to store smoking items at the bedside and the items should be secured by staff safely. 6. On 5/30/2024 and 5/31/2024, the DON, Admin, DSD, and Designee in-serviced staff on checking to ensure there were no cigarettes, e-cigarettes, or lighters at any of the residents ' bedsides and to remove those items for the safety and security of residents. 7. On 5/31/2024, the DON, Admin, DSD, and SSD held Resident Council Meetings to inform residents of the facility ' s smoking policy, specifically the safety of properly securing cigarettes, e-cigarettes, and lighters and of the deficient practice found by California Department of Public Health (CDPH) on 5/30/2024 which placed the facility in non-compliance and in Immediate Jeopardy. 8. The Admin ensured all 152 staff on assignment and who worked daily were in-serviced by 6/7/2024. Non-active staff, not currently on assignment and on leave, in-serviced by 6/15/2024 prior to returning to assignment/ work/ duty. 9. On 5/31/2024 and 6/1/2024, the Admin, DON, DSD, Quality Assurance (QA) Nurse, and RN 1 met with facility staff to educate staff on the facility ' s smoking P&P specifically the safe and secure storage of cigarettes, e-cigarettes, and lighters. 10. The Admin posted a notice of the IJ at the front and rear entrance door, the activity room, and at all four Nurses ' Stations to inform residents, families, and staff of the following: I. Visitors, friends, and family were not allowed to provide cigarettes, e-cigarettes, or lighters directly to the resident. These items must be checked in with the on-duty staff nurse. The nurses will place the smoking items at Station 1 in a locked drawer until picked up by the Activity Director. II. All residents ' cigarettes, e-cigarettes, and lighter must be kept by the facility in Station 1 drawer and in the activity office ' s locked cabinet. The resident ' s name will be labeled on the cigarettes, e-cigarettes, and lighters. III. Residents who smoke, should not keep cigarettes, e-cigarettes, or lighters at their bedside. IV. The 10 smoking sessions were held on the smoking patio located by Station 2 with supervision provided by the activity staff and assigned nursing staff for residents ' safety. V. Residents that smoked should abide by the facility ' s policy regarding smoking session times to ensure residents, visitors, and staff safety. 11. The Activity Supervisor who was in charge of the smoking sessions will report any concerns to the facility Admin in the daily meeting or as needed. 12. The QA Nurse developed the Performance Improvement Plan (PIP) to address the assessment, safety, and storage of cigarettes, e-cigarettes, and lighters to ensure residents ' safety. The QA nurse will monitor findings and report to the Quality Assurance Committee monthly for three months to ensure the system ' s effectiveness and performance was sustained. Findings: 1). A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and extrapyramidal movements (involuntary, uncontrollable movements). A review of Resident 1 ' s care plan titled At risk for accidental injuries due to smoking, but not limited to risk/benefit/outcome explained and understood, dated 9/21/2023, indicated the facility will provide safe smoking environment and resident will smoke safely while abiding (follow) the facility policy. The interventions indicated Resident 1 was informed of designated smoking areas because smoking is prohibited within the facility. The interventions indicated Resident 1 required visual monitoring during scheduled smoke breaks. The interventions indicated the smoking policy was discussed with Resident 1 during resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care and quality of life). A review of Resident 1 ' s Smoking Safety Evaluation, dated 4/11/2024, indicated supervision will be required for all residents during designated smoking times. The Smoking Safety Evaluation indicated evaluation will be utilized for resident ' s smoking care plan on admission and as indicated. However, the Smoking Safety Evaluation form did not indicate a system for safe storage of Resident 1 ' s smoking materials. A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 4/15/2024, indicated Resident 1 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 1 required supervision with sit to lying (ability to move from sitting on the side of bed to lying flat on the bed), sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), chair/bed-to-chair transfer (ability to transfer to and from a bed to a chair (or wheelchair) and walk of 10 feet. The MDS indicated Resident 1 independently used a wheelchair for mobility (the ability to move freely). During an observation in Resident 1 ' s room on 5/29/2024 at 11:24 a.m., a cigarette lighter was observed on Resident 1 ' s bedside table. During a concurrent observation and interview on 5/29/2024 at 11:28 a.m. with the DON, in Resident 1 ' s room, a lighter was observed at Resident 1 ' s bedside table. The DON stated residents should not have lighters in their room or at bedside because it is dangerous and could cause accidents to happen. During an interview on 5/29/2024 at 2:09 p.m., with the Activity Assistant, the Activity Assistant stated smoking paraphernalia (materials) should be stored in the activity ' s office. The Activities Assistant indicated residents were not allowed to keep smoking materials with them because it was hazard and residents could burn themselves. 2). A review of Resident 2 ' Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including paralytic syndrome (progressive weakness) following cerebral infarction (stroke) and generalized weakness (weakness on most areas of the body). A review of Resident 2 ' s care plan titled At risk for accidental injuries due to smoking, dated 9/21/2023, indicated the facility will provide Resident 2 with a safe smoking environment and the resident will smoke safely per the facility ' s policy. The care plan interventions indicated staff informed Resident 2 of designated smoking areas because smoking was prohibited within the facility. The interventions indicated staff will provide Resident 2 with an ash tray when smoking, remind, provide diversional activities to minimize smoking tendencies and visual monitoring during scheduled smoke breaks. A review of Resident 2 ' s Smoking Safety Evaluation, dated 4/11/2024, indicated supervision will be required for all residents during designated smoking times. The Smoking Safety Evaluation indicated evaluation will be utilized for resident ' s smoking care plan on admission and as indicated. However, the Smoking Safety Evaluation form did not indicate a system for safe storage of Resident 2 ' s smoking materials. A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 had intact cognition (ability to think and reason). The MDS indicated Resident 2 had impairment to both sides (left and right) of the lower extremities (lower body). The MDS indicated Resident 2 was dependent with chair/bed-chair transfer. The MDS indicated Resident 2 independently used a wheelchair for mobility. During a concurrent observation and interview on 5/29/2024 at 2:51 p.m. in Resident 2 ' s room, Resident 2 was observed with 2 cigarette sticks and a lighter in her purse. Resident 2 stated she (Resident 2) always kept the lighter and cigarettes in her (Resident 2) room. 3). A review of Resident 3 ' s Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis of unspecified (not named or stated) mood disorder (unstable mood) and schizophrenia. A review of Resident 3 ' s MDS, dated , 3/21/2024, indicated Resident 3 had cognitive impairment (loss). The MDS indicated Resident 3 had no impairment with upper and lower body. The MDS indicated Resident 3 was able to walk 10 feet with supervision. The MDS indicated Resident 3 required supervision with sit to stand, chair/bed-to-chair transfer. The MDS indicated Resident 2 independently used a wheelchair. A review of Resident 3 ' s Smoking Safety Evaluation, dated 3/19/2024, indicated supervision will be required for all residents during designated smoking times. The Smoking Safety Evaluation indicated evaluation will be utilized for resident ' s smoking care plan on admission and as indicated. However, the Smoking Safety Evaluation form did not indicate a system for safe storage of Resident 3 ' s smoking materials. A review of Resident 3 ' s care plan titled, Resident is a smoker and agreed to abide with facility ' s policy for smoking, (risk/benefit/outcome explained and understood), risk for injuries to self and others, dated, 9/15/2022, indicated the resident will be free from injuries related to smoking and no injuries to others. The interventions indicated the facility will monitor Resident 3 frequently during smoke durations and remind the resident of the designated smoking area. A review of Resident 3 ' s care plan titled, Resident is a smoker, at risk for injury to self or others, required supervision with smoking, dated 9/16/2022, indicated Resident 3 will not smoke without supervision or suffer any injury from unsafe smoking. The interventions indicated Resident 3 required supervision while smoking and staff will inform Resident 3 about smoking locations, times, and safety concerns. The interventions indicated staff will allow Resident 3 to smoke only in designated areas, and monitor Resident 3 frequently during smoking breaks. During an observation on 5/30/2024 at 9:07 a.m., Resident 3 was observed in the hallway with 2 cigarettes in one hand and a cigarette lighter on the other hand. During a concurrent observation and interview on 5/30/2024 at 10:05 a.m. with Resident 3, in Resident 3 ' s room, a cigarette lighter and a pack of cigarettes were observed on Resident 3 ' s bedside table. Resident 3 stated the cigarettes were provided by the facility and the cigarette lighter was kept in his (Resident 3) room. Resident 3 stated he always had the cigarette lighter in his room and was never taken away by the staff. Resident 3 stated he did not have to wait for staff to provide him a cigarette or a lighter, whenever he wanted to smoke. During a concurrent observation and interview on 5/30/2024 at 10:17 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 3 ' s room, LVN 2 stated there was a cigarette lighter and a pack of cigarettes on Resident 3 ' s bedside table. LVN 3 stated some of the residents bought their own packs of cigarettes. LVN 3 stated cigarette lighters should not be kept by residents because it could be a safety hazard and could result in a fire. LVN 3 stated all lighters should be kept in the Activities Department. During an interview on 5/30/2024 at 11:56 a.m. with the Activities Director (AD), the AD stated, he (the AD) assessed all residents who smoked during admission, by completing the Smoking Safety Evaluation form in the electronics medical record. The AD stated residents ' lighters and cigarettes were stored in the activities department. The AD stated the facility did not have documentation of room checks performed by the activities department to ensure residents did not have smoking materials in their room. During an interview on 5/30/2024 at 3:55 p.m. with CNA 2, CNA 2 stated residents should not have lighters or cigarettes in their room due to the risks involved. Residents could light up linens which could lead to fire, burn themselves or other safety concerns (not specified) if residents had oxygen in the room. During an interview on 5/30/2024 at 4:33 p.m., with RN 1, RN 1 stated residents should not keep lighters or cigarettes by themselves. RN 1 stated if a resident lit a cigarette in a room with oxygen, it could lead to injuries and burns. RN 1 stated appropriate storage of residents ' smoking materials is part of assessing for a smoker resident ' s safety. During a concurrent interview and record review on 5/30/2024 at 4:50 p.m. with the DON, Resident 1 ' s Smoking Safety Evaluation dated 4/11/2024 was reviewed. The DON stated appropriate assessment and storage of smoking materials were part of safety evaluation because residents who were not responsible, could light a cigarette anytime and cause burns. The DON stated the evaluation did not indicate where Resident 1 ' s smoking materials should be stored. The DON stated residents ' bedside tables were not a secure area to store smoking materials, especially a lighter, as anyone could grab the lighter and start a fire even if they were alert and oriented. The DON stated residents using oxygen were in danger if a resident lit a lighter or cigarette close to oxygen. The DON stated per the facility ' s smoking policy, smoking materials were to be stored in a secured area. A review of the facility ' s P&P titled, Smoking: Nursing Manual - Nursing Administration dated 2/19/2022, indicated all smoking materials should be stored in a secured area basing on the resident ' s smoking safety assessment to ensure safety. The P&P indicated the facility staff should determine the most appropriate method of secured storage.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the corona virus ([COVID-19] an illness caused by a virus that can easily spread from person to person) per their mitigation plan (MP). The MP indicated the facility would provide and ensure the employees wear a facemask or respirator and other necessary personal protective equipment (PPE) when exposure to individuals with suspected or confirmed COVID-19 in accordance with the facility's respiratory protection program (N95 Respiratory Respirator policy) for 110 of 110 residents residing in the facility. The facility failed to: 1. Fit Test (check to ensure a respirator [mask] properly fits the face of the wearer to protect from inhaling infectious particles) 87 staff members with the N95-3 (non-fittest mask) respirator prior to use. 2. Complete initial fit test for newly hired staff members prior to working. 3. Ensure staff completed an annual N95 fit test after one year. 4. Staff were wearing the required properly fitted N95 respirators in the Yellow (area housing covid-19 suspected, symptomatic or exposed residents) zone, caring for 101 residents, and Red zone (area housing COVID-19 confirmed residents) caring for 9 residents. 5. In-serviced staff (134) on the use of N95 respirators prior to use. These deficient practices had the potential to expose the residents, staff, visitors and community to the COVID-19 Virus and likely to cause serious harm. Findings: During a review of the Daily Census on December 16, 2021 at 11 am, the daily census indicated there were 110 residents residing in the facility: Nine residents were COVID 19 confirmed located in the red zone. One hundred one (101) residents were in the yellow zone. During a concurrent observation and interview on December 16, 2021 at 12:08 p.m., with the Infection Prevention Nurse ([IP] nurse in charge of infection prevention in the facility), IP stated most staff members were wearing one of three different brands of N95 respirators, (N95-1, N95- 2 and N95- 3). The receptionist, the DON, the Infection Preventionist (IP), the Assistant Director of Staff Development (ADSD), Registered Nurse 1 (RN) were observed wearing the new N95-3 respirator. IP stated the facility staff started using the N95-3 respirator on December 15, 2021. IP stated that facility staff had not been fit-tested for the N95-3 respirator prior to using the N95-3 because the person assigned to do the N95 respirator fit testing did not come to work. During an interview on December 16, 2021 at 1:45 p.m., with the ADON, the ADON stated 134 staff were not fit tested with the [NAME] N 95 and should have been fit tested before using the respirator to prevent the spread of Covid-19. DON stated that in-service training of staff for the new N95 respirator [NAME] had not started. During a concurrent observation and interview on December 16, 2021 at 2:30 p.m., Certified Nurse Assistant (CNA) 1 was wearing a N95-2 respirator in the yellow zone while helping other nurses remove trays inside the resident's room. CNA 1 stated she was newly hired and started working in the facility on November 11, 2021. CNA 1 stated she was not fit tested for the N95-2 respirator. During a concurrent observation and interview on December 16, 2021 at 2:38 p.m., with Registered Nurse (RN) 1, RN 1 was wearing a N95-3 respirator and stated that she was not fit tested for that N95 -3 respirator. RN 1 stated the N95 respirator should be properly fitted prior to using it, because there is a risk of cross contamination of Covid-19 within the facility due to the current outbreak within the facility. During an interview on December 16, 2021 at 2:41 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated he was not fit tested for the N95-3 respirator before using it. CNA 2 stated he had not been fit-tested for any N95 in over a year. CNA 2 stated it was important to wear fit-tested N95 respirators prior to using the respirator to prevent getting the Covid-19 infection. During a concurrent observation and interview on December 16, 2021 at 3:00 p.m., with Laundry Personnel (LP) 1, LP 1 was wearing a N95-3 respirator. LP 1 stated she was fit tested for an unknown N95 respirator last year. LP 1 stated she thought all respirators were the same and had not been fit-tested for the N95-3 that she was wearing and had not been in-serviced on the various N95's. During a concurrent observation and interview on December 16, 2021 at 3:10 p.m., with Maintenance Personnel (MP) 1, MP 1 was observed wearing a N95 -3 respirator. MP 1 stated he was told by the Director of Staff Development (DSD), to use the N95-3 respirator even though he was not fit tested for it. During an interview on December 16, 2021 at 3:16 p.m., with DSD stated the N95-3 respirator should not be used by the staff in the facility, because the staff were not yet fit tested . The DSD stated the last fit testing done in the facility was on October 1, 2021 for the N95-1, N95-2 and 3M - N95 respirators. During an interview with the Infection Preventionist Nurse (IP) on December 17, 2021 at 11:59 am, IPN stated she was not fit tested for the N95-3 respirator and there were a 134 staff total that needs to be fit tested . During a review of the N95 Respirator Fit Testing Listing form dated October 1, 2021, the form indicated Licensed Vocational Nurse (LVN) 1's last fit testing was on October 20, 2020. During a review of the N95 Mask Fit Testing Log dated 11/20/ 2020, the log indicated the last fit testing was conducted on 11/20/2020 for the N95-1 for the facility's staff. During a review of facility's policy and procedures (P/P) revised 2020 titled Policy and Procedures for N95 Respiratory Respirator, the P/P indicated it was the facility's major goal to ensure employee's health was of utmost priority in order to function properly and safely while caring for residents. The P/P stated its purpose was to ensure employees had proper respiratory personal protective equipment (PPE) to protect themselves when on duty, to ensure there will be proper fitted N95 respirators and that employees used the proper fitted N95. During a review of facility's mitigation plan (MP) dated 6/15/2021, the MP indicated the facility provided a safe and healthy workplace for all employees and that a COVID-19 Plan minimized the risk of transmission of COVID-19. The MP indicated the facility would provide and ensure employees wear respirators that meet federal, state, and local regulations, and that a respirator was worn by each employee over the nose and mouth when indoors. The MP also indicated the facility would provide respirators and other necessary personal protective equipment ([PPE] protective wear such as goggles, face masks and gowns to prevent the spread of infections) when exposure to individuals with suspected or confirmed COVID-19 was anticipated in accordance with the facility's respiratory protection program.

Based on interviews and record review, the facility failed to adhere to its policy and procedures and ensure a resident's transfer and discharge was safe, appropriate, and the resident did not require the services of a skilled nursing facility (SNF) for two of four sampled residents (Residents 1 and 2). Resident 1 was homeless for eight (8) days after being discharged from the SNF to the street against his wishes on 3/4/2020 and without an appropriate discharge plan. Resident 2 was discharged to a hotel on 11/21/19 and was admitted into a general acute care hospital (GACH) on 11/23/19 for chest pain. These deficient practices resulted in Resident 1 being admitted to the GACH on 3/12/2020 for neck/chest pain and hypertension (high blood pressure) urgency requiring surgery for [REDACTED]. Resident 2 was readmitted back to the facility for chest pain recovery after a three (3) day hospitalization . Findings: a. A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P), dated 9/5/19 indicated Resident 1 had the mental capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 12/4/19 indicated Resident 1 was able to be understood and understand others. The MDS indicated Resident 1 required a one-person physical assist for dressing, personal hygiene and supervision to eat. The MDS indicated Resident 1's balance was not steady during standing, walking and transfer from surface-to-surface. A review of Resident 1's care plan titled, Activities of Daily Living (ADL), dated 8/28/19 indicated Resident 1 had a self-care deficit performance related to generalized weakness, impaired balance and history left hip replacement. The staffs' interventions included to provide a sponge bath when a full shower cannot be performed and staff to assist with personal hygiene and oral care. A review or Resident 1's care plan titled, Unspecified, dated 8/28/19 indicated Resident 1's primary physician gave orders to discharge resident to a lower level of care facility on 1/13/2020. The care plan indicated a discharge was not feasible due to Resident 1 requiring long term care and the resident wishing to remain in the facility. The staffs' interventions included to assure resident/family that long-term living arranges are in place and decision to remain in the facility can be changed and evaluate discharge plan every 90 days through the review period 3/18/2020. A review of the Interdisciplinary Team ((IDT) group of medical specialist that coordinate, collaborate, and plan the delivery of care for residents) meeting, dated 2/14/2020 and attended by Social Services Director (SSD), Social Services Assistant (SSA), Activities Director (AD) and Administrator in Training (AIT) indicated Resident 1 Was informed repeatedly that after numerous opportunities, he failed to pay his share of cost for consecutive months, therefore, the facility believed placing him at a lower level of care will be a more suitable place for him to reside as he does not need to be at the facility in order to receive his medical needs. A review of the unsigned Physician's telephone order, dated 3/4/2020 and timed at 5:13 p.m., indicated to discharge Resident 1 with medications. The telephone order did not indicate the place of discharge. Multiple fails attempts made to clarify orders for discharge. A review of the unsigned and undated Physician's Discharge Summary indicated Resident 1 was discharged home on[DATE] because his health had improved sufficiently and no longer needed the services provided by the facility. A review of a Notice of Proposed Transfer/discharge date d 3/4/2020 indicated Resident 1 refused to sign the discharge form. A review of Resident 1's undated Post Discharge Plan of Care indicated Resident 1 was discharge home with medications. The discharge instructions indicated to take blood pressure medication if systolic (first number) blood pressure (BP) was greater than 160 (139/89 - 100/70 normal reference ranges (NRR)) and to hold BP medications if systolic BP was less than 110 or heart rate less than 60 beats per minute ((bpm) NRR 60-100 bpm). A review of Resident 1's Nurses Notes dated 3/4/2020 and timed at 4:53 p.m. indicated Resident 1 was discharged with medications and belongings. The nurse's notes indicated the facility provided Resident 1 with transportation (unspecified destination) did not specified. A review of the GACH's Emergency Department (ED) report, dated 3/12/2020 and timed at 1:48 p.m., indicated Resident 1 arrived at the ED complaining of neck/chest pain. The report indicated Resident 1 was kicked-out from the SNF eight (8) days prior and had been homeless living under an awning (a frame used to keep the sun or rain off a storefront, window, doorway, or deck) of a parking lot. The ED note indicated Resident 1 had a hypertensive (high blood pressure) urgency of 170/110 and was admitted for further evaluation. A review of the GACH's Procedure Report, dated 3/13/2020 and timed at 5:47 p.m., indicated Resident 1 underwent a right and left heart catheterization (long thin tube inserted in an artery or vein in the groin, neck or arm and threaded through the blood vessels to the heart) to treat severe [DIAGNOSES REDACTED] (valves become stiff and thickened having a difficult time opening and closing to pump blood throughout the body). On 1/10/2020 at 2:42 p.m., during an interview, Resident 1 stated the facility had discharged him because of not paying the share of cost ((SOC) is the amount you agree to pay for health care before Medi-Cal starts to pay). Resident 1 stated he was paying the SOC and had not received a notice for discharge. Resident 1 stated he did not want to leave the nursing home because he did not know how to take his medication and blood pressure. On 1/10/2020 at 3:38 p.m., during an interview with the Administrator in Training (AIT) and Admissions Coordinator (AC), the AIT stated Resident 1 was being discharge due to not paying his SOC. The AC stated Resident 1 received his first letter for outstanding SOC balance on 1/8/2020. The AIT stated she did not know if the physician assessed Resident 1 prior to discharging the resident. On 4/16/2020 at 11:10 a.m., during a telephone interview, the Administrator (ADM) stated Resident 1 was discharged to a lower level of care facility ((LLC) housing for the elderly or disabled people that provides nursing care, housekeeping, and prepares meals) on 3/4/2020. On 4/17/2020 at 4:09 p.m., during a telephone interview, the owner of the LLC facility stated Resident 1 was not admitted and did not have on record Resident 1's admission. The LLC owner stated not being made aware a resident was being transfer to the facility. On 4/17/2020 at 4:20 p.m., during a telephone interview, the LLC supervisor stated no records where found of Resident 1's admission or arrival to the LLC on 3/4/2020. The LLC supervisor stated they did not receive a phone call from the SNF to admit Resident 1. On 4/17/2020 at 4:48 p.m., during a telephone interview, Resident 1 stated he was thrown out of the SNF to the streets on 3/4/2020. Resident 1 stated he refused to leave and sign any documents from the facility on 3/4/2020. Resident 1 stated he explained to the facility not feeling well and needing help. Resident 1 stated he was sleeping in abandon parking lots and was taken to the GACH on 3/12/2020 due to chest/neck pain. Resident 1 stated he underwent surgery due to high blood pressure problem. Resident 1 stated he felt worthless and bad they threw him out of the facility. On 4/20/2020 at 2:18 p.m., during a telephone interview, the SNF SSD stated she did not ensure the LLC was an appropriate placement for Resident 1. The SSD stated she paid for an Uber for Resident 1 to be taken to the LLC. The SSD stated Resident 1 refused to sign the discharge documents and at the time he was discharge COVID-19 was not as bad. The SSD stated Resident 1 was given a notice for discharge to a shelter in 1/2020. The SSD stated she had to cancel the notice because a shelter was not an appropriate placement for discharge for Resident 1. On 4/20/2020 at 3:26 p.m., during a telephone interview, the SNF's Registered Nurse 1 (RN 1) stated she called Resident 1's physician to initiate the discharge and perform a discharge assessment but Resident 1 refused to sign the documents for discharge because he did not want to leave the facility. RN 1 stated Resident 1 was discharge from the facility because he was non-compliant with the SOC payments. RN 1 stated she did not call the LLC to ensure Resident 1 arrived at the facility safe. b. A review of Resident 2's Face Sheet (Admission Record) indicated Resident 2 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's History and Physical (H/P), dated 5/22/19 indicated Resident 2 had mental capacity to understand and make decisions. A review of the unsigned and undated Physician's Discharge Summary indicated Resident 2 was discharged to a hotel on 11/21/19 because his health had improved sufficiently and no longer needed the services provided by the facility. A review of the SSD note, dated 11/21/19 and timed at 2:32 p.m. indicated Resident 2 was given $216.00 and discharge to a hotel via taxi. The SSD note indicated Resident 2 needed to be at the shelter no later than 1:30 p.m. to be admitted . The SSD note indicated the facility gave Resident 2 money for two nights to stay at the hotel. On 4/20/2020 at 2:18 p.m., during a telephone interview, the SSD stated she process Resident 2's discharge to a hotel on 11/21/19. The SSD stated Resident 2 was admitted to a GACH for chest pain two days after his discharge to the hotel and then transfer back to the facility on [DATE] from the GACH. The SSD stated she knew discharging the residents to a shelter was not a safe and appropriate discharge. A review of the facility's policy and procedures, revised on 5/1/18 and titled, Transfer and Discharge, indicated the facility was responsible to ensure a complete, safe and appropriate discharge planning and necessary information is provided to the continuing care provider. The policy indicated when the facility anticipates a resident's discharge to an LLC facility, the IDT with the assistance of the resident would develop a discharge summary and post-discharge plan to assist the resident to adjust. The policy indicated the medical record should contain written documentation from the resident's physician regarding the reason for transfer and enough evidence of the attempts from the facility to address residents needs.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors when Resident 1 did not receive 16 doses of rifaximin (medication to lower the level of ammonia (a toxic body waste product that will accumulate in the blood when there is a liver disease or liver damage)). This deficient practice resulted in an elevated ammonia level (an elevated ammonia level could adversely affect the brain function). Resident 1 had episodes of altered mental status requiring multiple hospitalization s. Findings: A review of Resident 1's Admission Face Sheet, indicated Resident 1 was initially admitted to the facility on (MONTH) 22, 2019 and last readmitted on (MONTH) 24, 2019. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated (MONTH) 27, 2019, indicated Resident 1 did not have problems with memory and cognition (thought process). The MDS indicated Resident 1 required extensive assistance and physical assistance from one staff when eating, toileting, dressing and with personal hygiene. A review of Resident 1's Detailed Census Report, dated (MONTH) 21, 2019, indicated the resident was hospitalized on the following dates: (MONTH) 3, 2019; (MONTH) 28 through 30, 2019; (MONTH) 14 through 16, 2019; (MONTH) 15, 2019; (MONTH) 20 through 23, 2019; (MONTH) 11 through 13, 2019 and (MONTH) 24 through 26, 2019. A review of Resident 1's Prescription History Report, dated from (MONTH) 23, 2019 to 11/10/19, indicated the pharmacy dispensed rifaximin on the following dates and in the following quantities: (MONTH) 23, 2019 (three-day supply), (MONTH) 28, 2019 (four-day supply), (MONTH) 2, 2019 (three-day supply), (MONTH) 6, 2019 (three-day supply), (MONTH) 11, 2019 (seven-day supply), (MONTH) 17, 2019 (two-day supply), (MONTH) 19, 2019 (two-day supply), (MONTH) 23, 2019 (14-day supply), (MONTH) 5, 2019 (14-day supply), (MONTH) 16, 2019 (seven-day supply), (MONTH) 3, 2019 (three-day supply), (MONTH) 5, 2019 (seven-day supply), (MONTH) 26, 2019 (30 day supply) and (MONTH) 27, 2019 (14 day supply). Resident 1 was present in the facility from (MONTH) 23, 2019 through (MONTH) 10, 2019, for a total of 151 days and the facility received a total of 113-day supply of Rifaximin medication. A review of Resident 1's general acute care hospital (GACH ( GACH 1)) records indicated Resident 1 was admitted in the hospital with an altered mental status, hepatic [MEDICAL CONDITION] and elevated ammonia levels on (MONTH) 7, 2019. The records indicated Resident 1 was treated with rifaximin 550 mg twice daily while at GACH 1. According to GACH 1's records, Resident 1 was discharged to the facility on (MONTH) 22, 2019, for continuation of present care and treatment. A review of Resident 1's Nurse Progress Note, dated (MONTH) 22, 2019 and timed at 7:56 p.m., indicated Resident 1 was admitted from the hospital with physician's orders [REDACTED]. A review of Resident 1's Order Summary Report, dated (MONTH) 23, 2019, indicated an order date of (MONTH) 22, 2019 for [MEDICATION NAME] (brand name for Rifaximin) 550 mg one tablet by mouth every 12 hours for liver cirrohosis. A review of Resident 1's Nurse Progress Note, dated (MONTH) 23, 2019 and timed at 8:09 a.m., indicated Resident 1 was confused due to [MEDICAL CONDITION] and hepatic [MEDICAL CONDITION]. A review of Resident 1's 2019 Medication Administration Records (MAR), from (MONTH) through (MONTH) 2019, indicated Resident 1 was present at the facility and did not receive the medication rifaximin as ordered by the physician on the following dates: (MONTH) 2 (p.m. dose), (MONTH) 7 (p.m. dose); (MONTH) 26 (p.m. dose), (MONTH) 29 (p.m. dose), (MONTH) 30 (p.m. dose), (MONTH) 31 (p.m. dose); (MONTH) 1 (p.m. dose), (MONTH) 14 (p.m. dose), (MONTH) 25-26 (a.m. and p.m. doses), (MONTH) 29 (a.m. and p.m. doses), (MONTH) 30 (a.m. dose); and (MONTH) 17, 2019 (p.m. dose). A review of Resident 1's Care Plan, dated (MONTH) 23, 2019, indicated the resident had a history of [REDACTED]. The care plan indicated Resident 1 had been hospitalized for [REDACTED]. The care plan interventions indicated Resident 1's medications would be administered as ordered. A review of Resident 1's Care Plan, dated (MONTH) 23, 2019, indicated the resident had a liver [MEDICAL CONDITION] and would be free from complications such as cognitive decline or mental status changes through (MONTH) 27, 2019. The care plan interventions included giving Resident 1 his medications as ordered. A review of Resident 1's Nurse Progress Notes dated from (MONTH) 26, 2019 to (MONTH) 30, 2019, indicated the facility did not have Resident 1's rifaximin available for administration and the pharmacy was contacted for delivery of the medication on the following dates and times: (MONTH) 26, 2019 at 1:53 p.m., (MONTH) 2, 2019 at 4:59 pm; (MONTH) 7, 2019 at 5:10 pm; (MONTH) 26, 2019 at 1:22 p.m., (MONTH) 29, 2019 at 1:49 p.m., (MONTH) 31, 2019 at 1:15 p.m., (MONTH) 1, 2019 at 2:01 p.m., (MONTH) 14, 2019 at 4:20 p.m., (MONTH) 25, 2019 at 1:54 p.m., (MONTH) 26, 2019 at 9:43 a.m. and at 3:02 p.m., (MONTH) 29, 2019 at 9:35 a.m. and at 2:54 p.m., (MONTH) 30, 2019 at 9:47 a.m. A review of Resident 1's Laboratory Results Report indicated the following elevated ammonia levels: June 24, 2019 121 umol/L; (Normal reference range (NRR) is 11 to 32 µmol/L) July 9, 2019 156 umol/L July 10, 2019 104 umol/L July 11, 2019 79 umol/L August 19, 2019 102 umol/L September 2, 2019 91 umol/L September 16, 2019 76 umol/L October 2, 2019 124 umol/L October 24, 2019 375 umol/L A review of Resident 1's GACH 2 Discharge Summary indicated Resident 1 was admitted to the GACH with elevated ammonia levels on the following dates: (MONTH) 28, 2019, (MONTH) 14, 2019, (MONTH) 15, 2019, (MONTH) 20, 2019, (MONTH) 11, 2019 and (MONTH) 26, 2019. GACH 2's discharge summary instructions on each of the dates indicated Resident 1 was discharged back to the facility and was to continue receiving Rifaximin 550 mg two times daily. A review of Resident 1's GACH 2 Discharge Summary, dated (MONTH) 24, 2019 indicated Resident 1 had an elevated ammonia level of 241. The documents indicated the physician at GACH 2 was concerned by Resident 1's elevated ammonia levels and considered the elevated ammonia level to be a sign of reduced medication at the facility. A review of Resident 1's Case Management Note, dated (MONTH) 27, 2019 and timed at 10:23 a.m., indicated the Administrator (ADM), Director of Nursing (DON) and Case Manager (CM) met to discuss the high cost ($1083.93 for 28 tablets) of Resident 1's medication rifaximin. According to the note, the DON indicated the medication would be continued and could not be changed at that time. On (MONTH) 7, 2019 at 11:20 a.m., during a concurrent interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated the facilities' pharmacy was not always timely with medication delivery for the residents. According to LVN 1, there were occasions Resident 1 did not receive rifaximin according to the physician's orders [REDACTED]. On (MONTH) 30, 2019 at 1:45 p.m., during a telephone interview, the facility's Consultant Pharmacist ((Pharm 1) person who is professionally qualified to prepare and dispense medicinal drugs) stated rifaximin was used to treat hepatic [MEDICAL CONDITION] and to reduce ammonia levels. According to the pharmacist, it was important for Resident 1 to receive the Rifaximin as ordered and if Resident 1 did not receive the rifaximin, it could result in an increase of ammonia levels and a decrease in mental alertness. Pharm 1 stated medication order request from the facility were filled the same day if received before the cutoff time or the next day if received after the cutoff time. Pharm 1 denied knowing why there were multiple gaps in the delivery of Resident 1's rifaximin. On (MONTH) 30, 2019 at 2:20 p.m., an attempted telephone call was placed to Resident 1's physician. Voice message was left requesting for a callback and no return call was received. On (MONTH) 4, 2019 at 11:20 a.m., during a concurrent interview and review of the nurses' notes, LVN 1 denied knowing why Resident 1 needed rifaximin, was not sure of the medications purpose and was not sure if the medication affected Resident 1's ammonia levels. LVN 1 was unable to locate any documentation in the nurses' notes that Resident 1's physician was notified of the resident's missed doses of rifaximin. On (MONTH) 4, 2019 at 11:55 a.m., during a telephone interview, the pharmacy owner (Pharm 2) stated the gaps in Resident 1's Rifaximin delivery was due to the medication being very expensive. Pharm 2 stated medications that were very expensive were dispensed in small amounts to contain costs and have control over the bills. According to Pharm 2, medications from the pharmacy should be filled and sent to the facility in a timely manner. On (MONTH) 4, 2019 at 2 p.m., during an interview, in the presence of the ADM , the DON denied knowing Resident 1 had missed doses of rifaximin and denied knowing about the concerns with the pharmacies medication delivery. On (MONTH) 5, 2019 at 11:20 a.m., during a telephone interview, the Director of Nursing (DON) stated the facility's physician reviewed the GACH discharge medication upon Resident 1's admission to the facility. The DON stated the admitting nurse would contact the physician for instructions on which meds were to be continued and which medications were to be discontinued. The DON stated the nurse then would document the information in the resident's chart. On (MONTH) 4, 2019 at 1:15 p.m., during a concurrent interview and record review, Case Manager (CSM 1) stated the cost of Residents 1's rifaximin was expensive but the facility had always covered the cost. On (MONTH) 18, 2019 at 2:30 p.m., a telephone call was placed to Resident 1's physician. Voice message was left requesting for a callback and no return call was received. A review of the facility's Pharmaceutical Service Agreement, dated (MONTH) 22, (YEAR), indicated the pharmacy would ensure all deliveries of medication were performed in a timely manner. The agreement indicated Monday through Friday, the pharmacy would perform deliveries three times a day and provide emergency deliveries as requested by the facility. A review of the facility's undated policy and procedure, titled Medication Ordering and Receiving from Pharmacy, indicated medication was to be reordered three to four days in advance to ensure an adequate supply was on hand. According to the policy, if a medication was needed before the next regular delivery, the pharmacy was to be called immediately to request a prompt delivery within four hours. The policy stated the licensed nurse would promptly notify the pharmacy, charge nurse and supervisor of any pharmacy medication discrepancies or omissions. A review of the facility's undated policy and procedure titled, Medication Administration- General Guidelines, indicated if two consecutive doses of a vital medication was withheld, the physician was to be notified.

Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of nine medication errors out of 29 opportunities for error, to yield a cumulative error rate of 31 % for four out of five residents observed (21, 23, 27, 105). The facility failed to: 1. Ensure Resident 23 was administered the right dose and the right medication of Magnesium [MEDICATION NAME] (a laxative used to treat constipation) as ordered by the physician and not Magnesium [MEDICATION NAME] (a saline laxative used for bowel evacuation). and failed to ensure Resident 23 was not administered the wrong form of [MEDICATION NAME] (a medication typically used for bowel motility and to treat nausea) as ordered by the physician. Medication was ordered to administer in a liquid form and instead was given in a form of tablet. 2. Ensure Resident 27's morning medications that were held from administration were not documented as administered. 3. Ensure Resident 21's prescribed daily morning dose of Aspirin (a medication used to prevent the formation of blood clots), was administered to the resident as ordered. 4. Ensure Resident 105 was not administered the wrong form of [MEDICATION NAME] Acid (a Vitamin C supplement) a tablet form was administered instead of the prescribed liquid form. These deficient practices had the potential to result in harm to Residents 23, 27, 21, and 105 by not administering medication as prescribed by the physician in order to meet their individual medication needs. Findings: 1. On 10/23/18 at 8:36 a.m., a licensed vocational nurse (LVN 1) was observed preparing medications for administration to Resident 23. The medications included the following: a. Vitamin C 500 milligram (mg) one tablet. b. [MEDICATION NAME] 10 milliliters (ml)([MEDICATION NAME] Sodium) 50 mg/5 ml liquid (a stool softener). c. Folic Acid 1 mg (a medication used to prevent [MEDICAL CONDITION], a blood condition), one tablet. d. [MEDICATION NAME] 5 mg, one tablet. e. [MEDICATION NAME] 50 mg (a heart medication), one tablet. f. Magnesium [MEDICATION NAME], 10 ml. g. Multivitamin tablet (a daily vitamin supplement), one tablet. h. 10 ml of Milk of Magnesia 400 mg/5 ml. During a concurrent interview, LVN 1 was asked how many medications she had to administer and she replied, Seven, the resident usually has eight, but I do not have Milk of Magnesia and I asked another nurse to call to the doctor to get an order for [REDACTED]. A review of Resident 23's physician's orders [REDACTED]. At 8:51 a.m., on 10/23/18, LVN 3 was observed coming to the medication cart and handed LVN 1 a bottle of Magnesium [MEDICATION NAME]. The directions on the bottle of Magnesium [MEDICATION NAME] indicated that the usual dosage was half of eight-ounce (240 ml) bottle. However, LVN 1 opened the Magnesium [MEDICATION NAME] and poured 10 ml into a medication cup and then added 30 ml of water. LVN 1 was asked to mark the medication cup that contained Magnesium [MEDICATION NAME]. Concurrently, LVN 1 was observed to administer one crushed 5 mg tablet of [MEDICATION NAME] mixed with 30 ml of water. LVN 1 was stopped and asked to review Resident 23's Medication Administration Record (MAR) prior to the administration of the 10 ml of Magnesium [MEDICATION NAME]. When asked if she knew why she was stopped from giving the medication LVN 1 replied, This is not the right medication, and it was supposed to be this one. LVN 1 was observed pulling out the bottle of Magnesium [MEDICATION NAME] 400 mg/5 ml. The directions on that bottle indicated that the usual adult dosage was two to four tablespoonful (30-60 ml). Next, LVN 1 was observed to pour and administer 10 ml of the Magnesium [MEDICATION NAME] to Resident 23 via the gastrostomy tube ((GT) a soft tube surgically inserted directly into stomach for administration of nutrition, hydration and medication). A review of Resident 23's physician's orders [REDACTED]. a. [MEDICATION NAME] HCL Solution ( liquid) 5 mg/5 ml, to give 5 ml via GT three times a day for gastrointestinal distress. b. Milk of Magnesia (Magnesium [MEDICATION NAME]) suspension 2400 mg/10 ml, to give 10 ml via GT one time a day for bowel management. c. Milk of Magnesia (Magnesium [MEDICATION NAME]) suspension 400 mg/5 ml, to give 30 ml by mouth every day as needed for constipation. A review of Resident 23's clinical records indicated that there was no prescribed order for Magnesium Oxide or Magnesium [MEDICATION NAME] for Resident 23. On 10/23/18 at 8:51 a.m., LVN 1 was observed to administer a different dose of Magnesium [MEDICATION NAME] than what was prescribed (one-third of the prescribed dose of Magnesium [MEDICATION NAME]) and a different form of [MEDICATION NAME] than what was prescribed (a tablet instead of the liquid form). On 10/23/18, at 2:25 p.m., during an interview, LVN 1 was asked about the order for the Magnesium [MEDICATION NAME] LVN 1 stated, I got nervous and was looking for the wrong medication. When asked about the dose of the Magnesium [MEDICATION NAME], LVN 1 stated, The one I gave was the routine dose. When asked about the dosage form of [MEDICATION NAME], LVN 1 stated, I should have verified the order. Concurrently, during an interview, LVN 1 was asked to demonstrate which strength of Magnesium [MEDICATION NAME] was administered to the resident. LVN 1 pulled a bottle from the medication cart and verified the strength was 1200 mg/15 ml, instead of 400 mg/5 ml, as ordered. When asked about the policy to follow when there is a discrepancy between the strength of the medication in the order and the medication that will be administered she stated If there is a discrepancy, I should clarify the order with the doctor and the pharmacy. LVN 1 was asked what could happen if the resident got a dose of Magnesium [MEDICATION NAME] that was too low she stated I did not give enough. The strength was not enough, it would not work and the resident would not be able to clear his bowel the way he should. When asked to see if the correct strength of the Magnesium [MEDICATION NAME] for routine use was available LVN 1 stated I know I do not have the correct one on the cart. LVN 1 and an Assistant Director of Nursing (ADON) searched the medication cart to find [MEDICATION NAME] 5 mg/ 5ml solution and Magnesium [MEDICATION NAME] 2400 mg/10 ml but the only strength of the Magnesium [MEDICATION NAME] available was the 400 mg/ 5 ml. There was no [MEDICATION NAME] solution available. A review of the facility's policy titled, Medication Administration, with a revised date of 5/18, indicated, Purpose: To provide practice standards for safe administration of medications for residents in the facility. The nurse must know the following information about the medication they are administering .The medication name .The medication usual dosage . 2. On 10/23/18 at 9:58 a.m., observed LVN 2 preparing the following medications to administer to Resident 27: a. Prostat (a liquid protein supplement), 30 ml. b. [MEDICATION NAME] 0.5 mg (a medication used to treat symptoms of [MEDICAL CONDITION]), one tablet. c. [MEDICATION NAME] sodium 100 mg (a stool softener), two tablets. d. Memantine 5 mg (a medication used to treat [MEDICAL CONDITION]). e. [MEDICATION NAME] Acid 250 mg/5 ml solution (a medication used to treat or prevent [MEDICAL CONDITION] and sometimes used to stabilize mood). Concurrently, LVN 2 was observed to crush each medication in tablet form in preparation for administration to Resident 27 through the GT. LVN 2 did not add water to any of the crushed tablets but did add 5 ml of water to the Prostat because I need to thin it out so that it does not clog the tube. All aforementioned medications LVN 2 broght to the resident's room for admininstration. According to Resident 27's admission record, the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 27 had a GT in place for administration of food and medication. Upon checking the patient, LVN 2 stated I am not going to give her the meds. It looks like she has thrown up. I need to talk to her doctor. At 11:43 a.m., on 10/23/18, during an interview, LVN 2 stated, The doctor ordered [MEDICATION NAME] (a medication used to treat nausea and vomiting) every eight hours for Resident 27. I did not give the morning medications, I wasted them per the doctor's instructions. A review of Resident 27's MAR for the 9 a.m. medications on 10/23/18 indicated it was marked as administered. At 3:14 p.m., on 10/23/18, during an interview, ADON stated she was aware that the 9 a.m. morning medications for 10/23/18 were ordered to be held due to an episode of vomiting per instructions of attending physician. The ADON indicated that in this case the medication would be wasted and the MAR should have been updated to indicate that the medication were held and disposed of for that day. The ADON read the physician's orders [REDACTED]. The ADON read Resident 27's MAR under the entry for 9 a.m. for 10/23/18 and each of the orders had a check mark next to it. The ADON indicated that a check mark next to each order signifies that the medication was given to the resident. At 3:30 p.m., on 10/23/18, during a telephone interview, LVN 2 stated, I did mark the MAR as if I had given the medication. I did not go back into the records to mark them as held (not administered). The medications were held. The physician gave orders to hold the medication. A review of the facility's policy titled, Medication Administration, with a revised date of 5/18, indicated, Purpose: To provide practice standards for safe administration of medications for residents in the facility .Whenever a medication is held for any reason the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initial. The Licensed Nurse will document the reason the medication was held on the back of the MAR. 3. On 10/24/18, at 8:18 a.m., during a medication pass observation, LVN 4 was observed preparing the following medication for administration to Resident 21: a. Potassium Chloride 20 millequivalents (mEq) (a Potassium supplement), one tablet. b. [MEDICATION NAME] 40 mg (a medication used to treat high blood pressure), one tablet. c. [MEDICATION NAME] 10 mg (a medication used to treat high blood pressure), three tablets. d. [MEDICATION NAME] 25 mg (a medication used to treat high blood pressure), one tablet. e. Quetiapine [MEDICATION NAME] 25 mg (am antipsychotic medication used to treat [MEDICAL CONDITION]), one tablet. f. Multivitamin, one tablet. g. [MEDICATION NAME] Acid 500 mg (a Vitamin C supplement), one tablet. Concurrently, LVN 4 was asked how many total medication were being administered to Resident 21, LVN 4 stated, nine pills, but seven medications. LVN 4 was observed successfully administered all seven medications by mouth to Resident 21. According to Resident 21's admission record, the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of Resident 21's MAR for 10/24/18 at 9 a.m., indicated the order for the Aspirin had been marked as administered. On 10/24/18, at 2:56 p.m., during an interview with LVN 4, when asked why the Aspirin had been omitted, LVN 1 was adamant that the Aspirin had, in fact, been administered to Resident 21. However, when confronted with the surveyor's record of the medications prepared and administered, as well as the total number of medications administered to Resident 21, LVN 4 did not have an explanation for the discrepancy between the seven medications observed administered and the eight medications documented as administered. 4. On 10/24/18, at 7:51 a.m., during a medication pass observation, LVN 4 was observed preparing the following medication for administration to Resident 105: a. [MEDICATION NAME] acid 500 mg, one tablet. b. Celecoxib 200 mg, (an anti-[MEDICAL CONDITION] medication for arthritis), one capsule. Concurrently, LVN 4 was observed crushing the Vitamin C tablet and mixing the powder with applesauce. LVN 4 then administered the mixture to Resident 105 by mouth. LVN 4 then opened the Celecoxib capsule, mixed the contents with applesauce and administered the mixture to Resident 105 by mouth. A review of Resident 105's admission record, indicated the resident was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. At 2:56 p.m., on 10/24/18, during an interview, LVN 4 was asked to see whether the liquid form of [MEDICATION NAME] Acid was available in the medication cart. The LVN 4 produced a bottle of the [MEDICATION NAME] Acid liquid from the bottom drawer of medication cart. When asked why Resident 105 was given the tablet instead of the liquid LVN 4 stated We can give the tablet or liquid form. When shown the physician's written order specifying the liquid form, LVN 4 stated it should have been given as liquid. A review of the facility's policy titled, Medication Administration, with a revised date of 5/18, indicated, Purpose: To provide practice standards for safe administration of medications for residents in the facility. Medication will be administered .per the order of an Attending Physician. On 10/25/18 at 5:12 p.m., a pattern of systemic failures that included the observation of LVN 1 administering wrong medication to Resident 23 through the GT in a wrong dose and in a wrong form. Two other licensed nurses, LVN 2 and LVN 4 were observed failing to administer medications to residents, however documenting the prescribed medications as administered to Resident 21 and 27, and admininstering prescribed medication to Resident 105 in a wrong form.These failures resulted in an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause serious injury, harm, impairment, or death to a resident). The facility's Administrator and Director of Nurses (DON) were notified of the immediacy and seriousness to the residents' health and safety. On 10/26/18 at 4:20 p.m., the facility submitted an acceptable Plan of Action (POA) and the IJ was lifted after the team verified the POA was implemented through observations, interviews and record reviews as follows: 1. The identified licensed nurse was placed on suspension pending investigation. 2. All licensed nurses on duty were immediately in-service by the DON and Clinical consultant. 3. Any resident expressing the desire for self-administration of medications was assessed by the IDT. 4. Licensed nurses will monitor the resident's consistency with medication instructions. 5. All licensed nurses will have skilled checks on medication pass, which would include [DEVICE] administration and Narcotics administration by the Nurse Pharmacist Consultant, DON, and RN supervisors. 6. Routine skill checks for medication pass would be done upon hire and yearly.

Based on observation, interview, and record review, the facility failed to follow physician's orders and its policy to ensure residents who were at high risk for falls had fall prevention measures in place and received care in accordance with residents' plan of care for four of four sampled residents (Residents 1, 2, 3 , and 4). a. Resident 1's bed alarm was not on and the resident had an unwitnessed fall sustaining a fractured (broken bone). b. Resident 2 was on a wheelchair without an alarm, as per physician's orders. c. Resident 3's floor mats were away from the bed; call light, bedside table and water pitcher were not within reach, as per the resident's plan of care and physician's orders. d. Resident 4 had no wheelchair alarm, as per physician's orders. These deficient practices resulted in Resident 1 having an unwitnessed fall that resulted in a right leg fracture and a three-day hospital admission and had the potential to result in further falls and injuries to Residents 2, 3 and 4. Findings: a. A review of Resident 1's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's physician's orders, dated 1/3/18, indicated the following: a bed alarm when in bed to alert staff to assist the resident with needs, and to replace the alarm in ninety (90) days, monitor for bed alarm placement every shift, monitor Resident 1's attempts of getting out of bed (OOB) without assistance and tally (add up) every shift, and monitor the resident for pain using 0-10 scale every shift. A review of Resident 1's care plan, dated 3/16/17, indicated Resident 1 had a bed alarm used to prevent the resident from getting OOB unassisted and to alert the staff of Resident 1's needs. The staff's interventions indicated to change the bed alarm battery or place a new one every 90 days, position Resident 1 correctly in bed while the alarm was in place, evaluate the resident's alarm use and to monitor and report any changes regarding the effectiveness of the alarm. A review of Resident 1's History and Physical report (H/P), dated 5/6/18, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Fall Risk Assessment, dated 6/27/18, indicated the resident's score was 50 (45 or greater = high risk for falls). A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 6/27/18, indicated the resident had severe impairment in thought process. Resident 1 required staff's assistance with bed mobility, transferring to and from the bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 1 did not have any mobility device like a cane, walker or wheelchair for ambulation. The MDS indicated Resident 1 was always incontinent (inability to control) of bladder and bowel functions. A review of a Situation, Background, Assessment and Recommendation ((SBAR) internal communication record), dated 8/5/18 and timed at 12:58 a.m., indicated on 8/5/18; Resident 1 slid to the floor and was found sitting on the floor mat by Resident 1's family member (FM 1). The SBAR indicated the resident was assessed by a licensed vocational nurse (LVN 1) and had no injuries. According to the SBAR, no x-ray or pain assessment were done for Resident 1. A review of a Safety Devices Flowsheet, dated 8/3/18 and 8/4/18, indicated Resident 1 did not have floor mats, but did indicate the resident had a bed and chair alarm. A review of another Safety Devices Flowsheet, dated 8/5/18, indicated Resident 1 had floor mats, and a bed and chair alarm. A review of another Safety Devices Flowsheet, dated 8/6/18, did not indicate Resident 1 had any safety devices. A review of a care plan, dated 8/6/18, indicated Resident 1 had an actual fall. The staff's interventions indicated to monitor the resident for seventy-two (72) hours for pain, bruise, or any change of condition (C[NAME]), use of bilateral floor mats to minimize injuries and the use of a bed alarm. A review of another SBAR, dated 8/7/18 and timed at 2:51 p.m., indicated FM 1 requested Resident 1 to be sent to a general acute care hospital (GACH) to rule out brain damage because the residents face was twitching (sudden small movements of the body). A review of Resident 1's x-ray report, dated 8/7/18, indicated Resident 1 had a right leg fracture. On 8/24/18, at 11:30 a.m., during a concurrent interview and record review, the Quality Assurance nurse (QA) stated that every shift licensed nurses had to ensure residents safety devices were in place. The QA nurse stated that upon assessing the residents, the staff were supposed to sign in the Safety Devices Flowsheets. According to the QA nurse, the safety devices flowsheets, dated 8/6/18, did not indicate Resident 1 had any safety devices. The QA nurse stated that it was an error. On 8/24/18, at 12:52 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that Resident 1 had a tendency of sliding out of bed to the floor. LVN 2 stated that the day (8/4/18) Resident 1 was found on the floor, the alarm did not go off. On 8/24/18, at 1:22 p.m., during an interview, LVN 1 stated that FM 1 found the resident on the floor next to her bed on 8/4/18, at 12:15 a.m., during a random visit to the facility. LVN 1 also stated that she did not hear any alarm sound and was not sure if Resident 1 had a bed alarm or not. b. A review of Resident 2's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's Morse Fall Scale, dated 11/1/17, indicated the resident was at high risk for falls. A review of Resident 2's care plan dated 11/1/17, and titled, The resident was at risk for falls related memory loss (dementia) and gait/balance problems. The staff's interventions included to place the resident's call light within reach, bed/chair alarm on to alert staff to assist the resident, and provide a safe environment for the resident. That same care plan indicated Resident 2 had an actual fall on 4/26/18, and the interventions were the same. There were no other specific interventions to prevent further falls. A review of Resident 2's Fall Risk Assessment, dated 8/17/18, indicated the resident's score was 75. A review of another Fall Risk Assessment, dated 4/26/18, indicated Resident 2 was still at high risk for falls. A review of Resident 2's SBAR, dated 4/26/18, indicated on 4/26/18, at 2:10 a.m., the resident was found on the floor in his room, complained of pain and was transferred to a GACH for evaluation. A review of another SBAR, dated 8/17/18, indicated on 8/17/18, at 7:45 a.m., Resident 2 was found on the floor again in his room. A review of Resident 2's Physician's Orders, dated 7/19/18, indicated the following: a bed alarm when in bed to alert staff to assist the resident with needs, and bilateral floor mats. A review of Resident 2's MDS, dated [DATE], indicated the resident had could not understand and be understood by others. Resident 2 required a staff's assistance with bed mobility, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, toilet use and personal hygiene. According to the MDS, Resident 2 used a wheelchair for ambulation. The MDS also indicated Resident 2 was frequently incontinent of bladder. A review of a Safety Devices Flowsheet, dated 8/3, 8/4, 8/5 and 8/24/18, indicated Resident 2 had floor mats, and a bed and chair alarm. A review of Resident 2's Nurses Progress Notes, dated 8/17 and 8/18/18, indicated the resident was monitored status [REDACTED]. A review of Resident 2's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 8/24/18, at 11:30 a.m., during a concurrent interview and record review, the QA nurse stated that every shift the licensed nurses had to ensure residents safety devices were in place. According to the QA nurse, upon assessing, the staff were supposed to sign on the safety devices flowsheets. On 8/24/18 at 12:10 p.m., during a concurrent observation and interview, Resident 2 was sitting in a wheelchair in the Activity Room, without an alarm. LVN 3 stated that the resident always removed his chair alarm. According to LVN 3, Resident 3 should always have an alarm to alert the staff if the resident tried to get up unassisted. LVN 3 stated that the resident was at risk for falls. c. A review of Resident 3's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's Physician's Orders, dated 1/22/18, indicated the following: a bed alarm when in bed to alert staff to assist the resident with needs, to replace the alarm in ninety (90) days, monitor for bed alarm placement every shift, bilateral floor mats and bed in the lowest position. A review of Resident 3's SBAR, dated 2/24/18, indicated the resident was found on the floor in his room, on 2/24/18 at 7:24 a.m. A review of Resident 3's care plan, dated 2/24/18, indicated the resident had a fall on 2/24/18. The staff's interventions indicated a bed alarm, bilateral floor mats and to continue interventions on the at risk for falls care plan. A review of Resident 3's Nurses Progress Notes, dated 2/25 to 2/26/18, indicated the resident was being monitored for falls, the call light was within reach, and bilateral floor mats in place. A review of Resident 3's Fall Risk Assessment, dated 4/26/18, indicated the resident's score was 75 (above 45 = high risk). A review of Resident 3's MDS, dated [DATE], indicated the resident had severe impairment in thought process. Resident 3 required a staff's assistance with bed mobility, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 3 did not have any mobility devices such as a cane, walker or wheelchair for mobility. The MDS indicated Resident 3 was always incontinent (inability to control) of bladder and bowel functions. A review of a Safety Devices Flowsheet, dated 8/3 to 8/5/18 and 8/24/18, indicated Resident 3 had floor mats and a bed alarm. It also indicated the resident did not have a chair alarm. A review of Resident 3's MAR, dated 8/1 to 8/24/18, indicated the resident had a bed alarm and the staff was monitoring the alarm's placement every shift. It also indicated Resident 3 had bilateral floor mats. On 8/24/18, at 10:55 a.m., during a concurrent observation, interview, and record review, Resident 3 was in bed without a bed alarm, and the floor mats was away from the resident's bed. The call light was hanging behind the bed and the bedside table was not within the resident's reach. LVN 3 stated that the resident's belongings should be within reach for easy access and to prevent falls. LVN 3 added that Resident 3 was supposed to have a bed alarm. On 8/24/18, at 11:30 a.m., during a concurrent interview and record review, the QA nurse stated that every shift the licensed nurses had to ensure residents safety devices were in place. According to the QA nurse, upon assessing, the staff were supposed to sign on the Safety Devices Flowsheets. d. A review of Resident 4's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident could not understand and be understood by others. Resident 4 required two or more staff's assistance with bed mobility, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 4 used a wheelchair for mobility and was always incontinent of bladder. The staff failed to include Resident 4's fall on the MDS. A review of Resident 4's H/P indicated the resident had a fluctuating capacity to understand and make decisions. A review of Resident 4's care plan, dated 2/7/18, indicated the resident was at risk for falls due to gait/balance problems. The staff's interventions included a chair alarm when the resident was in the wheelchair to alert the staff to assist the resident with needs, replace the alarm every 90 days and monitor placement of the chair alarm every shift. A review of Resident 4's Fall Risk Assessment, dated 2/6/18, indicated the resident was at high risk for falls. A review of another Fall Risk Assessment, dated 5/16/18, indicated the resident was at moderate risk for falls. A review of Resident 4's SBAR, dated 8/6/18, indicated on 8/6/18 at 4:45 p.m., the resident had an unwitnessed fall that resulted in discoloration to the right leg. A review of a care plan, dated 8/6/18, indicated Resident 4 had an actual fall due to poor balance. The staffs interventions indicated the use of a chair alarm when up in the wheelchair and to monitor for placement every shift. A review of Resident 4's Physician's Order, dated 8/7/18, indicated the use of a chair alarm when up on a wheelchair to alert staff to assist the resident and to replace the alarm in 90 days. A review of Resident 4's Nurses Progress Notes, dated 8/6 to 8/8/18, indicated the resident was monitored for falls and that the call light was within the resident's reach. A review of a Safety Devices Flowsheet, dated 8/3 to 8/5/18, indicated Resident 4 did not have any floor mats, and/or bed or chair alarms. A review of another Safety Devices Flowsheet, dated 8/24/18, indicted Resident 4 had floor mats, and bed and chair alarms. A review of Resident 4's MAR, dated 8/1 to 8/24/18, indicated the resident had a chair alarm and the staff was monitoring the alarm's placement every shift. On 8/24/18, at 11:30 a.m., during a concurrent interview and record review, the QA nurse stated that every shift the licensed nurses had to ensure residents safety devices were in place. According to the QA nurse, upon assessing, the staff were supposed to sign on the Safety Devices Flowsheets. On 8/24/18 at 12:44 p.m., during a concurrent observation, interview, and record review, Resident 4 was sitting in a wheelchair in the Dining Room with no chair alarm. LVN 4 stated that he had been Resident 4's nurse since admission and that he was not sure if Resident 4 needed an alarm. LVN 4 stated he should have checked the physician's orders for a wheelchair alarm. According to LVN 4, an alarm was used to prevent resident falls and injuries. On 10/15/18, at 11:12 a.m., during a concurrent record review and interview, the QA nurse stated that Resident 4 was not on the Safety Devices Flowsheet until 8/6/18 because the resident only had a moderate risk for falls. According to the QA nurse, Resident 4 wore a helmet for safety and should have been on the safety device lists as well. A review of the facility's undated policy titled, Tab Alarms, Bed Alarms, Wander Guard System, indicated tab alarms or bed alarms would be used on a resident who was deemed unsafe through assessment and documented on the resident's care plan that the resident was at risk for falls. It also indicated documentation's of the use of alarms would be in the treatment books on each unit, daily. A review of the facility's policy titled Physician Orders dated 11/17, indicated physician's orders would be maintained and carried out without any questions. A review of the facility's policy titled, Fall Management Program, with a revised date of 5/1/18, indicated the purpose of the policy was to prevent falls and minimize complications from falls. It also indicated the facility would provide the highest quality of care in the safest environment for residents by developing a fall management program that prevented residents from falling through interventions, assessments, interventions, education and reevaluation. A review of a policy titled, Care Planning, with a revised date of 5/1/18, indicated the facility would develop a person-centered care plan on each resident, and update it to reflect changes in the resident's condition or needs.

Based on interview and record review, the facility failed to follow its policy, physician's orders and care plan to ensure one of four sampled residents, who was a high risk for falls received supervision and used assistance devices as prescribed by the physician to prevent falls and injuries for one of four sampled residents (Resident 1). Cross referenced to F 684. This deficient practice resulted in Resident 1 having an unwitnessed fall and sustaining a right leg fracture (broken bone) that required admission to a general acute care hospital (GACH) for three (3) days for further evaluation and treatment. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 6/27/18, indicated the resident had severe impairment in thought process. Resident 1 was totally dependent on staff with bed mobility, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 1 did not have any mobility device such as a cane, walker or wheelchair for mobility. The MDS also indicated Resident 1 was always incontinent (inability to control) of bladder and bowel functions. A review of Resident 1's physician's orders, dated 1/30/18, indicated the following: a bed alarm when in bed to alert staff to assist the resident with needs, to replace the alarm in ninety (90) days, monitor for bed alarm placement every shift, monitor Resident 1's attempts of getting out of bed (OOB) without assistance and tally (add up) every shift, and monitor the resident for pain using 0-10 pain scale every shift. A review of Resident 1's care plan titled, Resident at risk for falls related to confusion, gait/balance problems, incontinence and muscle weakness, unaware of safety needs and dependent for mobility, dated 3/16/17, indicated the staff's interventions included to anticipate and meet the resident's needs, provide a safe environment such as bed in the lowest position at night, personal items and call light within reach, the use of chair/bed electronic alarms and to ensure the devices are in place as needed. A review of Resident 1's care plan titled, Bed alarm used to prevent the resident from getting out of bed unassisted and to alert staff of resident's needs, dated 3/16/17, indicated the staff's interventions indicated to change the bed alarm battery or place a new one every 90 days, position the resident correctly in bed while the alarm was in place, evaluate the resident's alarm use and to monitor and report any changes regarding the effectiveness of the alarm. A review of Resident 1's History and Physical report (H/P), dated 5/6/18, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Fall Risk Assessment, dated 6/27/18, indicated the resident's score was 50 (45 or greater = high risk for falls). A review of a Situation, Background, Assessment and Recommendation ((SBAR) internal communication), dated 8/5/18, and timed at 12:58 a.m., indicated on 8/5/18, Resident 1 slid to the floor and was found sitting on the floor mat by Resident 1's family member (FM 1). The SBAR indicated the resident was assessed by a licensed vocational nurse (LVN 1) and had no injuries. According to the SBAR, no x-ray or pain assessment were done on the resident. A review of a Safety Devices Flowsheet, dated 8/3 to 8/5/18, indicated Resident 1 had a bed and chair alarm. A review of a Safety Devices Flowsheet, dated 8/6/18, did not indicate Resident 1 had any safety devices. A review of Resident 1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. According to the MAR, the staff did not observe the resident for fall maintenance every shift. Resident 1 was monitored for pain every shift and had no indication of having pain or was medicated for pain. According to the MAR, for (MONTH) (YEAR), Resident 1 had attempted to get out of bed unassisted on the following dates: 1. On 8/1/18, had two episodes on the night shift. 2. On 8/4/18, had three episodes on the night shift. 3. On 8/5/18, had three episodes on the day shift. 4. On 8/6/18, had two episodes on the night shift. 5. On 8/7/18, had two episodes on the day shift. A review of Resident 1's care plan did not address the resident's episodes of attempting to get out of bed nor did it include the use of other specific interventions to reduce the risk of falling. A review of a care plan, dated 8/6/18, indicated Resident 1 had an actual fall. The staff's interventions indicated to monitor the resident for seventy-two (72) hours for pain, bruise, or any change of condition (C[NAME]), use of bilateral floor mats to minimize injuries and the use of a bed alarm. A review of another SBAR, dated 8/7/18 and timed at 2:51 p.m., indicated FM 1 requested Resident 1 to be sent to a general acute care hospital (GACH) to rule out brain damage because the resident's face was twitching (sudden small movements of the body). A review of Resident 1's GACH Emergency Department (ED) Note, dated 8/7/18, indicated the resident was brought into the ED in severe pain and swelling to her right leg. A review of Resident 1's right leg x-ray, dated 8/7/18, indicated the resident had a right leg fracture. A review of Resident 1's GACH Discharge Summary, indicated the resident was admitted on [DATE], and discharged on [DATE], with a right ankle fracture. It also indicated Resident 1 had a temporary splint (strip of rigid material used for supporting and immobilizing a broken bone) placed to the right leg, treated for [REDACTED]. According to the discharge summary, Resident 1 had a follow up with an outpatient orthopedic (study and research of the musculoskeletal system (bones, joints, nerves)) physician. On 8/24/18, at 8:30 a.m., during an interview, FM 1 stated that she found Resident 1 kneeling on the floor on 8/5/18, at 12 a.m., during a random visit to the facility. FM 1 stated that Licensed Vocational Nurse 2 (LVN 2) stated that Resident 1 had been falling and was surprised FM 1 did not know about the falls. According to FM 1, the facility did not inform her that Resident 1 had ever fallen in the facility. FM 1 stated that on 8/7/18, the resident's right foot was swollen and the resident was screaming in pain. FM 1 was concerned because after the fall, there was no x-ray was done and she had to request the facility to transfer the resident to a GACH for further evaluation. FM 1 stated that Resident 1 screamed so loud in pain when she was transferred to an ambulance. On 8/24/18, at 12:53 p.m., during an interview, LVN 2 stated that Resident 1 was not ambulatory and slid out of bed to the floor quite often. LVN 2 stated Resident 1 always slid off the bed to the floor during the night shift. LVN 2 stated on 8/5/18, when FM 1 found the resident on the floor, the bed alarm did not sound. LVN 2 further stated there was no care plan to address the resident's behavior of sliding off the bed. On 8/24/18, at 1:15 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 1 had a tendency of uneasiness, tossing and turning in bed. According to CNA 1 the resident had a floor mat and padded side rails but no bed alarm, as prescribed by the physician. On 8/24/18 at 1:22 p.m., during an interview, LVN 1 stated that Resident 1 was found on the floor on 8/5/18 at 12:15 a.m., by FM 1. LVN 1 also stated that she did not know if Resident 1 had a bed alarm and did not hear the alarm sound when the resident got out of bed. LVN 1 added that if Resident 1 had an alarm, the nurse should have been monitoring for placement and functioning. According to LVN 1, she did not monitor Resident 1 for the use of the alarm and its function because she was not aware Resident 1 had an order for [REDACTED].>A review of an undated policy titled, Tab Alarms, Bed Alarms, Wander Guard System, indicated tab alarms or bed alarms would be used on a resident who was deemed unsafe through assessment and documented on the resident's care plan that the resident was at risk for falls. It also indicated documentation of the use of alarms would be in the treatment books on each unit, daily. A review of another policy titled, Care Planning, with a revised date of 5/1/2018, indicated the facility would develop a person-centered care plan on each resident, and update it to reflect changes in the resident's condition or needs. A review of the facility's policy titled, Fall Management Program, with a revised date of 1/5/18, indicated the purpose of the policy was to prevent falls and minimize complications from falls. It also indicated the facility would provide the highest quality of care in the safest environment for residents by developing a fall management program that prevented residents from falling through interventions, assessments, interventions, education and reevaluation.

Based on interview and record review, the facility failed to follow its policy and ensure one of three sampled residents (Residents 1) was treated with dignity and respect. Resident 1 was told she smelled like urine and told to take a shower by Certified Nursing Assistant 1 (CNA 1). This deficient practice resulted in Resident 1 feeling humiliated, intimidated, disrespected and leaving the facility against medical advice (AMA). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 3/16/18, indicated the resident had the ability to understand and be understood by others. Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 (8-15 = interviewable). The MDS indicated Resident 1 required limited assistance with transferring, dressing, toilet use, and personal hygiene. The MDS indicated the resident used a walker to ease movement, and was occasionally incontinent (ability to control) bowel and bladder. According to the MDS, Resident 1 was receiving diuretics ((water pill) medication that causes one to urinate more than normal). A review of Resident 1's care plan, dated 3/10/18, indicated the resident had activities of daily living (ADL) self-care performance deficit related to impaired balance. The staff's interventions included providing Resident 1 with a sponge bath when a full bath or shower could not be tolerated, encourage the resident to participate fully, and praise the resident's efforts of self-care. A review of Resident 1's shower log, dated 3/10 to 3/20/2018, indicated the resident received a bath and or shower daily. A review of Resident 1's Situation, Background Assessment and Recommendation ((SBAR) communication tool used amongst the licensed nurses), dated 3/14/18, indicated Certified Nursing Assistant 1 (CNA 1) asked Resident 1 to take a shower because the resident smelled like urine. The SBAR indicated Resident 1 stated she did not have to shower if she did not want to. A review of Resident 1's progress notes, dated 3/14 to 3/16/2018, indicated Resident 1 was being monitored for refusing care, and there were no episodes of Resident 1 refusing care documented. A review of Resident 1's nurses' progress note, dated 3/15/18, and timed 15:51 (3:51) p.m., indicated the resident refused care, and was instructed on the risk and benefits of refusing care. A review of Resident 1's physician's discharge summary, dated 3/23/18, indicated the resident left the facility against medical advice. On 4/10/18 at 1:26 p.m., during a telephone interview, Resident 1 stated that the facility's staff humiliated her stating she smelled like urine and needed to take a shower. Resident 1 stated the staff was intimidating her, and would open the window in her room even when it was cold because, according to the staff, the resident smelled and had a mental problem. Resident 1 stated that the staff refused to provide her with water and several other things. Resident 1 stated she requested to leave the facility against medical advice because she had no other choice. The resident was emotional as she recounted the treatment she received from the facility. Resident 1 paused, sobbed, and her voice quivered as she spoke. On 4/11/18 at 10:23 a.m., during an interview, CNA 1 stated that Resident 1 smelled like urine and did not want to shower, so staff had to open the windows to let fresh air in because CNA 1 did not like the resident's room to have an odor. On 4/11/18 at 11 a.m., during an interview, Registered Nurse 1 (RN 1) stated Resident 1 did not want to take showers. RN 1 stated if Resident 1 refused care, the staff should have called the family, notified the physician, met with interdisciplinary team ((IDT) group of disciplines that work together towards a common goal of a resident) and the refusal of care should have been addressed in the resident care plan. On 4/11/18 at 11:15 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated LVN 1 stated Resident 1 refused to shower. According to LVN 1, she told Resident 1 to listen to Resident 2's complaints and Resident 1 became upset. LVN 1 stated that Resident 1 agreed to shower only after Infectious Disease (ID) Nurse was called to speak to the resident. LVN 1 stated the only documentation done regarding Resident 1's non-compliance with care was the SBAR on 3/14/18. On 4/11/18 at 11:40 a.m., during an interview, the ID Nurse stated she spoke to Resident 1 after the staff informed her about the resident refusing to take a shower. The ID Nurse stated Resident 1 told her that she sometimes leaked urine and that her urine had a strong odor. The ID Nurse stated that Resident 1 felt like the staff was forcing her to take a shower and had explained to her about the shower schedule. According to ID nurse, Resident 1 understood and took a shower after they spoke and added that she did not smell any urine odor at the time she went into the resident's room. The ID Nurse stated there might have been a misunderstanding on how the CNAs talked to the resident, about taking a shower, which made Resident 1 feel like she was being disrespected. On 4/11/18 at 11:59 a.m., during an interview, the Director of Nursing (DON) stated she was not aware of Resident 1's allegations and that if she knew, she would have investigated. The DON stated Resident 1 might not have liked the manner in which the staff spoke to her, and that the resident should have been allowed to choose when she preferred to shower and the staff were to treat the resident with dignity and respect. On 4/12/18 at 11:58 a.m., during an interview, CNA 2 stated Resident 1's room did not smell and that she would only open the windows when the residents requested and if the weather was not cold. CNA 2 stated whenever Resident 1 refused to take a shower, the charge nurse was notified. CNA 2 stated that Resident 1 would agree to take a shower with encouragement. A review of the facility's policy titled, Resident Rights, with a revised date of 10/1/17, indicated the facility must treat residents with respect and dignity and care for the residents in an environment that promoted each resident's individual quality of life. The policy indicated the staff had to encourage residents to participate in planning their daily care routines and did not force or treat any resident differently for exercising their rights. According to the policy, residents had the right to choose care needs such as bathing methods and grooming styles.

Based on interview and record review, the facility failed to follow its policy to ensure one of three sampled residents were free from financial abuse (Resident 1). A certified nursing Assistant (CNA 1) used Resident 1's debit card several times without permission. This deficient practice resulted in Resident 1 being a victim of financial abuse with a loss of $1200.00. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/14/17, indicated Resident 1 had no impairment with cognitive skills (thought process) and the ability to make decisions. According to the MDS, Resident 1 required limited to extensive assistance from staff for all activities of daily living ((ADLs) grooming and bathing .etc.) On 3/6/18 at 10:20 a.m., during an interview, the director of nursing (DON) stated that on 2/15/18, Resident 1 approached the facility's Admission Coordinator (AC) and asked for assistance in regards to a bank statement. The DON stated the bank statement was reviewed with Resident 1 and there was up to $1200.00 missing from the resident's account. The DON stated Resident 1 had not authorized any charges or removed the money from the account himself. The DON stated once she was informed about the incident she started an investigation. The DON stated she reported the incident to Ombudsman (patient advocacy), the police, the Department of Public Health and the CNA board of certification. A review of Resident 1's Allegation of Financial Misappropriation summary, authored by the DON, dated 2/21/18, indicated CNA 1 was identified by some of the local merchants as the individual fraudulently using Resident 1's debit card. The summary indicated the local Police Department and Ombudsman were notified and Resident 1 would be reimbursed by the debit card company once the Police Department finished their investigation. On 3/6/2018 at 11:40 a.m., during an interview, the AC stated she became suspicion when Resident 1 was receiving frequent letters from the bank. The AC stated when Resident 1 came to her with his concern, she was alarmed by the amount of money that was taken from the account. The AC stated Resident 1 denied making the bank transactions charges, especially from the various eateries, cell phones stores and the Department of Motor Vehicle (DMV). The AC stated when she called Info Pay they were able to tell her the e-mail address that was attached to the account number used for the many transactions. According to the AC, the e-mail address belonged to one of the facility's ex-employee's address, CNA 1. The AC stated she printed CNA 1's picture from a social media account and took the picture to the various stores and restaurants where the charges were made. The AC stated the employees were able to confirm that CNA 1 was the person that used Resident 1's debit card. A review of CNA 1's employee file indicated he was hired at the facility on 3/25/15. A review of a background criminal search done for CNA 1, dated 3/19/15, had no findings. There were no other disciplinary concerns. On 3/6/18 at 1:05 p.m., during an interview, Resident 1 stated that CNA 1 had been his primary care giver and he usually took good care of him. Resident 1 stated he usually put his debit card under his bed pillow and denied given it to any of the staff member. Resident 1 stated once he had given his debit card with the pin number to his roommate's family to withdraw money from the automatic teller machine (ATM), without any problems. Resident 1 stated he choose to keep his debit card with him, because the facility had lost his identification card in the past. On 3/6/18 at 3 p.m., during an interview, the Administrator stated he was aware of the incident and the facility was working with the bank and the police to ensure Resident 1 would be refunded all his money. A review of a hand written letter, dated 8/23/17, CNA 1 indicated he was effectively terminating his employment on 8/31/17. A review of the facility's policy titled Abuse Prevention and Prohibition Program, dated (MONTH) 8, 2014, indicated each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The policy also indicated that the facility was committed to protecting residents from abuse by anyone, including, but not limited to facility's staff, other residents, consultants, family members, friends and visitors.

Based on interview and record review, the facility's staff failed to follow its policy regarding changes in condition and a resident's plan of care for one of three sampled residents (Resident 1). Resident 1 had a change in condition and the staff failed to follow Resident 1's care plan and the facility's policy to assess and notified the physician. Resident 1, who had respiratory diseases, had shortness of breath (SOB) with weakness, after not receiving prescribed ongoing oxygen consuming food that was not prescribed on her therapeutic diet. This deficient practice, of not assessing Resident 1 and notifying the physician resulted in Resident 1's condition deteriorating and was found unresponsive. Cardiopulmonary resuscitation ((CPR) a procedure to support and maintain breathing and circulation for someone who has stopped breathing) was done and the resident was transferred to the general acute care hospital (GACH) requiring intubation (placement of a flexible plastic tube into the windpipe for breathing and medication administration), placed on a ventilator (a machine used to move breathable air into and out of the lungs), and expiring on [DATE]. Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. breathing), [MEDICAL CONDITION] (([MEDICAL CONDITION]) the heart does no beat as it should), diabetes ((DM) high blood sugar) and hypertension ((HTN) high blood pressure). A review of Resident 1's History and Physical (H/P) record, dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's physician's orders [REDACTED]. According to the physician's orders [REDACTED]. A review of a care plan, dated [DATE] and titled, [MEDICAL CONDITION] at Risk for SOB, indicated Resident 1 was to receive continuous oxygen. The goal indicated the resident would not have poor oxygen exchange. The facility's staff interventions included to ensure that Resident 1's O2 was continuously maintain at two liters per minute, position the resident properly to improve breathing, minimize the resident's exposure to allergens, monitor the resident for signs of an asthma attack, difficulty breathing, and administer the breathing medications/treatments as ordered. A review of a care plan, dated [DATE] and titled, At risk for choking, aspiration or pneumonia ((PNA) disease. The care plan indicated Resident 1 required 1:1 feeding for breakfast, lunch and dinner. The goal indicated Resident 1 would be free from signs and symptoms (S/S) of aspiration and choking. Resident 1 was to be in an upright position for all meals, and thirty minutes after meals. The staff was to use small meal portions of small sips, feed the resident a pureed diet and monitor for s/s of aspiration like SOB, respiratory distress and congestion. A review of the physician's orders [REDACTED]. A review of Resident 1's Speech Therapy (ST) Evaluation, dated [DATE] indicated Resident 1 was diagnosed with [REDACTED]. The ST Evaluation indicated that Resident 1 was to receive a pureed diet, thin liquids (water, coffee, milk, soup, broth) and 1:1 feeding (had to be fed/supervised). According to the ST Evaluation, Resident 1 as well as the caregivers were trained on how the resident should eat and swallow safely. A review of Resident 1's Medication Administration Record [REDACTED]. The resident's O2 saturation (sat) was being monitored every shift. A review of a Transfer to the Hospital Summary, dated [DATE] and timed at 7:24 a.m., approximately seven hours after Resident 1 was found unresponsive, indicated at 11 p.m. the resident was sitting up in bed receiving 2 LPM of O2, verbally responsive and in no distress. At 12 a.m., on [DATE], Resident 1 was observed lying in bed receiving O2 with a blood pressure (BP) of ,[DATE]. According to the note, at 12:35 a.m., on [DATE], Certified Nursing Assistant 3 (CNA 3) found Resident 1 unresponsive in bed. CNA 3 notified the charge nurse (LVN 3) and the note indicated CPR was started and 911 was called. Resident 1 was transferred to the GACH via paramedics. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) internal communication form, dated [DATE] and timed at 1:45 a.m. indicated the resident was found unresponsive at 12:35 a.m. on [DATE]. A review of the GACH's emergency room (ER) records indicated Resident 1 was found unresponsive in the skilled nursing facility (SNF) for 15 minutes on [DATE], before the emergency medical services (EMS) arrived. The resident's vital signs were as follows BP ,[DATE] (normal reference range (NRR) = ,[DATE]), HR 64 (NRR= ,[DATE] bpm), respiration at 28 breaths per minute (NRR= ,[DATE]), and O2 sat at 98% while on the ventilator. Resident 1's [DIAGNOSES REDACTED]. A review of another ER record on the same date indicated when the EMS arrived at the SNF, Resident 1 was unresponsive and CPR was resumed. Resident 1 was given 1 round of [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) and intubated by the EMS. It also indicated that the resident's respiration had an abnormal crackling and rattling sound. A review of ER note also indicated upon arriving the ER, Resident 1's HR was 110, skin was cold and had irregular patch colors; O2 sat was difficult to detect/read. Resident 1's BP suddenly dropped to ,[DATE]s, and the resident had to be receive rapid amounts of normal saline intravenously ((IV) water through the veins as bolus to increase the B/P). The note indicated Resident 1 had severe acidosis (excessive acid condition in the body fluids/ tissues), due to excessive carbon [MEDICATION NAME] in the blood with [MEDICAL CONDITION]. A review of Resident 1's GACH discharge Documentation titled Death Summary, dated [DATE] indicated the resident was declared dead on [DATE] at 5:47 p.m. A review of Resident 1's Certificate of Death, indicated Resident 1 expired on [DATE] at 1747 (5:47 p.m.), three days later after the change in condition, with the immediate cause of death being: 1. Cardiopulmonary arrest (heart and lungs failure) 2. Respiratory (breathing) failure. 3. Metastatic [MEDICAL CONDITION] On [DATE], at 9:55 a.m., during an interview, Resident 1's family (FM 1) stated the resident was found unresponsive on the floor at the SNF. At 1 a.m., on [DATE], FM 1 stated Resident 1 left the facility without O2. FM 1 stated Resident 1 was O2 dependent and was not allowed to leave the facility. At 10:06 a.m., on [DATE], during an interview, Resident 1's friend stated he took the resident to a fast food restaurant without her O2. According to Resident 1's friend, the resident ate a chicken burrito while out at the restaurant. Resident 1's friend stated when they returned to the facility, Resident 1 had SOB and was very tired. On [DATE], at 1:03 p.m., during an interview, CNA 1 stated Resident 1 refused to eat lunch on [DATE], at 11 a.m., because she was going out of facility. According to CNA 1, she did not ask where Resident 1 was going to eat and did not the licensed nurse. CNA 1 stated when Resident 1 returned to the facility, the resident was tired and had SOB. CNA 1 stated she administered (sic) an unknown amount of O2 to Resident via a nasal cannula. Per CNA 1, the resident was assisted to a wheelchair where she sat at the nurses' station for a long time. On [DATE], at 1:20 p.m., during an interview, LVN 1 stated when Resident 1 returned to the facility she sat at the nurse's station for three hours while receiving O2 and was happy to have gone out to eat. LVN 1 stated she assumed Resident 1 ate from the fast food place because she came back with cup from the restaurant. LVN 1 stated she did not ask Resident 1 what she ate while out and did not assess the resident after she was having SOB and was very tired. LVN 1 stated she did not notify the physician, director of nursing (DON) and the oncoming shift about Resident 1's change in condition, but should have. LVN 1 stated the resident was supposed to be receiving continuous O2, but did not take her O2 when she left the facility. LVN 1 stated she was worried about what Resident 1 might have eaten while out because the resident was prescribed a puree diet. LVN 1 stated that she should have assessed the resident, notified the physician and the DON about the resident's change in condition upon her return. On [DATE], at 1:44 p.m., during an interview, a registered nurse (RN 1) stated she only found out that Resident 1 left the facility without permission after FM 1 called angry and told her looking for the resident. RN 1 stated she did not assess Resident 1. RN 1 stated she was new to the facility and had not been briefed on how to handle such incidents. RN 1 stated she should have assessed Resident 1 to ensure she was not in any distress. On [DATE], at 2:30 p.m., during an interview, the DON stated she was not aware Resident 1 had left the facility and without physician orders. According to the DON, staff should have assessed the resident upon her return of leaving without permission without staff and notify Resident 1's physician, family and the DON regarding the situation with emphasis on the resident's status change. On [DATE], at 1:26 p.m., during a telephone interview, Resident 1's family member (FM 2) stated the resident left the facility without permission and without O2 and ate a burrito, when she was only supposed to eat a puree diet, and might have choked on the burrito. A review of the facility's policy titled Change of Condition Notification, with a revision date of [DATE], indicated an acute change of condition (AC[NAME]) was a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional domains. According to the policy, the licensed nurses should document the date, time and details of the incident and subsequent assessment in the nursing notes. The nurse should also update the care plan, document the incident and brief details in the 24-hour report and communicate any changes.

Based on record review and interview, the facility failed to follow its policy and ensure physician's orders and a resident's plan of care was followed to ensure care and services were provided for one of three sampled residents (Resident 1). Resident 1, who was prescribed a puree textured diet (pudding-like texture that is smooth and blended) and required the staff to feed the resident; had a physician order for [REDACTED]. These deficient practices resulted in Resident 1 returning to the facility with shortness of breath (SOB) and was later found unresponsive requiring cardiopulmonary resuscitation ((CPR) a procedure to support and maintain breathing and circulation for someone who has stopped breathing), intubation (placement of a flexible plastic tube into the windpipe for breathing and medication administration) by 911 paramedics while in the facility and a transfer to a general acute care hospital (GACH) for further treatment. Resident 1 expired on [DATE]. Findings: A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. breathing), [MEDICAL CONDITION] (([MEDICAL CONDITION]) the heart does no beat as it should), diabetes ((DM) high blood sugar) and hypertension ((HTN) high blood pressure). A review of Resident 1's History and Physical (H/P) record, dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's physician's orders, dated [DATE] indicated the resident was to receive [MEDICATION NAME] solution (breathing treatment) 0XXX,[DATE].5 milligrams (mg) per three (3) milliliters (ml) three times (TID) a day for SOB and wheezing (an abnormal high-pitched [MEDICATION NAME] sound made while breathing). According to the physician's orders, a swallowing evaluation was ordered due to dysphagia (difficulty in swallowing) and placed on a pureed (food crushed into a thick, soft sauce) textured diet; receive continuous O2 through a nasal cannula ((N/C) a tube that delivers supplemental O2 via the nose). A review of Resident 1's Speech Therapy (ST) record dated [DATE] indicated Resident 1 had decreased safety and functional activity when eating and was at risk for aspiration (breathing in food particles and liquids into the lungs). Resident 1 was on puree diet, thin liquids, and 1:1 feeding (had to be fed). The speech therapist trained Resident 1 and her caregivers on how to eat and swallow safely. A review of Resident 1's Physical Therapy Evaluation of Plan of Treatment record, dated [DATE], indicated the resident was at risk for decrease mobility and was limited in out of bed activity. A review of Resident 1's care plan, dated [DATE], indicated Resident 1 had deficits in ADL (activities of daily living) self-care performance due to fatigue, confusion, generalized muscle weakness, impaired balance and limited mobility. The interventions included the staff would assist Resident 1 in bathing, dressing, personal hygiene, and transfers. A review of Resident 1's care plan, dated [DATE], indicated the resident was at risk for choking, aspiration (breathing in food particles and liquids into the lungs), or pneumonia (disease that causes difficulty breathing). The care plan indicated Resident 1 required 1:1 feeding (had to be fed/supervised) for breakfast, lunch and dinner. The care plan goal was Resident 1 would be free from signs and symptoms (s/s) of aspiration and choking. Resident 1 was to be in an upright position for all meals, and thirty minutes after meals. The staff was to use small meal portions of small sips, feed the resident a pureed diet and monitor for s/s of aspiration such as SOB, respiratory distress and congestion. Another care plan, dated [DATE], indicated Resident 1 had DM and was at risk for complications. The goal for this care plan indicated Resident 1 would be free from any s/s of low or high blood sugar. The interventions included the staff would monitor Resident 1's compliance with diet and document any problems. A review of Resident 1's care plan, dated [DATE], indicated the resident was at risk for poor food intake by mouth (po). The interventions included the staff would explain and reinforce to Resident 1 the importance of maintaining the ordered diet, monitor the resident for s/s of choking or holding food in mouth and record the amount of food eaten by the resident. The interventions also included Resident 1 had to eat in a calm, quiet place. A review of the care plan, dated [DATE], indicated Resident 1 was on O2 for SOB, asthma, respiratory distress, PNA, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The goal for this scare plan indicated the resident would not have a s/s of poor O2. The facility's staff had to ensure that Resident 1 had O2 during meals, maintain O2 at two (2) liters per minute (L/min) continuously, position the resident properly to improve breathing, minimize the resident's exposure to allergens, monitor the resident for s/s of an asthma attack, difficulty breathing, and give the resident breathing medications as ordered. Another care plan, dated [DATE], indicated Resident 1 had decreased strength, impaired balance and impaired ADLS. The intervention for this care plan indicated the staff was to provide self-care training to Resident 1 and provide the resident with exercises and activities. A review of Resident 1's Progress Note, dated [DATE], and timed at 3:38 p.m., indicated Resident 1 was lying in bed, sleeping with no distress. A Progress Note, dated [DATE], and timed at 12 a.m. indicated Resident 1 was lying in bed, was still receiving O2, her blood pressure (BP) was ,[DATE]. The Progress Note did not have documentation that Resident 1 had left the faciity on [DATE] without the knowledge of the facility, when Resident 1 had returned to the facility and her respiratory condition. The resident's vitals record dated [DATE], from 11:55 p.m., indicated Resident 1's BP was ,[DATE], pulse (Heart rate (P) was 100 beats per minute (bpm), O2 saturation (a measurement of the blood oxygen and normal reading is between 95 and 100) 99 percent (%). The Progress Note dated [DATE], indicated at 11p.m., Resident 1 was sitting up in bed, receiving oxygen at 2 liters per minutes, verbally responsive and in no distress. A review of a Transfer to the Hospital Summary, dated [DATE] and timed at 7:24 a.m., approximately seven hours after Resident 1 was found unresponsive, indicated at 11 p.m. the resident was sitting up in bed receiving 2 LPM of O2, verbally responsive and in no distress. At 12 a.m., on [DATE], Resident 1 was observed lying in bed receiving O2 with a blood pressure (BP) of ,[DATE]. According to the note, at 12:35 a.m., on [DATE], Certified Nursing Assistant 3 (CNA 3) found Resident 1 unresponsive in bed. CNA 3 notified the charge nurse (LVN 3) and the note indicated CPR was started and 911 was called. Resident 1 was transferred to the GACH via paramedics. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) internal communication form, dated [DATE] and timed at 1:45 a.m. indicated the resident was found unresponsive at 12:35 a.m. on [DATE]. A review of Resident 1's Physician's Order, dated [DATE], and timed at 7:16 a.m., indicated to transfer Resident 1 to the GACH via 911 (medical emergency telephone) ambulance due to the resident being unresponsive. A review of Resident 1's Transfer Record, dated [DATE], indicated at 12:35 a.m., the resident was found unresponsive, cardiopulmonary resuscitation (CPR) was started and 911 was called. Resident 1 was transferred to the GACH via paramedics. A review of the GACH's emergency room (ER) records indicated Resident 1 was found unresponsive in the skilled nursing facility (SNF) for 15 minutes on [DATE], before the emergency medical services (EMS) arrived. The resident's vital signs were as follows BP ,[DATE] (normal reference range (NRR) = ,[DATE]), HR 64 (NRR= ,[DATE] bpm), respiration at 28 breaths per minute (NRR= ,[DATE]), and O2 sat at 98% while on the ventilator. Resident 1's [DIAGNOSES REDACTED]. A review of another ER record, dated [DATE], indicated when the EMS arrived at the SNF, Resident 1 was unresponsive and CPR was resumed. Resident 1 was given 1 round of [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) and intubated by the EMS. It also indicated that the resident's respiration had an abnormal crackling and rattling sound. A review of ER note also indicated upon arriving the ER, Resident 1's HR was 110, skin was cold and had irregular patch colors; O2 sat was difficult to detect/read. Resident 1's BP suddenly dropped to ,[DATE]s, and the resident had to be receive rapid amounts of normal saline intravenously ((IV) water through the veins as bolus to increase the B/P). The note indicated Resident 1 had severe acidosis (excessive acid condition in the body fluids/ tissues), due to excessive carbon [MEDICATION NAME] in the blood with [MEDICAL CONDITION]. A review of Resident 1's GACH discharge Documentation titled Death Summary, dated [DATE] indicated the resident was declared dead on [DATE] at 5:47 p.m. A review of Resident 1's Certificate of Death, indicated Resident 1 expired on [DATE] at 1747 (5:47 p.m.), three days later after the change in condition, with the immediate cause of death being: 1. Cardiopulmonary arrest (heart and lungs failure) 2. Respiratory (breathing) failure. 3. Metastatic [MEDICAL CONDITION] On [DATE], at 9:55 a.m., during an interview, Resident 1's family (FM 1) stated the resident was found unresponsive on the floor at the SNF. At 1 a.m., on [DATE], FM 1 stated Resident 1 left the facility without O2. FM 1 stated Resident 1 was O2 dependent and was not allowed to leave the facility. At 10:06 a.m., on [DATE], during an interview, Resident 1's friend (Visitor 1) stated he took the resident to a fast food restaurant without her O2. According to Visitor 1, the resident ate a chicken burrito while out at the restaurant. Visitor 1 stated when they returned to the facility, Resident 1 had SOB and was very tired. On [DATE], at 1:03 p.m., during an interview, CNA 1 stated Resident 1 refused to eat lunch on [DATE], at 11 a.m., because she was going out of facility. According to CNA 1, she did not ask where Resident 1 was going to eat and did not the licensed nurse. CNA 1 stated when Resident 1 returned to the facility, the resident was tired and had SOB. CNA 1 stated she administered (sic) an unknown amount of O2 to Resident via a nasal cannula. Per CNA 1, the resident was assisted to a wheelchair where she sat at the nurses' station for a long time. On [DATE], at 1:12 p.m., an interview was conducted with CNA 2. CNA 2 stated CNA 1 had endorsed Resident 1's care to her. CNA 2 stated she was busy with another resident and did not know Resident 1 had left the facility unsupervised. According to CNA 2, she failed to monitor Resident 1. On [DATE], at 1:20 p.m., during an interview, LVN 1 stated when Resident 1 returned to the facility she sat at the nurse's station for three hours while receiving O2 and was happy to have gone out to eat. LVN 1 stated she assumed Resident 1 ate from the fast food place because she came back with cup from the restaurant. LVN 1 stated she did not ask Resident 1 what she ate while out and did not assess the resident after she was having SOB and was very tired. LVN1 stated she did not notify the physician, director of nursing (DON) and the oncoming shift about Resident 1's change in condition, but should have. LVN 1 stated the resident was supposed to be receiving continuous O2, but did not take her O2 when she left the facility. LVN 1 stated she was worried about what Resident 1 might have eaten while out because the resident was prescribed a puree diet. LVN 1 stated that she should have assessed the resident, notified the physician and the DON about the resident's change in condition upon her return. On [DATE], at 1:44 p.m., during an interview, a registered nurse (RN1) stated she only found out that Resident 1 left the facility without permission after FM 1called angry and told her looking for the resident. RN 1 stated she did not assess Resident 1. RN1 stated she was new to the facility and had not been briefed on how to handle such incidents. RN 1 stated she should have assessed Resident 1 to ensure she was not in any distress. On [DATE], at 2:11 p.m. during an interview. LVN 2 stated she found out from Resident 1's family member that the resident had left the facility unsupervised. According to LVN 2, the residents are supposed to have out on pass orders to leave the facility. If a resident was on puree diet, the staff had to check the food that family brought from home. According to LVN 2, if a resident left the facility unsupervised, a search had to be conducted, physician, family and police were to be notified, and the licensed nurse had to document the incident, for continuity of care. LVN 2 added upon returning to the facility, Resident 1 had to be assessed and treated as needed. The incident had to also be care planned per LVN 2. On [DATE], at 2:30 p.m., during an interview, the DON stated she was not aware Resident 1 had left the facility and without physician orders. According to the DON, staff should have assessed the resident upon her return of leaving without permission without staff and notify Resident 1's physician, family and the DON regarding the situation with emphasis on the resident's status change. On [DATE], at 2:52 p.m., during an interview, LVN 3 stated during rounds, Resident 1 was up in bed at 11 p.m. According to LVN 3, CNA 3 found Resident 1 was unresponsive at 12:30 a.m. LVN 3 stated that cardio-pulmonary resuscitation (CPR) was initiated, 911 was called, and Resident 1 was transferred to the GACH. LVN 3 stated she was unaware Resident 1 left the facility unsupervised to go to a fast food restaurant. On [DATE], at during an interview, CNA 3 stated the last time Resident 1 was seen awake was at 11:30 p.m. on [DATE]. CNA 3 stated the resident was sitting in bed, with feet on the floor. According to CNA 3, at 12:30 a.m. on [DATE], she noticed Resident 1 was leaning forward and was unresponsive. CNA 3 notified LVN 3. CNA 3 stated that she did not get report from the previous shift CNA regarding Resident 1. On [DATE], at 1:26 p.m., during a phone interview, Resident 1's Family Member 2 (FM 2) stated Resident 1 left the facility without permission and without her O2. FM 2 stated the facility staff did not know Resident 1 was out of the facility until the family member had asked where the resident was. FM 2 stated Resident 1 ate a burrito and was supposed to only eat a puree diet. A review of the facility's policy and procedures titled, Out on Pass, revised [DATE], indicated the purpose of this policy was to provide residents with the opportunity to participate in family and community life in ways to support well-being and optimal functioning. This policy also indicated when a resident requested to go out on pass, the care team would assess the resident's ability to participate in activities outside the facility considering the resident's decision-making capacity, physical disabilities and ability to take medications. The policy also indicated prior to leaving, a licensed nurse had to assess the resident's physical and mental status and ensure that resident had required assistive devices, medications to last for the time period of the pass and that the resident/family had been instructed on any special needs like a special diet or medications. A review of a facility policy titled, Care planning, revised [DATE], indicated a care plan served as a course of action where the resident, family and care team work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. A review of the facility's policy titled, Oxygen Therapy-Tank, revised [DATE] indicated oxygen would only be administered by a licensed nurse. A review of a facility's policy titled, Therapeutic Diets, revised [DATE], indicated therapeutic diets were diets that deviated from the regular diet and required a physician order. According to this policy, therapeutic diets were planned, prepared and served in consultation with the dietitian. A review of a policy titled, Unusual Occurrence Reporting, revised [DATE], indicated the facility should notify the Department of Health Services of all unusual occurrences, within twenty-four hours of the occurrence. According to this policy, occurrences that threaten the welfare, safety or health of residents such as injuries that affect health and safety as identified by the facility and the department of health services (DHS) as requiring reporting. A review of the facility's policy titled, Leaving Against Medical Advice/Without A Discharge Order/Elopement, revised [DATE], indicated the facility would provide oversight and protect the rights, health and safety of each resident. According to this policy, the administrator (ADM), DON, the resident's physician and family had to be notified of residents who left the facility without notification. Another policy titled, Post Elopement Checklist, revised [DATE], indicated elopement was a situation where a cognitively impaired resident with impaired safety judgment left the facility without a staff's knowledge. According to this policy, if a resident eloped or showed signs of elopement, the staff would analyze the resident's actions and develop appropriate interventions for that resident. A review of the facility's policy titled, Wandering and Elopement, revised [DATE], indicated the purpose of this policy was to enhance the safety of residents. It also stated the staff who finds a resident missing would alert facility's staff including the DON, Administrator, physician and the responsible party. The licensed nurse familiar with the resident would document in the resident's medical record how the elopement occurred. This policy also indicated when the eloped resident returned to the facility, the DON or licensed nurse would assess the resident for any possible injuries, initiate or update the resident's care plan and implement immediate interventions to prevent further elopement by the resident. According to this policy, the care team would conduct a thorough review of the elopement, document its findings and update the care plan to prevent a recurrence.

Based on observation, interview, and record review, the facility failed to follow and adhere to it policy and procedure to ensure residents were protected and free from abuse for three of three sampled residents (Residents 2, 3, and 4). Resident 1, who had a history of [REDACTED]. This deficient practice resulted in Residents 2, 3, and 4 being fearful of Resident 1. Resident 2 sustained a laceration (deep wound) to the hand, after Resident 1 slammed the door on it, requiring a transfer to a general acute care hospital (GACH) for wound closure. Findings: a. A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P), dated 11/13/17, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool), dated 11/17/17, indicated the resident's cognition (thought process) was intact and required supervision to limited assistance with activities of daily living ((ADLs) routine activities, such as: eating, bathing, dressing, toileting, transferring and walking). A review of the Situation, Background, Assessment and Request ((SBAR) a licensed staff communication tool) form, dated 9/3/17, and timed at 8 a.m., indicated Resident 1 was accused of bullying other residents when they were housed in the room with him. The SBAR indicated this was the second resident who requested a room change out of the room with Resident 1. The SBAR indicated when Resident 1's roommate (Resident 2) asked Resident 1 to lower the volume on his television, Resident 1 began slamming doors and made verbal threats. The SBAR further indicated when Resident 1 laughed while denying the allegations of verbal threats and slamming doors, Licensed Vocational Nurse 1 (LVN 1) and another licensed nurse did not feel Resident 1 was sincere in his claims of denial. A review of the SBAR dated 12/19/17, and timed at 7:50 a.m., indicated Resident 1 had a prior history of questionable encounters with other residents and was assessed as not wanting to share the restroom. The SBAR indicated Resident 1 had attempted to remove Resident 2 from the restroom, when Resident 1 closed the door on Resident 2. A review of Resident 1's plan of care titled, Resident 1 has potential to be further physically aggressive related to slamming a peer's (Resident 2's) hand in the joint of the bathroom door. The staff's listed interventions included to monitor, document and report as needed of signs and symptoms of Resident 1 posing danger to self and others. b. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's admission assessment indicated the resident communicated in Spanish. A review of Resident 2's H/P, dated 11/3/17, indicated Resident 2 had a fluctuating capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was intact and required minimal assistance with ADLs. A review of the nurses' progress note, dated 12/19/17, and timed at 8:47 a.m., indicated Resident 2 was observed chasing Resident 1 while bleeding from the left hand two fingers and stated Resident 1 slammed the bathroom door on his left pointer and middle fingers. Resident 2 required a transfer to the GACH. A review of Resident 2's emergency room discharge instructions, dated 12/19/17, and timed at 9:40 a.m., indicated Resident 2 had a left hand laceration that required 14 sutures (wound closures). A review of the facility's investigative report, dated 12/19/17, indicated during an interview, Resident 2 stated that he believed Resident 1 intentionally slammed his fingers in the door, Resident 2 stated he did not want to press charges. A review of Resident 2's wound care record, dated 12/29/17, indicated the resident's sutures were removed. During a concurrent observation and interview, on 1/8/18 at 10:53 a.m., Resident 2's index, middle, and fourth fingers were wrapped in a gauze bandage. Resident 2 stated on 12/19/17, he had gone to the bathroom he shared with Resident 1 and as he entered the door, Resident 1 closed the door on his hand. c. A review of Resident 3's Admission Record indicated the resident was initially admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident's cognition was intact. During an interview, on 1/8/18 at 2:45 p.m., Resident 3 stated there was a resident (Resident 1) who was near room [ROOM NUMBER], who was mean and bullied other residents. Resident 3 stated, this particular resident yelled at Resident 3 because he did not want to use a shared bathroom that is connected to another resident's room. Resident 3 further stated that he had reported the incident to the Administrator and this particular resident made lots of noise. d. A review of Resident 4's Admission Record indicated the resident was initially admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's MDS indicated the resident's cognition was intact and required supervision to limited assistance with ADLs. During an interview, on 1/8/18 at 4:28 p.m., the Assistant Director of Nursing (ADON) stated that she was not aware of the allegations of Resident 1's bullying and threatening behaviors toward others. During a telephone interview, on 1/8/18 at 4:42 p.m., LVN 1 stated, on 9/3/17, she was made aware of Resident 1 bullying Resident 4. LVN 1 stated Resident 4 was hard of hearing and would increase the volume on his television. LVN 1 stated Resident 1 became upset, went into the bathroom and slammed the door. LVN 1 stated that she did not report the incident to the Director of Nursing (DON) or to the ADON, but reported the incident to the oncoming shift staff and moved Resident 4 to another room in the facility. A review of the facility's undated policy titled, Reporting Resident Abuse indicated all employees of this company must immediately report any incident or suspected incident of resident neglect, abuse or misappropriation of resident property. Any employee of this company shall not knowingly fail to report an incident or suspected incident of abuse. Any employee who has knowledge or reason to believe that a resident has been a victim of abuse is under a duty to immediately report such incident or suspicion to the charge nurse. The charge nurse must complete a resident abuse form and provided to the administrator within 24 hours.

Based on observation, interview and record review, the facility failed to ensure two of 24 sampled residents (Residents 10 and 1) were assessed and reassessed for pain, provided appropriate care and treatment to manage and/or prevent the pain from being experienced daily. Resident 10, the facility failed to accurately assess for the pain in accordance with the plan of care, follow through with the physician's orders [REDACTED]. The failure resulted in Resident 10 suffering severe pain, on a daily basis, with pain level of nine to ten in a pain rating scale of 0 to ten (zero being no pain and ten being the worst pain experienced), causing the resident not able to sleep. Resident 1 pain was not reassessed; [MEDICATION NAME] for moderate and severe pain was not reordered, and was not provided pain relief in accordance with the facility policy and procedures. The failure resulted in Resident 1 not being provided pain relief during four wound treatments with dressing changes, which lasted for 45 minutes. Findings: a. On 11/17/17, at 10 a.m., Licensed Vocational Nurse (LVN 11) and the wound care physician (MD 1) were observed providing wound treatment to Resident 10's left leg. During the treatment, Resident 10 was observed with facial grimacing, continuously rubbing her left leg and was heard moaning the entire time. Resident 10's body flinched every time MD 1 or LVN 11 touched the wound. When asked if she was having pain, Resident 10 replied, Yeah, but just get it over with. LVN 11 did not ask Resident 10 her pain level, how long she had been in pain and was not provided with non-pharmacological interventions (measures to relieve pain other than the use of medications such as; repositioning and reassessing to ensure it was working) to relieve the pain. A review of Resident 10's undated record titled, Admission Record, indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 10's record titled, History and Physical, dated 10/12/17, indicated Resident 10 had a left [MEDICAL CONDITION] (part of a limb surgically removed) with stump (the residual limb or what is left of the limb) infection. A review of Resident 10's record titled, Comprehensive Resident Assessment, dated 10/18/17, indicated Resident 10 was alert, oriented, cooperative, and was involved in her plan of care. A review of Resident 10's record titled, Pain Assessment, dated 10/18/17, indicated Resident 10 had experienced pain occasionally over the past five days and the pain had limited her activities. The pain assessment also indicated Resident 10's pain was moderate. The assessment indicated Resident 10 had not been on a scheduled pain medication regimen or received any as needed pain medication. A review of Resident 10's physician order, dated 10/18/17, indicated the following: 1. Tylenol 325 milligrams (mg), two tablets as needed every six hours for mild pain. 2. [MEDICATION NAME] 5-325 mg, one tablet every six hours as needed for moderate pain. A review of Resident 10's physician order, dated 10/19/17, indicated the resident was to be monitored for pain pre (before) and post (after) wound treatments using the pain rating scale of 0 to 10. A review of Resident 10's care plan dated 10/19/17, indicated Resident 10 had a right above the knee and left [MEDICAL CONDITION] (surgically cutting off the leg). The nursing interventions included monitoring and documenting the frequency, duration and intensity of pain, giving [MEDICATION NAME] (medications to relieve pain) as ordered by the physician and reporting to the physician if the medications were not effective. On 11/21/17 at 11:30 a.m., during an interview with LVN 11 about Resident 10's pain, stated she only asked the resident if she was okay or wanted her to stop when she complained of pain. However, she did not assess the resident's pain for monitoring and documenting the frequency, duration and intensity of pain per plan of care. A review of Resident 10's care plan, dated 10/19/17, indicated potential for pain related to concerns including wounds, amputation, and diabetic [MEDICAL CONDITION] (nerve damage and pain). The nursing interventions included anticipating the resident's need for pain relief and respond immediately, monitor/document for probable causes of pain and monitor/report complaints of pain to the nurse. A review of Resident 10's physician order, dated 10/24/17 indicated the resident had a Stage 4 (full thickness skin loss with extensive destruction and skin tissue necrosis (death), or damage to muscle, bone, or supporting structures) left [MEDICAL CONDITION] to be cleansed with normal saline, patted dry, apply Santyl (medication that removes dead tissue) and to be covered with a dry dressing. During an interview and review of Resident 10's records titled, Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of Resident 10's physician order, dated 11/7/17 indicated the resident had a Stage 4 wound Left below the knee to be cleansed with normal saline, patted dry, apply Collagen (protein treatment used to heal wounds) and covered with a dry dressing. The treatment order indicated to be provided daily and as needed if the wound dressing was soiled or dislodged. On 11/21/17 at 11:20 a.m., during an interview, Resident 10 stated the pain medication was not working. Resident 10 stated she gets the medication early in the morning and by the time her treatment (wound) was done, it (medication) was no longer working. Resident 10 stated whatever pain medication she was getting, it was not working and she was always in pain. Resident 10 stated on a scale of zero to ten, her pain stays at eight or nine and sometimes creeps up to a ten. Resident 10 stated her pain was worse during rehabilitation therapy (Physical Therapy/Occupational Therapy) and during wound treatments. Resident 10 stated at night her pain gets so bad it makes it difficult for her to sleep and the pain, It's usually a nine or ten. Resident 10 described the pain to her left lower extremity as a sharp, stabbing type of pain and stated, Sometimes it just throbs. Resident 10 stated the staff do not always ask if she was having pain and never asked for a description (type, intensity, duration, frequency, location) of the pain. Resident 10 stated she had complained to the staff the pain medication was not working but they would tell her they will call the doctor. Resident 10 stated no one had gotten back to her and she had not spoken to the doctor since she was admitted to the facility. Resident 10 stated she could not recall anyone specifically checking her pain level on each shift and it has never been a zero. Resident 10 stated she was frustrated because she was in pain all day, every day and the staff was not doing anything about it. A review of Resident 10's MAR for November 2017 indicated Resident 10 had not experienced pain on the 7 am - 3 pm, 3 pm - 11 pm, or the 11 pm - 7 am shift during the entire month. The MAR indicated [REDACTED]. A review of a fax sent from the pharmacy to the facility on [DATE], indicated pharmacist's attempts to have Resident 10's physician sign the order for [MEDICATION NAME] on 10/19/17, 11/2/17, 11/7/17, and 11/19/17. The pharmacist sent another fax to the physician that same day (11/21/17) requesting the [MEDICATION NAME] order to be signed. On 11/21/17, at 11:30 a.m., LVN 12 and 13 observed looking through the medication cart and reviewed the narcotic sheets. There was no narcotic administration/sign out sheet for [MEDICATION NAME] medication in the medication cart for Resident 10. There was no documented evidence the [MEDICATION NAME] had been sent to the facility from the pharmacy. There was no documented evidence the licensed staff attempted to follow up with the physician to acquire the [MEDICATION NAME] for Resident 10 as requested by the pharmacist. On 11/21/17 at 11:30 a.m., during an interview, the Director of Nursing (DON) stated Resident 10 was probably complaining of pain because she was not getting any pain medication at all. On 11/21/17 at 11:30 during an interview, LVN 11 stated she asked the charge nurse to medicate Resident 10 for pain prior to the wound treatment. LVN 11 stated she was not sure what was given or what time Resident 10 received the pain medication. LVN 11 stated she asked Resident 10 if she was okay or wanted her to stop when she complained of pain during the wound treatment on 11/17/17 at 10 am. LVN 11 stated she did notice Resident 10 moaning, flinching, and rubbing her leg in addition to verbal complaint of pain. LVN 11 stated she did not assess the type, location or intensity of the pain experienced by Resident 10, but she should have done so. On 11/21/17, at 11:45 a.m., the DON stated she spoke with the pharmacist about Resident 10's [MEDICATION NAME], but it was never sent to the facility. The DON stated the pharmacist attempted to get in touch with the physician on five different occasions, but heard no response back. The DON stated the physician had not signed the Resident 10's order for [MEDICATION NAME]. The DON stated the licensed nurses should have followed up with the physician to make sure the order for [MEDICATION NAME] was signed by the physician. The DON stated there was no reason for Resident 10 to be in the facility for over a month without adequate pain management. On 11/22/17, at 9:45 a.m., an interview was conducted with the DON, Assistant DON (ADON) and LVN 11. LVN 11 stated she asked Resident 10 if she had pain before providing the dressing change. LVN 11 stated she did not ask specifically for the type or the level of pain experienced by Resident 10. The DON stated she tells all of her licensed staff to review the care plan and pain assessment to be familiar with the nursing approaches and/or interventions. The DON stated she was not aware the staff were not assessing Resident 10 for pain. A review of a facility policy and procedures titled, Pain Management, dated 1/1/12, indicated a licensed nurse will assess residents for pain upon admission and routinely. The staff is responsible for helping to prevent or manage the resident's pain and implement timely interventions to reduce the increase in the severity of pain. b. A review of Resident 1's undated record titled, Admission Record, indicated Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and swelling). A review of Resident 1's record titled, Minimum Data Set, (MDS), a standardized resident assessment and care screening tool, dated 1/18/2017, indicated the resident's speech was clear, was able to make himself understood and understood others. The MDS indicated Resident 1's skills for daily decision-making were intact. The MDS indicated Resident 1 required extensive assistance (staff provided support with bearing weight) from the nursing staff with transferring (how resident moves between surfaces) and was using a wheelchair as mobility device. A review of Resident 1's record titled, Pain Assessment, dated 4/14/2017, indicated Resident 1 was on a scheduled pain medication regimen, received pain medications as needed (PRN) and non-pharmacological interventions for pain management. The Pain Assessment indicated when Resident 1 was asked, Have you had pain or had been hurting at any time in the last five days Resident 1 stated yes and described it as occasional pain experienced with the level of 8 out of 10 on the pain rating scale. A review of Resident 1's plan of care dated 9/15/17, indicated Resident 1 had a Stage 4 sacral pressure sore or the potential for pressure sore development due to history of ulcers, immobility (inability to move), [MEDICAL CONDITION], heart failure, and incontinent (lacking control) of bowel and bladder function. The nursing interventions included to treat pain as per physician's orders [REDACTED]. A review of Resident 1's physician's recapitulated (summarized) orders for 11/2017 included to administer [MEDICATION NAME] 600 mg (treats [MEDICAL CONDITION] (damage to peripheral nerves causes weakness, numbness and pain)) twice a day, [MEDICATION NAME] 5/325 mg every six hours as needed for moderate and severe pain and Tylenol two tablets every six hours as needed for mild pain. A review of Resident 1's physician's orders [REDACTED]. 1. Right heel diabetic ulcer, to cleanse with normal saline (NS), pat dry, apply Calcium Alginate (highly absorbent and promotes healing) and cover with dry gauze and wrap with bandage roll every day and as necessary (PRN) or when dislodged. 2. Right plantar (bottom) foot diabetic ulcer, to cleanse with NS, pat dry, pack with [MEDICATION NAME] (an antiseptic, prevents the growth of disease-causing microorganisms), cover with dry gauze and wrap with a bandage roll every day and or PRN when soiled or dislodged. 3. Sacral Stage 4 pressure sore, to cleanse with NS, pat dry, apply Collagen followed by Hydrogel (keep the wound slightly moist, absorbing secretion) and cover with dry dressing every day and or PRN when soiled or dislodged. 4. On 11/17/2017, lateral left dorsal (top) foot abrasion (damage to the upper layer of skin), to treat with Hydrogel. On 11/17/2017, at 9 a.m., LVN 11 was observed providing the wound treatments and dressing changes for Resident 1's sacral pressure sore, right plantar foot, right heel, and left lateral foot. Resident 1 yelled, Ouch! LVN 11 stated to Resident 1, You had medication. Resident 1 stated loudly, No, I did not have any medication [MEDICATION NAME]. LVN 11 continued the sacral pressure sore dressing change and did not stop to assess Resident 1's pain nor ask the charge nurse (LVN 15) if Resident 1 was medicated. LVN 11 then proceeded with the dressing change to the right plantar foot and packed the foot with [MEDICATION NAME]. Resident 1 stated he was in pain. LVN 11 did not stop the treatments nor the dressing changes for the remaining two sites that included the right heel and the left lateral foot. LVN 11 completed the dressing changes at 9:45 a.m. During an interview on 11/21/2017 at 4 p.m., LVN 15 stated she medicated Resident 1 on 11/17/2017 with Tylenol 325 mg, two tablets for mild pain prior to the dressing changes. On 11/21/2017 at 4 p.m., a review of Resident 1's Medication Administration Records (MAR) along with LVN 15. When asked why Resident 1 did not receive [MEDICATION NAME] 5/325 on 11/17/2017, prior to his dressing changes, LVN 15 stated Resident 1 did not have [MEDICATION NAME] 5/325 mg at the facility from 11/13/2017, to 11/17/2017 (5 days). LVN 15 stated [MEDICATION NAME] 5/325 mg had to be re-ordered. A record review on 11/21/2017 at 4 p.m., in the presence of LVN 15 for the MAR indicated [REDACTED]. However, the MAR indicated [REDACTED]. On 11/22/2017, at 6:30 a.m., during an interview with Registered Nurse Supervisor (RNS 20), when asked how often should the Pain Assessment be reviewed and updated, RNS 20 stated quarterly. When asked why the last Pain Assessment filed in Resident 1's clinical records was dated 4/14/2017, and there were no quarterly review and update of the Pain Assessment, RNS 20 did not respond.

Based on interview and record review, the facility failed to ensure Resident 1, who was assessed as totally dependent on staff for transfers, and required two staff or more for physical assistance, was transferred out of bed by one staff person, Certified Nursing Assistant (C.N.A.) 5 while using the Hoyer lift. During this transfer from the bed by C.N. A. 5, Resident 1's left foot struck the door frame of the resident's room which resulted in a fracture of the resident's left fourth toe. Findings: A review of Resident 1's, admission records indicated Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) Resident Assessment and Care Screening Tool, dated April 22, 2014, the resident was moderately impaired in cognitive skills for daily decision making, and was totally dependent on staff for transfers and required the physical assistance of two or more staff for assistance. In the Licensed Personnel Progress notes, dated April 17, 2014 at 10 a.m., the licensed nurse documented the CNA 5 bumped Resident 1's fourth toe nail on the left foot which caused an open wound with a moderate amount of bleeding. The documentation indicated pressure was applied until the bleeding stopped. At 11 a.m. the physician was notified of the open wound on the left foot, fourth toe. The physician ordered the application of triple antibiotic ointment, (a medication that destroys or slows down the growth of bacteria) and a dry dressing to the open wound, x-ray of the left foot, and a podiatry (a branch of medicine devoted to the disorders of the foot) consultation. The x-ray report, dated April 17, 2014, indicated a fracture at the base of the left fourth toe. During an interview on June 6, 2014, at 2:10 p.m., CNA 5 stated he used the Hoyer lift by himself to take Resident 1 to the shower room. As he wheeled the resident through the resident's room doorway the resident's left foot hit the door frame. CNA 5 stated he did not notice the resident's left foot was bleeding until he got to the shower room. During further interview CNA 5 acknowledged the use of the Hoyer lift required a second staff person physical assistance. During an interview with Staff Developer on June 6, 2014, at 2:15 p.m., she stated CNA 5 was given a verbal warning for not having a second staff person to assist while transferring the resident with the Hoyer lift. A review of CNA 5 employee file revealed CNA 5 attended an in-service of body mechanics, lifeline/transfers/lifts on August 28, 2013. The facility policy and procedure titled "Total Mechanical Lift" dated, January 1, 2012, indicated the requirement that at least two people are present while the resident is being transferred with the mechanical lift.

Based on observation, interview, and record review, the facility failed to implement preventive or corrective measures to ensure one of nineteen sample residents (12) with escalating behavior problems was supervised, two of nineteen sample residents (2, 16) were not placed in situations where law enforcement and/or staff intervention was required to prevent serious injury, and all residents in the facility were protected from being placed at risk for injury from a resident with behavioral needs the facility was not able to meet. This deficient practice resulted in: a. All residents in the facility that walked or used wheelchairs in the hallways of the facility being placed at risk for injury from Resident 12 hitting them in a motorized wheelchair. b. Resident 12 leaving the facility unsupervised, without a valid physicians order, in a motorized wheelchair her assessment had indicated she was incapable of safely operating and staff reports of having observed the resident meeting known neighborhood drug offenders. c. Law enforcement intervening to prevent Resident 12 from pulling Resident 2, a visually impaired resident, through the streets on her motorized wheelchair while he held on in a manual wheelchair. d. Resident 12 turning off the alarm that would notify staff Resident 16, a resident with a history of multiple falls, was standing up unassisted. Findings: a. On June 27, 2014 at 7 p.m., Resident 12 was observed speeding down the facility hall in a motorized wheelchair. The resident swerved to the right to avoid hitting Resident 3, who was self- propelling down the hallway in a manual wheelchair. A review of Resident 3' s clinical record indicated the resident was an [AGE] year old female admitted to the facility May 1, 2010, with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS), dated [DATE] indicated she was wheelchair dependent and totally dependent on the facility ' s staff for assistance with personal hygiene and transferring from the bed to a chair. A review of Resident 12's clinical record indicated she was a [AGE] year female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 12's Minimum Data Set (MDS), dated [DATE] and May 5, 2014, indicated she was fully intact cognitively, was able to understand others and make herself understood at all times, required only supervision with bed mobility, transfers, ambulation, and dressing. The MDS indicated during the observation period the resident had exhibited behaviors such as hitting, scratching, pacing, rummaging, public sexual acts, disrobing in public, screaming and throwing or smearing food and/or bodily waste. In addition, the MDS indicated Resident 12 had displayed behavior symptoms that indicated she was an immediate threat to herself and others. A review of Resident 12' s clinical record indicated the plan of care had not been updated to address the behavior. A review of the social services designee (SSD) notes dated February 12, 2014, indicated a loaner motorized wheelchair was delivered to Resident 12. Review of a motorized wheelchair assessment dated [DATE] indicated the facility staff were concerned because the Resident did not adjust the speed of the wheelchair when around other people, did not have the ability to avoid moving objects and collisions, was unable to remain calm in all situations, or control her anger toward others. The assessment indicated Resident 12 could not comply with safety rules or maintain a safe distance between her wheelchair and others. A review of a motorized wheelchair assessment, dated May 28, 2014, three months later, indicated Resident 12' s ability to safely operate the motorized wheelchair had deteriorated. The assessment indicated the resident's ability to judge distances and speed, wait for others to move out of the way, control her anger and avoid confrontations was poor. A review of Resident 12's care plan for motorized wheelchair safety indicated the facility staff did not inform the physician or alter the plan of care to reflect the resident's deterioration. In addition, Resident 12 was allowed to continue using the motorized wheelchair. b. On June 28, 2014 at 9:45 a.m., licensed vocational nurse (LVN 30) stated Resident 12 had a physician's orders [REDACTED]. The LVN stated the facility staff had on multiple occasions observed Resident 12 in an alleyway near the facility neighborhood. When asked what the staff would do when they observed the resident in the alleyway, the LVN stated, " We would try to persuade her to come back in, but she would curse at us and tell us to leave her alone." However, review of the clinical record indicated there was no documentation of the staff ' s observations or physician notification of these incidents. On June 29, 2014 at 3 p.m., the director of nurses (DON) stated Resident 12 had a physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of that physician's orders [REDACTED]. The DON stated the physician's orders [REDACTED]. c. On June 26, 2014 at 6 p.m., Resident 2, a visually impaired resident, stated he and Resident 12 had recently been stopped by a law enforcement officer and given a traffic citation. The resident stated they were riding through the city streets with him, in his manual wheelchair, holding onto Resident 12's motorized wheelchair while she pulled him through the streets. This behavior placed both residents at risk for injury. A review of Resident 2's clinical record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 2's MDS dated [DATE], indicated he was fully intact cognitively, had severely impaired vision (no vision or only able to see light and shapes only) required extensive assistance with bed mobility and transferring from the bed to chair and bathing, and required the use of a wheelchair or walker for ambulation (walking). On June 28, 2014, the director of staff development (DSD) stated she had observed Resident 12 traveling at top speeds through the facility hallway pulling Resident 2 seated in a manual wheelchair, holding on to her motorized wheelchair. Review of Resident 2's clinical record indicated the physician had not been notified of the potentially dangerous behavior, nor had the facility developed a plan of care to address the potentially dangerous behavior. On June 30, 2014 at 5 p.m., the DON verified the facility had not developed a plan of care to address the risk to Resident 2. d. On June 28, 2014, at 9:45 a.m., LVN 30 stated Resident 12 had turned off the pad alarm (an alarm attached to either a chair or bed to alert the staff the resident was at risk for a fall due to a change in position) on her roommate, Resident 16's, bed. Resident 12 stated she had turned the machine off because she did not want to hear the alarm. A review of Resident 16's clinical record indicated she was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 16's MDS, dated [DATE], indicated the resident exhibited inattention, difficulty focusing attention, rambling or irrelevant conversation, and illogical thinking continuously. According to Resident 16's clinical record she was at high risk for falls and wandering due to confusion, history of multiple falls, and decreased muscle coordination. Resident 16 was found on the floor on February 7, 2014 and the physician wrote an order on February 10, 2014, for a bed and a chair alarm to prevent unassisted standing and walking. On June 29, 2014, at 1:45p.m., the SSD verified that the clinical record indicated, on April 22, 2014, Resident 12 admitted to turning Resident 16's alarm off. The SSD stated she explained to Resident 12 the importance of not turning her roommates alarm off because the Resident may fall, but Resident 12 stated the noise bothered her and she would continue to turn the alarm off, thus placing Resident 16 at risk for falls and injury. On August 4, 2014, at 2 p.m., RN 40 stated the facility had been aware of Resident 12 ' s history of turning other resident's pad alarms off from her previous facilities. According to the SSD, the facility held an Interdisciplinary Team (IDT) meeting with Resident 12 on April 22, 2014 regarding her turning her roommate's alarm off, and Resident 12 was moved to another room. On April 23, 2014, the SSD documented at 2 p.m., she saw Resident 12 going in and out of Resident 16's and Resident 12 continued to complain about Resident 16's alarm. According to a Licensed Nurses note on April 23, 2014 at 1:15 a.m., Resident 16 was found on the floor of her room after sustaining an unwitnessed fall. Review of the Post Fall Assessment indicated Resident 16's alarm was "not activated."

Based on observation, interview, and record review, the facility failed to ensure one of nineteen residents (13) was free of physical abuse and one of nineteen residents (19) was free of verbal abuse by failing to provide adequate supervision to a resident with a history of aggressive and violent behavior. This deficient practice resulted in Resident 13 requiring admission to an acute care hospital after Resident 12 struck her two times with her fist. Resident 13 was admitted to an acute care hospital with [DIAGNOSES REDACTED]. breathing and medication to maintain her blood pressure). Reference F 323 Findings: A review of Resident 12's clinical record indicated she was a [AGE] year female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 12's Minimum Data Sets (MDS), a comprehensive assessment tool, dated February 3, 2014 and May 5, 2014, indicated she was fully intact cognitively, was able to understand others and make herself understood at all times, required only supervision with bed mobility, transfers, ambulation, and dressing. The MDS indicated during the observation period the resident had exhibited behaviors such as hitting, scratching, pacing, rummaging, public sexual acts, disrobing in public, screaming and throwing or smearing food and/or bodily waste. In addition, the MDS indicated Resident 12 had displayed behavior symptoms that indicated she was an immediate threat to herself and others. A review of a social services note dated January 31, 2014, indicated the facility's activities personnel had expressed concern to the social services designee (SSD) because Resident 12 refused to give a pair of scissors back to the staff after an arts and crafts activity. A review of Resident 12's clinical record indicated the plan of care had not been updated to address the behavior. On June 28, 2014 at 8:30 a.m., during an interview, Resident 12 stated she felt the facility was trying to, "get rid" of her because she had, "hit a crazy old woman" , that had gotten too close to her (Resident 13), and had an argument with another old woman. (Resident 19). On June 28, 2014 at 9 a.m., the assistant director of nurses (ADON) stated Resident 12 had struck a [AGE] year old resident with dementia (Resident 13). The ADON stated Resident 13 was very friendly and liked to pat people's hands. Resident 13 had gotten close to Resident 12, and Resident 12 punched Resident 13's arm two times with her fists. Review of Resident 13's clinical record indicated she was a [AGE] year old admitted to the facility November 4, 2011 with [DIAGNOSES REDACTED]. Review of Resident 13's MDS dated [DATE] indicated she was cognitively impaired, rarely able to make herself understood, or understand others. The MDS indicated the resident was unable to walk and was totally dependent on the facility staff for bathing, transferring from bed to chair, and all personal hygiene care. A review of a licensed personnel progress note dated June 3, 2014, a.m. indicated twenty minutes after Resident 12 punched Resident 13 , at 9:30 a.m., Resident 13 was noted to have a rapid respiratory rate of 42 (normal rate is 16 to 24), and required oxygen administration for a low oxygen saturation of 87% (normal oxygen saturation rate is 97% to 99). Resident 13's physician was notified and the resident was transferred to a general acute care hospital (GACH). Review of the acute care records indicated Resident 12 was admitted to the hospital with [REDACTED]. Further review of the records from the acute care hospital indicated Resident 13 was admitted to the intensive care unit (ICU), placed on life support (a machine to help with her breathing and given a medication to maintain her blood pressure). In addition, Resident 13 required a cardioversion procedure (electrical shock delivered to the heart to slow and/or stabilize an irregular heart rate). Resident 13 remained in the acute care hospital for five days and then required transfer to a long term acute care facility. As of July 7, 2014, Resident 13 remained in the acute care facility. Resident 13 suffered a significant change in her condition as a result of the abuse from Resident 12. There was no documentation in the acute care hospital clinical records indicating the facility had reported to the acute care hospital Resident 12's physical abuse of Resident 13. An on-line article titled, "A Resident's Guide to Living With Afib", published by The American Heart Association, <<http://circ.ahajournals.org/>>., indicated stress is the most common trigger for [MEDICAL CONDITION]. Review of a letter dated June 3, 2014, written by the facility administrator indicated the facility had identified Resident 12 as an endangerment to other residents in the facility. However, the clinical record did not indicate the facility changed the plan of care or provided increased supervision of Resident 12. b. A review of Resident 12 ' s clinical record indicated Resident 12 had a verbal altercation with Resident 19 on April 24, 2014. Resident 19's clinical record indicated she was a [AGE] year old admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On June 30, 2014 at 11:45 p.m., LVN 35 stated on April 29, 2014, Resident 12 entered Resident 19's room and saw Resident 19, a newly admitted resident, in Resident 12's previous bed. Resident 12 became upset and started yelling and cursing at Resident 19. Resident 19 raised her cane, as if to protect herself, and the staff intervened before the altercation became physical. Upon notification of the incident, Resident 19's family requested she be transferred to the hospital. Resident 19 did not return to the facility. According to the social services notes Resident 12 was verbally abusive (calling names, making rascist comments, cursing, threatening to strike) to the staff and/or other residents on the following days from May 6, 2014 through June 26, 2014: 5/6/14, 5/15/14, 5/20/14, 5/28/14 at 11 a.m., 1 pm, and 4 p.m., 6/3/14 9:10 a.m., and 12:30 p.m.,6/19/14, and 6/25/17, A review of Resident 12 ' s clinical record indicated the facility called law enforcement on June 3, 2014, in an attempt to control Resident 12 ' s behavior. In addition, the clinical record indicated the facility was forced to call law enforcement on May 28, 2014 at 1 p.m., because Resident 12 was blocking emergency response personnel from gaining access to a resident that needed emergency care. According to the clinical record, Resident 12 rolled her motorized wheelchair over the foot of a facility staff member when that staff member attempted to move her out of the way so the paramedics could see the resident that was on the floor bleeding from a head injury. On June 30, 2014 at 3:30 p.m., the survey team determined immediate correction was required because the facility had allowed a situation in which one resident's behavior placed that resident, and other residents in the facility, at risk for injury by failing to implement preventive or corrective measures.

Based on observation, interview, and record review, the facility failed to maintain a sanitary, orderly and comfortable environment by not providing effective pest control to treat an insect infestation in a timely manner. The pest control company had found heavy gnat (small, biting, two-winged flies) activity in the kitchen area and exterior grounds near the kitchen on August 9, 2010, however, the facility did not act upon this finding until August 24 and 25, 2010, a total of 16 to 17 days. During the survey, gnats were observed throughout the facility, in the kitchen, hallways, Nurse's Station, DSS office, dining room, and resident ' s rooms from August 24 to 30, 2010. Interviews with five of seven residents attending the group meeting and one randomly selected resident indicated the flying pest infestation had become evident three to four weeks ago. Failure of the facility to perform needed maintenance, as recommended by their contractual pest control company, resulted in the residents suffering itching, irritation, fear, and loss of sleep for a three week period. One of twenty sample residents (6) and two randomly selected residents (RS21, RS22) expressed feeling frightened, frustrated, and angry as a result of the insects flying into their faces and food for three weeks. a. Resident 6, a terminally ill resident, stated the gnats flying into her food and face irritated her. Resident 6's family member stated she had to constantly wave the gnats away while feeding her mother every meal. b. RS 21, a blind resident, stated she felt afraid when the pests flew into her face because she could not see what was attacking her and she was afraid they would fly into her eyes. c. RS 22, a bed bound resident, stated the pests were constantly flying into her face, landing on her arms, and she was frequently awakened by the pests flying around her face and mouth during the day when she was trying to sleep. The resident, in a frustrated, distressed tone asked the surveyor if anything could be done about the pest problem. Findings: On August 24, 2010 at 8:25 a.m., several small black flying insects were observed in the kitchen. On August 24, 2010 at 9 a.m., during the initial tour of the facility with Licensed Vocational Nurse 30 (LVN 30), the staff and residents were observed waving away small black insects flying in the air. The insects were observed flying around throughout the facility. On August 24, 2010 at 3:05 p.m., during an interview, Resident 6 stated she was bothered by the way the pests flew around her face and food, necessitating she and her daughter wave them away while being fed. During an interview with Resident 6's daughter on August 26, 2010 at 10:15 a.m., the daughter stated she came into the facility everyday to feed her mother lunch and dinner. The resident's daughter stated the flying pests had been a problem for approximately three weeks. The family member further stated getting her mother to eat was a challenge because of the resident's cancer [DIAGNOSES REDACTED]. Resident 6's daughter complained the pests flying into her mother's food and face slowed the feeding process down even more so because she had to constantly wave the pests away from her mother's mouth. On August 24, 2010 at 3:20 p.m., during an interview, the facility administrator stated a pest control company came out on August 20, 2010, because of complaints from the residents and staff regarding the pest problem. On August 24, 2010 at 3:30 p.m., a representative from the facility's contractual pest control company identified himself to the surveyors as a Service Manager. The Service Manager stated his company had notified the facility on August 20, 2010, that they would need to have a plumber flush the drains in the facility then his company would insert a foam that would help eliminate the pest control problem. The Service Manager stated had the facility followed his company's recommendation to have the drains flushed on August 20, 2010, the pest problem would not be as severe as it is presently. An invoice, dated August 20, 2010, indicated the facility had been inspected for "filth fly activity", and the following steps had been recommended to the facility to decrease the pest problem: 1. Dumpsters have organic material built up and disposal company should clean or replace them. 2. Northside flowerbeds should have watering cycle turned off to allow soil to dry out. 3. Main drain should be cleaned out by a plumber to eliminate organic material in the line. 4. Sewer drain in storage area should be capped. Drain foam was needed in the kitchen drains and affected patient areas. On August 24, 2010, the Maintenance Supervisor stated the pest control company had come out that morning, August 24, 2010, and changed some "traps". The Maintenance Supervisor further stated the pest control person had stated, "He didn't know what the problem was." The Maintenance Supervisor verified that this was after the same company had given the facility a list of recommended actions four days prior. When the surveyor asked if the recommendations the pest control company had submitted four days earlier had been acted upon, the Maintenance Supervisor and Administrator stated they had not. The surveyor requested copies of all invoices for work done. On August 25, 2010 at 7:20 a.m., the dumpsters outside of the facility were observed to be heavily soiled, dinted, foul smelling, with a heavy concentration of the black insects flying in and around the dumpsters. On August 25, 2010 at 7:30 a.m., during an interview, RS 23 stated he had noticed the pest problem getting worse about three weeks ago. A review of RS 23's clinical record face sheet indicated he was a [AGE] year old, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RS 23's minimum data set (MDS), a comprehensive, systematic assessment tool, dated July 20, 2010, indicated he was cognitively independent, able to understand and make himself understood at all times. On August 25, 2010 at 1:20 p.m., two staff members and three residents were observed waving pests away from their faces and food in the facility dining room. On August 25, 2010 at 2 p.m., the surveyor again requested copies of all invoices from the facility administrator. On August 26, 2010 at 7:30 a.m., two staff members were observed sitting at the Nurses Station 2 charting and waving pests away from their faces. On August 26, 2010 at 2 p.m., during the group meeting, five of seven residents attending the meeting stated they had been complaining to the facility staff for approximately one month about the pest problem. The residents complained about the pests flying into their faces, food, and noses. During this meeting, RS 21, a blind resident, stated she felt frightened when the pests flew into her face because she could not see what was attacking her, and she was afraid the pests would fly into her eyes. A review of RS 21's clinical record face sheet indicated she was [AGE] year old, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RS 21's MDS indicated the resident had no cognitive impairment, was consistently able to understand others and make herself understood, and severely visually impaired. On August 26, 2010 at 3 p.m., the Administrator gave the surveyor invoices, for implementation of the pest control company's recommendations on August 20, 2010, indicating dates after the surveyor had raised the issue. a. An invoice from the plumbing company, dated August 24, 2010, untimed, indicated the company did some work on the facility's drainage lines. b. An invoice, dated August 24, 2010, untimed, from a pest control company indicating some insect bait and spraying of the facility had been done on that day. c. -An invoice, dated August 25, 2010, untimed, indicated the pest control company had "dropped off 12 cans of drain foam". On August 27, 2010 at 8:30 a.m., the Maintenance Supervisor stated the facility had hired a new pest control company and the new company had come out the night before, August 26, 2010 to spray Room 30, the facility outside grounds, the DSS (Dietary Services Supervisor) office, and the administrator's office. When asked if the recommendations suggested by the facility's contractual pest company on August 20, 2010, had been completed, the Maintenance Supervisor stated the dumpsters had not been cleaned yet, but, he was having the dumpster company come out "the next day", seven days after it was recommended by the pest control company. The Maintenance Supervisor further stated the drains had been foamed the night of August 24, 2010, four days after it was recommended by the pest control company. The survey started on August 24, 2010, the drains were foamed after the facility's owner, the administrator, the maintenance supervisor, and the pest control company representative were asked about the pest problem. On August 27, 2010 at 8:30 a.m., the Maintenance Supervisor was informed the residents had told the surveyors that they had been complaining to the facility staff about the flying pest problem for about a month. The Maintenance Supervisor stated he had the pest control company come on August 9, 2010. The surveyor requested a copy of the invoice for that visit. On August 27, 2010 at 8:30 a.m., a review of the invoice the maintenance supervisor gave to the surveyor, dated August 9, 2010, untimed, indicated the pest control company had found heavy gnat activity in the kitchen area and exterior grounds near the kitchen. On August 26, 2010 the administrator had given the surveyor invoices for the August 20, 24, and 25 pest control company visits. However, he had not provided the surveyor with the August 9, 2010 invoice. During a wound care treatment observation, in the resident ' s bed, on August 27, 2010 at 9:20 a.m., Treatment Nurse 1 was observed waving away flying pests from the dressings and medications he had just opened in preparation for the dressing change he was about to perform. During an interview with the administrator on August 27, 2010 at 12:15 p.m., when asked why no further actions had been taken by the facility to address the pest problem when the pest control company had identified the facility as having a heavy gnat infestation on August 9, 2010, the administrator stated, "That was my fault, I was depending on other people, I didn't read the invoices. We are now doing all we can." A review of the job description for the facility's administrator indicated the administrator would ensure that the building and grounds were maintained in good repair, assume administrative authority, responsibility, and accountability for directing activities and programs of the facility. The job description indicated the purpose of the administrator position was to ensure that the highest degree of quality care was provided to the residents at all times. On August 27, 2010 at 10:32 a.m., during an interview, RS 22 stated the pest problem had been bad for "few weeks". In a distressed, angry, and frustrated voice the resident stated she was tired of the insects flying into her face, she could feel them on her arms, and she was frequently awakened by the feel of the pests flying around her face and mouth. RS 22 ' s voice was loud and high pitched, and she was frowning. The resident asked the surveyor if there was anything that could be done about the pest problem. According to PubMed, an on-line publication from the U.S. National Library of Medicine, an article entitled " Symptoms of Psychological Distress, " outbursts of anger is one way patients may express anxiety and/or distress. StressFocus.com, an on-line resource, defines stress as a physiological response of the body to a hostile environment and symptoms of stress are manifestations of that response. A hostile environment is a threatening, intimidating or offensive atmosphere that interferes with a person ' s normal functioning. John Deri, M.D., a Psychiatrist and Psychotherapist, states in an on-line article entitled " Psychological Effects of Stress " , " The psychological effects of stress are not always obvious to others, but they can be just as serious as the physical symptoms of stress if they are not addressed. " A review of RS 22's clinical record face sheet on August 27, 2010 at 11 a.m,, indicated she was [AGE] year old, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RS 22's MDS, dated [DATE], indicated she was modified independent in her cognitive skills, experiencing some difficulty in new situations only, able to understand others, and make herself understood at all times. Further review of the MDS indicated the resident was totally dependent on staff for activities of daily living and required two staff to provide physical assistance for bed mobility. On August 30, 2010 at 7:30 a.m., the night shift charge nurse was observed sitting at Nurses Station 2, waving flying pests out of her face as she charted. A review of the facility's undated Pest Control policy indicated the facility's housekeeping and maintenance departments would conduct weekly inspections for evidence of pests, keep the dumpster area clean, and when pests were sighted determine why the infestation was occurring.