Every finding on record at Lawndale Healthcare & Wellness Centre LLC

Based on interview, and record review, the facility failed to create a comprehensive person-centered care plan (CP) for Resident 1's change of condition (CoC) on 6/22/2026 in accordance with the facility's policy and procedure (P&P) titled Change in Condition and Person-Centered Care Planning.This deficient practice had the potential to result in Resident 1's medical condition to worsen.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 that included chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic kidney disease (when kidneys are damaged and cannot filter blood as they should), dementia (a progressive state of decline in mental abilities) and cardiomegaly (an enlarged heart). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/28/2026, the MDS indicated Resident 1 had moderately intact cognitive (ability to think and process information) ability. The MDS indicated Resident 1 was dependent (helper does all the effort) for oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for eating. During a concurrent interview and record review on 6/27/2026 at 11:55 AM with Licensed Vocational Nurse (LVN) 3, Resident 1's SBAR Communication Form (documentation used to communicate a CoC to the attending physician [MD]) dated 6/22/2026 was reviewed. The COC indicated that Resident 1 had pitting edema to the legs and the MD recommendations were to monitor changes in swelling, pain or skin integrity. LVN 3 stated the procedure for a Change of Condition (COC) is to call the MD to get recommendations, put in new orders for the recommendations, follow up on them and update the resident's care plan to address the COC. During a concurrent interview and record review on 6/27/2026 at 12:03 PM with LVN 3, Resident 1's Care Plan History dated 5/21/2026 to 6/23/2026 was reviewed. LVN 3 stated that Resident 1 does not have a care plan for edema monitoring or monitoring for changes in swelling, pain or skin integrity. LVN 3 stated that Resident 1 should have had a care plan for edema monitoring and the monitoring mentioned in the COC. LVN 3 stated that if there is no care plan, a resident's condition may deteriorate. During a concurrent interview and record review on 6/27/2026 at 1:57 PM with the Director of Nursing (DON), the facility's P&P titled, Change in Condition, dated 8/25/2022, was reviewed. The P&P indicated the licensed nurse will document and update the care plan to reflect the resident's current status. The DON stated that the policy indicates that a resident should have a care plan that has measurable objectives and goals to address their needs and behaviors. The DON stated that a resident's care plan needs to be updated after a COC as mentioned in the policy for COC. The DON stated if a resident had edema as a COC, the nurse should have created a care plan to address the edema. During a concurrent interview and record review on 6/27/2026 at 2:15 PM with the DON, the facility's P&P titled, Person-Centered Care Planning, dated 5/22/2025, was reviewed. The P&P indicated:The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical needs that are identified in the comprehensive assessment.The services that are to be furnished to attain or maintain the resident's highest practical physical well-being must be included in the care plan.The DON stated that the policy indicates that it is important to update the care plan because it reflects the resident's care needs and interventions are implemented to reach a care goal. The DON stated if a resident does not have a care plan their problem is not addressed and their condition may worsen.

Based on interview, and record review, the facility failed to follow the facility's policy and procedure (P & P) titled Telephone Orders, regarding one of three residents' (Resident 1) change of condition (COC) on 6/22/2026 by failing to: Follow the attending physician's (MD) recommendations of monitoring edema, monitoring for changes in swelling, pain or skin integrity.Document orders for MD's recommendations.Document monitoring of edema, changes in swelling, pain and skin integrity. This deficient practice had the potential to cause Resident 1's medical condition to worsen. 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 that included chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic kidney disease (when kidneys are damaged and cannot filter blood as they should), dementia (a progressive state of decline in mental abilities) and cardiomegaly (an enlarged heart). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/28/2026, the MDS indicated Resident 1 had moderately intact cognitive (ability to think and process information) ability. The MDS indicated Resident 1 was dependent (helper does all the effort) for oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for eating. During a concurrent interview and record review on 6/27/2026 at 11:55 AM with Licensed Vocational Nurse (LVN) 3, Resident 1's SBAR Communication Form (documentation used to communicate a CoC to the attending physician [MD]) dated 6/22/2026 was reviewed. The COC indicated that Resident 1 had pitting edema to the legs and the MD recommendations were to monitor changes in swelling, pain or skin integrity. LVN 3 stated the procedure for a Change of Condition (COC) is to call the MD to get recommendations, put in new orders for the recommendations, follow up on them and update the resident's care plan to address the COC. During a concurrent interview and record review on 6/27/2026 at 12:03 PM with LVN 3, Resident 1's Care Plan History dated 5/21/2026 to 6/23/2026 was reviewed. LVN 3 stated that Resident 1 does not have a care plan for edema monitoring or monitoring for changes in swelling, pain or skin integrity. LVN 3 stated that Resident 1 should have had a care plan for edema monitoring and the monitoring mentioned in the COC. LVN 3 stated that if there is no care plan, a resident's condition may deteriorate. During a concurrent interview and record review on 6/27/2026 at 1:57 PM with the Director of Nursing (DON), the facility's P&P titled, Change in Condition, dated 8/25/2022, was reviewed. The P&P indicated the licensed nurse will document and update the care plan to reflect the resident's current status. The DON stated that the policy indicates that a resident should have a care plan that has measurable objectives and goals to address their needs and behaviors. The DON stated that a resident's care plan needs to be updated after a COC as mentioned in the policy for COC. The DON stated if a resident had edema as a COC, the nurse should have created a care plan to address the edema. During a concurrent interview and record review on 6/27/2026 at 2:15 PM with the DON, the facility's P&P titled, Person-Centered Care Planning, dated 5/22/2025, was reviewed. The P&P indicated:The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical needs that are identified in the comprehensive assessment.The services that are to be furnished to attain or maintain the residents' highest practical physical well-being must be included in the care plan.The DON stated that the policy indicates that it is important to update the care plan because it reflects the resident's care needs and interventions are implemented to reach a care goal. The DON stated if a resident does not have a care plan their problem is not addressed and their condition may worsen.

Based on record review and interview, the facility failed to ensure the Director of Staff Development (DSD) and nursing staff did not sign the In-service/Meeting (on-going education program designed to ensure staff maintained necessary skills and training on resident safety, care quality and regulatory compliance) Sign-In sheets when the DSD did not provide the education or training and staff did not attend the In-service. This deficient practice had the potential to result in staff providing resident care without proper training or competencies, which places residents at risk for improper care and adverse outcomes.Findings:During a review of the facility's In-Service/Meeting Sign-In Sheets dated 3/1/2026 through 3/20/2026, the Sign-In Sheets indicated the DSD was the instructor for the following in-services and signed by multiple nursing staff:Assisting Resident Transfer and Ambulation on 3/1/2026- 3/5/2026Interpersonal Relationship and Communication skills on 3/2/2026-3/7/2026Skin integrity, Body Positioning, Turning and Repositioning on 3/9/2026-3/14/2026Catheter and Perineal Care on 3/10/26- 3/13/2026Confidentiality/HIPAA on 3/16/2026- 3/18/2026Documentation (3/16/2026- 3/19/2026)Sexual Abuse (3/18/2026- 3/20/2026)During interviews on 4/20/2026 at 1:10 p.m. and 4/21/2026 at 10:30 a.m., with the DSD, the DSD stated she was on vacation on 3/1/2026 through 3/20/2026. The DSD stated she signed the In-service Sign-In sheets dated 3/1/2026 through 3/20/2026 as the instructor, because she forgot she was on vacation and thought she provided the trainings. The DSD stated she should not have signed the documents and was unsure who provided the trainings to staff. During a concurrent interview and record review on 4/20/2026 at 4:00 p.m., with the Director of Nursing (DON), the Licensed Nurses monthly schedule for the month of 3/2026 was reviewed. The DON stated VL indicated that the staff had was on vacation leave. The DSD was on vacation and not in the building from 3/2/2026 through 3/20/2026.During a concurrent interview and record review on 4/20/2026 at 4:15 p.m., with Certified Nursing Assistant (CNA) 1, the In- Service Meeting Sign-In Sheet titled, Assisting Resident Transfer and Ambulation dated 3/1/2026- 3/5/2026 were reviewed. CNA 1 stated she worked 3:00 p.m. - 11:00 p.m. shifts during this timeframe and could not remember attending the training. During a concurrent interview and record review on 4/21/2026 at 8:50 a.m., with CNA 2, the In-Service/Meeting Sign-in Sheets dated 3/1/2026 through 3/20/2026 were reviewed. CNA 2 stated she did not attend any of the In-services dated 3/1/2026 through 3/20/2026. The last In-service or training she attended was around three months ago regarding abuse. CNA 2 stated she signed the in-service/Meeting Sign-in Sheets because the DSD and the Assistant DSD (ADSD) asked staff to sign the In-Service /Meeting Sign-in Sheets even though the staff have not attended the trainings. They (DSD and ADSD) would bring the Sign-In Sheets around for staff to sign them. During an interview on 4/21/2026 at 10:45 a.m., with CNA 3, CNA 3 stated the DSD and the ADSD asked her to sign the In-Service /Meeting Sign in Sheets (dates unspecified) so she signed them, but she did not attend the In-Services. The last meeting she attended was several months ago regarding abuse. During a subsequent interview on 4/21/2026 at 11:00 a.m., with the DON, the DON stated the Inservice Sign-in sheets should not have been signed by the DSD if the DSD did not provide the training and the sign-in sheets should have the name of the staff who conducted the training.During a review of the undated Director of Staff Development Job description, the Job description indicated the DSD coordinates and conducts an effective ongoing in-service plan to all employees, coordinates in service training for all CNAs for a minimum of 24 hours on an annual basis with at least 12 hours of the 24 hours provided in person, and provides or coordinates mandatory annual/ongoing education and competency to all employees in accordance to State and Federal regulations. During a review of the facility's policy and procedure (P&P) titled, In-service Training and Record Keeping dated 2/20/2025, the P&P indicated the purpose is to provide required in-service education in accordance with Federal and State regulations. The facility will provide in-service training for all Certified Nurse Assistants (CNAs) for a minimum of twenty-four hours on an annual basis and the training records shall be maintained by the DSD including training program documents (lesson plans, written exams) and attendance records.

Based upon interview and record review, the facility failed to: 1. Follow its' policy and procedures for the testing of Legionella (a serious type of pneumonia caused by Legionella bacteria found in [NAME] environments that can thrive in human-made water systems) and other opportunistic waterborne pathogens within the facility's water systems. This deficient practice had the potential to cause residents and staff to become ill with Legionnaire's disease or other opportunistic waterborne pathogens.Findings: During a review of the facility's water management binder, on 1/23/2026 at 8:25 a.m., the water management binder was observed to have blank testing logs for Legionella and other water pathogens. The facility's water management binder only contained 2 annual receipts for water backflow testing (a test used to check if plumbing valves are working to prevent contaminated water from flowing backward into the clean water supply) from the city's water company. During an interview, on 01/23/2026 at 8:30 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated the city's water company came out to the facility for water backflow testing in 2024 and 2025. The IPN stated she did not know if the city's water company tested for Legionella or other opportunistic waterborne pathogens. The IPN stated the facility did not have any documentation to show testing was completed. During an interview, on 01/23/2026 at 10:36 a.m., with the Administrator (Adm), the Adm stated the facility had their water backflow tested by the city's water company. The Adm stated he was not sure if the water was tested for Legionella and/or other waterborne pathogens. The Adm stated he was under the impression that testing was being done but said it was not. During an interview, on 01/23/2026 at 10:51 a.m., with the Maintenance Supervisor (MS), the MS stated there were no invoices that stated the company had tested for Legionella or other waterborne bacteria in the facility's water supply. The MS stated the facility's water should be tested every year for Legionella or any other waterborne pathogens. The MS stated the risk of not testing the facility's water supply for Legionella and other waterborne pathogens could result in water containing bacteria, virus, fungi and mold growth placing the residents at risk of becoming ill. During a review of the facility's policy and procedures (P&P), titled Water Management, dated 12/22/2025, the P&P indicated, The team leader will survey the facility using a risk assessment to determine its risk for Legionella growth and spread.

Based on observation, interview and record review, the facility failed to ensure for 52 of 56 medically compromised and vulnerable residents who received food from the kitchen: Ensure personal water bottle were not kept at dry storage area.Ensure opened disinfecting wipes were not kept at dry storage area.Ensure expired food items were removed from the kitchen area.Ensure test strips used to test sanitation strength were not expired.These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins). Findings:1.During a concurrent observation and interview on 1/20/2026 at 8:20 a.m., with the Dietary Food Supervisor (DSS), found personal water bottle kept at dry storage area. The DSS stated no staff personal items should be kept at dry storage area due to possible cross contamination with facility food for residents.2.During a concurrent observation and interview on 1/20/2026 at 8:25 a.m., with the DSS, found one opened disinfecting wipes at the dry storage area. The DSS stated all disinfecting wipes, and chemical solution should be placed in the designated chemical room due to possible cross contamination with the food items in the dry storage area.During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, undated, the P&P indicated, Food storage areas should be used only for food and items such as bleach, soap, and other cleaning supplies should be stored in entirely separate and specific areas.3.During a concurrent observation and interview on 1/20/2026 at 8:30 a.m., with the DSS in the kitchen, there were expired food items as follows:9 cans of prune juice from concentrate with received date on 4/10/2025 with best buy date on 11/10/2025.4 bags of hotdog buns with best buy date of 1/6/2026.The DSS stated dietary staff are responsible in checking all the food items in the kitchen making sure they are not expired. The DSS stated using food items past their best buy date could cause abdominal discomforts to residents that would jeopardize their health and safety. During a review of the facility's P&P titled, Dietary Department-General, dated 6/1/2024, the P&P indicated, The Primary objective of the dietary department includes maintenance of standards for quality of food. During a review of the facility's P&P titled, Storage of Food and Supplies, undated, the P&P indicated, All food products will be used per the times specified in the Dry Food Storage Guidelines. The Dry Food Storage Guidelines indicated bread to be used 5-7 days, and no food will be kept longer than the expiration date on the product. 4. During a concurrent observation and interview on 1/21/2026 at 9:28 a.m., in the kitchen dishwashing machine area, Dietary Aide 2 (DA 2) tested the dishwashing machine sanitation running water after it was sanitized with chlorine test paper strip (used to test commercial dishwasher for proper sanitation level). DA 2 stated the chlorine test paper strip bottle indicated an expiration date of 8/2025. DA 2 stated he forgot to check the expiration date of the chlorine test paper strip.During an interview on 1/21/2026 at 9:41 a.m., with the DSS, the DSS stated using an expired chlorine test paper strip will give an inaccurate reading and the plates and utensils won't be properly sanitized and putting residents at risk for infection.During a review of the 2022 U.S. Food and Drug Administration Food Code titled Equipment Code#4-501.114, indicated Verifying the adequacy of chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, temperature, and pH of the sanitizing solutions comply with paragraph 4-501.114 (A) using acceptable test methods and equipment.

Based on observation, interview and record review, the facility failed to ensure: 1. Registered Nurse (RN) 2 was competent in securing medication and preparation when administering medications to Resident 27. 2. The facility failed to ensure annual competencies were dated and completed for five out of six randomly selected staff members. These deficient practices had the potential for staff not securing medications, providing accurate medications to the residents and inconsistent competency assessments.Findings: a. During a review of 6 employees' files, on 01/22/2026 1:16 p.m., a random audit was conducted for Certified Nurse Assistant 2 (CNA 2), CNA 3, CNA 4, Licensed Vocational Nurse 3 (LVN 3), LVN 4 and Registered Nurse 2 (RN 2) on mandatory orientation and annual (yearly) staff competencies. CNA 4 did not have any issues with the facility's orientation and annual competencies. CNA 2 had missing dates for CNA Skills Competency Log, Repositioning Competency, Mechanical Lift Competency and Sit-to-Stand Competency Log. CNA 3 had missing dates and no scores listed for Confidentiality/HIPPA Written Competency, Palliative Care/End of Life Written Competency and Change in Condition Written Competency. LVN 3 did not have any competencies for the years 2024, 2025 and 2026 in his employee file. LVN 3's last competency tests were completed in 2023. LVN 4 had a missing date for New Employee General Orientation Checklist. RN 2 had missing dates for Blood Glucose Monitoring Observations Competency, Intramuscular Injection Observational Competency, Enteral Feeding Tube Observational Competency and Nurse Medication Pass Competency. During a concurrent interview and record review, on 1/22/2026 at 1:45 p.m., with the Director of Staff Development (DSD), the DSD stated all competencies were to be completed for staff upon hire during orientation and annually. The DSD stated all competencies were to be signed and dated upon completion. The DSD stated the risk of undated and incomplete competencies could result in staff being unable to provide necessary care at a competent level and not knowing when or if a competency skill was completed. b. During a review of Resident 27's admission Record (face sheet), the admission Record indicated the facility admitted the resident on 12/11/2023 and readmitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 27's History and Physical (H&P) dated 11/8/2025, the H&P indicated the resident did not have the capacity to understand or make decisions. During a review of Resident 27's Minimum Data Set (MDS- a resident assessment tool), the MDS indicated Resident 27 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 27 was dependent on staff for eating, toileting and bathing. During a concurrent observation and interview on 1/22/2026 at 8:05 a.m. with Registered Nurse (RN) 2 in front of Resident 27's room, a medication cup with four unlabeled medications was observed on RN 2's medication cart. RN 2 stated the medications in cup were for Resident 27, but Family Member (FM) 1 requested medications to be administered after breakfast. RN 2 placed the medication cup with unlabeled medications back into medication cart. During a concurrent observation and interview on 1/22/2026 at 9:00 a.m., RN 2 was observed preparing Resident 27's medications and took out the unlabeled medication cup from the medication cart. RN 2 stated she will use the medications she prepared at 8:00 a.m. and continued to prepare the rest of the medications that were to be given at this time. During a concurrent interview and record review on 1/23/2026 at 9:22 a.m. with the Director of Nursing (DON), RN 2's Nurse Medication Pass Competency was reviewed. The Nurse Medication Pass Competency indicated RN 2 demonstrated competency with all Medication Pass tasks, but did not have a date for when competency was completed. The DON stated competencies are completed for nursing staff upon hire, annually and as needed. The DON stated competencies that are undated place staff at risk for not being evaluated consistently. The DON stated leaving medications unattended on medication cart and preparing unlabeled medications an hour before administration does not demonstrate competency in medication administration. The DON stated nurses that do not demonstrate competency in medication administration place residents at risk for medication errors. During a review of facility policy and procedure (P&P) titled Staff Competency Validation dated 3/28/2024, the P&P indicated, Staff are required to have competency validation based on their job description or assigned duties.

Based upon observation, interview and record review, the facility failed to: 1.Ensure resident identifiable documentation was accurate for one of six sampled residents (Resident 25).This deficient practice had the potential to negatively impact Resident 25's psychological needs.Findings: During a review of Resident 25's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 25's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 25's history and physical (H&P) form, dated 11/26/2025/2025, the H&P indicated Resident 25 did not have the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/1/2025, the MDS indicated Resident 25's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 25 was dependent on 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 25's January 2026 Medication Administration Record (MAR), the MAR indicated staff had documented Resident 25 had 0 behaviors while monitoring for anxiety m/b constant screaming in January 2026 despite resident being heard and observed constantly screaming and yelling throughout various times of the day in the facility. During a review of Resident 25's nursing progress note, dated 1/19/25, the nursing progress noted indicated Resident 25 was alert & oriented x3 (A&Ox3- a medical abbreviation assessing a patient's cognitive status by checking if they are awake (alert), know their name/identity (person), current location (place), and the approximate date/time (time), communicated verbally with clear speech and was able to understand and be understood when speaking. During a concurrent interview and record, on 01/22/2026 at 12:05 p.m., with Registered Nurse 2 (RN 2), RN 2 stated types of non-pharmacological interventions (NPIs) included redirecting a resident, repositioning a resident, having a resident watch television or allowing a resident to talk on the phone. RN 2 stated when NPIs are ineffective for a resident, the staff will proceed to administer medication. RN 2 acknowledged hearing Resident 25 constantly screaming. RN 2 stated Resident 25's behavioral log was mostly charted as no behaviors which was inaccurate while NPI's were charted as ineffective. RN 2 stated Resident 25 should have been administered medication for constant screaming and the doctor should had been notified of Resident 25's behaviors. During a concurrent interview and record review, on 1/22/2026 at 12:23 p.m., with RN 2, RN 2 stated the meaning of A&O x3 meant a resident understood and could say their name, date, time and place. RN 2 stated when a resident's cognitive skills were severely impaired, it meant a resident was incoherent and would not be understood. RN 2 stated Resident 25 was A&O x0 (a medical notation indicating that a patient is awake and alert, but not oriented to any of the standard, tested cognitive categories). RN 2 stated nursing progress notes indicated Resident 25 was A&O x3 which was inaccurate. RN 2 stated the risk of documenting inaccurate resident information could negatively affect a resident's treatment and plan of care. During a review of the facility's policy and procedures (P&P), titled Completion & Correction, revised 1/1/2012, the P&P indicated, The Facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation.

Based on observation, interview and record review, the facility failed to: 1.Ensure low air loss mattresses settings were correct for one of six sampled residents (Resident 1). This deficient practice had the potential to result in further skin breakdown.Findings: During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included 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), schizophrenia (a mental illness that is characterized by disturbances in thought) and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's history and physical (H&P) form, dated 12/17/2025, the H&P indicated Resident 1 had the capacity to make needs know but not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/23/2025, the MDS indicated Resident 1's cognitive (thinking) skills were moderately impaired. The MDS also indicated Resident 1 was dependent on 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 an observation, on 1/20/2026 at 2:21 p.m., Resident 1 was observed lying in bed on a low air loss mattress with weight settings at 450 pounds. During a record review, on 1/20/2025 at 3:01 p.m., of Resident 1's weight, Resident 1's weight indicated he weighed 197 pounds. During a observation, on 1/22/2026 at 9:31 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 1's low air loss mattress was set to 450 pounds. During a concurrent interview and observation, on 1/22/2026 at 9:34 a.m., with LVN 2, LVN 2 stated all low air loss mattresses settings was based on a resident's weight in pounds. LVN 2 stated the purpose of a low air loss mattress was to prevent further skin breakdown in residents with pressure ulcers or skin issues. LVN 2 stated that Resident 1 weighed 197 pounds. LVN 2 stated Resident 1's low air loss mattress setting was incorrect. LVN 2 stated the risk of setting a low air loss mattress on a wrong weight or setting could result in further skin breakdown. During a review of the facility's policy and procedures (P&P), titled Mattresses, dated 1/1/2012, the P&P indicated, 1. The Facility will provide mattresses capable of meeting the following needs of residents: B. To provide stimulation and pressure relief to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure.

Based upon observation and interview, the facility failed to:1.Ensure resident rights were protected from a noisy environment caused by Resident 25 yelling and screaming for one of six sampled residents (Resident 52).This deficient practice resulted in a violation of resident rights.Findings:a. During a review of Resident 52's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 52 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52 diagnoses' list included rheumatoid arthritis (a chronic, systemic autoimmune disease where the immune system mistakenly attacks healthy joint tissue), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (the long-term, progressive, and irreversible loss of kidney function, lasting 3 months or more) and polyneuropathy (a disease or disorder that causes damage to multiple peripheral nerves simultaneously). During a review of Resident 52's Minimum Data Set (MDS- a federally mandated resident assessment tool, dated 11/14/2025, the MDS indicated Resident 52's cognitive (thinking) skills were intact. The MDS also indicated Resident 52 was dependent on 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). b. During a review of Resident 25's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 25's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 25's history and physical (H&P) form, dated 11/26/2025/2025, the H&P indicated Resident 25 did not have the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/1/2025, the MDS indicated Resident 25's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 25 was dependent on 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 an interview, on 1/20/2026 at 9:42 a.m., with Resident 52, Resident 52 stated there was a resident (Resident 25) down the hall from him who would scream loudly every 3-5 minutes every day and night for hours. Resident 52 stated the only time Resident 25 did not scream was when Resident 25 was asleep which would last for 30 minutes at a time. Resident 52 stated he informed the staff about Resident 25's screaming, but nothing had been done. Resident 52 stated Resident 25's screaming made him feel uncomfortable and angry especially when he would try to sleep. During an interview, on 1/22/2026 at 12:14 p.m., with Registered Nurse 2 (RN 2), RN 2 stated the protocol for a loud and noisy resident was to talk to the loud resident and attempt to redirect to stop the behavior. RN 2 stated if redirection did not work for the resident, another solution was to administer medication as ordered. RN 2 stated Resident 52 had complained previously about Resident 25's constant yelling. RN 2 stated the facility received a physician's order for medication related to Resident 25's constant screaming but Resident 25 hadn't been administered the prescribed medication. RN 2 stated a noisy environment due to a yelling resident could affect other residents as they would not be able to sleep, violating their resident's rights. During a review of the facility's policy and procedures (P&P), titled Residents Rights, dated 1/1/2012, the P&P indicated, Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the Facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety.

Based on observation, interview, and record review, the facility failed to:Ensure one out of 14 sampled residents (Resident 6) was provided a homelike environment and did not have chipped paint on the bathroom door.This deficient practice of not providing a homelike environment for Resident 6 had the potential to negatively impact her quality of life.Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), muscle weakness, and neuralgia (intense, sharp, or stabbing pain caused by damage, irritation, or compression of nerve).During a review of Resident 6's History and Physical (H&P), dated 7/20/2025, the H&P indicated, Resident 6 had the capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/2/2025, the MDS indicated, Resident 6 was independent (decisions consistent/reasonable) on cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 6 had the ability to make self-understood and understand others. The MDS indicated, Resident 6 was dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing.During a concurrent observation and interview on 1/20/2026 at 10:01 a.m., with Resident 6 in her room, there was scattered chipped paint on the bathroom door. Resident 6 stated she had already informed the management about the scattered chipped paint on the bathroom door, but nothing had been done. Resident 6 stated she felt depressed and it was not a homelike environment seeing scattered peeling chipped paint in her room.During an interview on 1/21/2026 at 12:54 p.m., with the Maintenance Supervisor (MS), the MS stated Resident 6's bathroom door needs to be repaired and painted. The MS stated he did not have a log to show that Resident 6's room was maintained in a sanitary condition.During an interview on 1/21/2026 at 2:20 p.m., with the Administrator in Training (AIT), the AIT stated it is not aesthetically (the look and feel of things as they are presented to the senses) pleasing for having a chipped paint on resident's room.During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, dated 1/1/20212, the P&P indicated, To provide residents with a safe, clean, comfortable and home like environment.During a review of the facility's P&P titled, Resident Rights-Accommodation of Needs, dated 1/1/20212, the P&P indicated, To ensure that the facility provides an environment and services that meet resident's individual needs.

Based on interview and record review, the facility failed to: 1. Implement the physician's orders to draw laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for two of two sampled residents (Residents 5 and 9).This deficient practice had the potential to result in the delay of identification of medical concerns, delaying the care and services necessary for the affected residents.Findings:1.During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included cerebral infarction (a condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) with hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), heart failure (a heart disorder that causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities).During a review of Resident 5's History and Physical (H&P), dated 12/8/2025, the H&P indicated, Resident 5 can make needs known but could not make medical decisions.During a review of Resident 5's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/14/2025, the MDS indicated, Resident 5's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor). The MDS indicated, Resident 5 had the ability to make self-understood and understand others. The MDS indicated, Resident 5 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene, showering, and lower body dressing.During a review of Resident 5's Order Summary Report (a document containing active orders), dated 1/20/2026, the Order Summary Report indicated the physician placed a telephone order on 1/7/2026 for Resident 5 to have laboratory orders for Complete Blood Count ([CBC] a blood test that checks the overall health of the blood by measuring the number and types of cells) and Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 key substances in the blood, assessing electrolyte balance, kidney, liver function, and blood sugar).During a concurrent interview and record review on 1/21/2026 at 1:50 p.m., with Registered Nurse 1 (RN 1), Resident 5's laboratory results, were reviewed. RN 1 stated Resident 5's order for CBC and CMP were not drawn and results were not available. RN1 stated it was important to complete laboratory tests as ordered by the physician to know and identify medical condition of the resident and give appropriate treatment immediately. 2.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 cerebral infarction (a condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), heart failure (a heart disorder that causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 9's History and Physical (H&P), dated 12/12/2025, 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 12/17/2025, the MDS indicated, Resident 9's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated, Resident 9 was dependent (helper does all of the effort) from staff with oral hygiene, toileting hygiene, and personal hygiene.During a review of Resident 9's Order Summary Report (a document containing active orders), dated 1/20/2026, the Order Summary Report indicated the physician placed a telephone order on 1/15/2026 for Resident 9 to have laboratory orders for B-type natriuretic peptide ([BNP] - a blood test that measures levels of protein called BNP that is made by your heart and blood vessels), and prothrombin time panel ([PT] - a blood test that measures how many seconds it takes for liquid plasma to form a clot).During a concurrent interview and record review on 1/21/2026 at 1:55 p.m., with Registered Nurse 1 (RN 1), Resident 9's laboratory results, were reviewed. RN 1 stated Resident 9's order for BNP and PT panel were not drawn and results were not available. RN 1 stated the process for ordering laboratory tests was to place the order electronically and place the laboratory order form in the binder. RN 1 stated failure to monitor Resident 9's PT panel would put her at risk for bleeding. RN 1 stated it was important to check Resident 9's BNP level to monitor for signs and symptoms of heart failure such as swelling and shortness of breath.During an interview on 1/21/2026 at 2:10 p.m., with the Director of Nursing (DON), the DON stated it was important to complete all laboratory test of all residents as ordered by the physician so they would have a baseline and to monitor their health condition.During a review of the facility's policy and procedure (P&P) titled, Laboratory Services, dated 1/1/2012, the P&P indicated, The facility should provide laboratory services in an accurate and timely manner to meet the needs of residents per attending physician orders.

Based upon observation, interview and record review, the facility failed to: 1.Report to the California Department of Public Health (CDPH- the state department responsible for public health in California) of an abuse allegation for one of three sampled residents (Resident 16). This deficient practice resulted in a delay of an onsite inspection by CDPH and had potential to place residents at risk for abuse.Findings: During a review of Resident 16's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 16 was admitted on [DATE] and readmitted on [DATE]. Resident 16's diagnoses list included psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with reality), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (apprehensive uneasiness or nervousness usually over an impending or anticipated misfortune) and cerebral infarction (stroke). During a review of Resident 16's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/23/2025, the MDS indicated Resident 16's cognitive (thinking) skills were moderately impaired. The MDS indicated Resident 16 required maximal assistance 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 16's Change of Condition (COC form), dated 11/20/2025, the COC note indicated staff noted bruising to the resident's left forearm and hand during rounds and notified the charge nurse. The COC indicated bruising on the left forearm appeared reddened to purplish with no swelling, open areas, or pain. The COC indicated when asked what happened, Resident 16 stated 'staff beat me' but could not provide names or details. The COC indicated Resident 16 frequently bangs her bed remote on the rails to gain attention which may contribute to bruising. The COC form indicated Resident 16 had a history of vague or exaggerated stories about being hurt. During an interview, on 1/23/2026 at 11:19 a.m., with Resident 16, Resident 16 stated she could not recall being hit on 11/20/2025. Resident 16 stated she felt safe at the moment. During an interview, on 1/23/2026 at 2:15 p.m., with the Director of Nursing, (DON), the DON stated on 11/20/2025, Resident 16 stated staff had hit her on her arms. The DON stated she called and informed the police and ombudsman. The DON stated she reported the abuse allegation to the Administrator who stated he would report the allegation to the appropriate agencies. The DON stated the time frame for reporting abuse was within 2 hours. The DON stated the risk of not reporting in a timely manner could result in further abuse. During an interview, on 1/23/2026 at 2:35 p.m., with the Administrator (Admin), the Adm stated he reported Resident 16's November 2025 abuse allegation but couldn't provide any documentation or evidence to show that the facility reported in a timely manner. the report for abuse allegations in [DATE] for [NAME]. The Adm stated he was responsible for reporting abuse allegations within 2 hours. The Adm stated the three agencies that the facility was supposed to report to were the ombudsman, LAPD (law enforcement) and CDPH. The Adm stated the risk of not reporting abuse allegations in a timely manner could result in harm to other residents if it is not reported. During a review of the facility's policy and procedures (P&P), titled Abuse Prevention and Management, dated 6/12/2024, the P&P indicated, The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours.

Based on observation, interview, and record review, the facility failed to:Ensure a physician order to wear lumbosacral orthosis ([LSO] - a back brace that supports the lower spine and sacrum (large, triangular bone at the base of the spine) when out of bed was followed for one of one sampled resident (Resident 38).This deficient practice had the potential to place Resident 38 for increased pain and muscle spasms.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included low back pain, chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and bipolar disorder (sometimes called manic-depressive disorder, mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 38's History and Physical (H&P), dated 1/12/2026, the H&P indicated, Resident 38 can make needs known but could not make medical decisions.During a review of Resident 38's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/6/2026, the MDS indicated, Resident 38's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor). The MDS indicated, Resident 38 had the ability to make self-understood and understand others. The MDS indicated, Resident 38 required setup assistance (helper assists only prior to or following the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 38's care plan, titled Resident may wear LSO when out of bed for back pain, dated 1/19/2026, indicated goal for resident to use LSO brace as ordered to maintain spinal support and improve mobility, until next reviews in 3 months. The care plan intervention included to apply LSO brace as ordered.During a review of Resident 38's Physician Progress Notes, dated 1/19/2026, the Physician Progress Notes indicated, per therapy team patient intermittently wears LSO brace when out of bed and appears to help with his pain.During a review of Resident 38's Order Summary Report (a document containing active orders), dated 1/20/2026, the Order Summary Report indicated the physician placed a telephone order on 1/12/2026 for Resident 38 to wear LSO when out of bed for back pain.During a concurrent observation and interview on 1/21/2026 at 2:00 p.m., in the activity room, observed Resident 38 with no LSO brace. Resident 38 stated the nurse did not put his back brace and he is supposed to use it every day. Resident 38 stated he has back pain and he needs his brace to reduce his pain.During an interview on 1/21/2026 at 2:18 p.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated she was not aware that Resident 38 needs the back brace when he gets out of bed.During an interview on 1/21/2026 at 2:30 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was not aware that Resident 38 has a physician order to wear LSO brace when he gets out of bed.During an interview on 1/21/2026 at 2:45 p.m., with the Physical Therapist (PT), the PT stated the physician of Resident 38 made the determination for Resident 38 to wear LSO brace when out of bed. The PT stated the physician order should be followed. The PT stated she believed that Resident 38 needs the LSO brace only for comfort measures only and it may or may not relieve his pain.During an interview on 1/23/2026 at 8:49 a.m., with the Director of Nursing (DON), the DON stated Resident 38's physician prescribed the LSO brace for Resident 38 as conservative treatment (any therapy that does not involve pharmacological or surgical intervention) to minimize his pain. The DON stated failure to follow physician order for Resident 38 to wear LSO brace when out of bed would result in more discomfort that could affect his quality of life.During a review of the facility's policy and procedure (P&P) titled, Resident Rights-Quality of Life, dated 3/2017, the P&P indicated, To ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.

Based on observation, interview and record review the facility failed to ensure two liters of oxygen was administered as ordered by physician for two of ten sampled residents (Resident 1 and Resident 23). This deficient practice had the potential to place residents at risk for not receiving oxygen therapy as prescribed by the physician and complications such as decreased breathing drive (result of too much oxygen in the body reducing the urge to breathe) and carbon dioxide retention (less breathing resulting in less carbon dioxide exhalation and increase of carbon dioxide in blood). a. During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included 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), schizophrenia (a mental illness that is characterized by disturbances in thought) and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's physician orders, dated 12/16/2025, the physician orders indicated Resident 1 was to receive oxygen at 2 liters per minute via nasal cannula to keep oxygen saturation at 92% or above every shift for shortness of breath. During a review of Resident 1's history and physical (H&P) form, dated 12/17/2025, the H&P indicated Resident 1 had the capacity to make needs know but not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/23/2025, the MDS indicated Resident 1's cognitive (thinking) skills were moderately impaired. The MDS also indicated Resident 1 was dependent on 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 an observation, on 1/20/2026 at 2:22 p.m., Resident 1 was observed lying in bed with oxygen running at 3 liters per minute via Resident 1's nasal cannula. During an observation, on 1/22/2026 11:58 a.m., with Registered Nurse 2 (RN 2), RN 2 stated Resident 1's oxygen was running at 3 liters per minute via nasal canula. During a concurrent interview and record review, on 01/22/2026 12:19 p.m., with Registered Nurse 2 (RN 2), RN 2 stated the protocol for oxygen was to obtain a physician's order and follow the instructions given by the physician. RN 2 stated Resident 1 had a physician order for oxygen at 2 liters per minute via nasal cannula keep O2 sat above 92%. RN 2 stated Resident 1 should not have received 3 liters of oxygen. RN 2 stated Resident 1 should've been receiving 2 liters as stated in the physician's order. RN 2 stated the risk of administering more oxygen than ordered could result in a decline in a resident breathing status. b. During a review of Resident 23's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 7/17/2024 with diagnoses including pneumonia (an infection/inflammation in the lungs), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 23's History and Physical (H&P) dated 1/9/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS- a resident assessment tool), dated 1/5/2026, the MDS indicated Resident 23 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 23 was dependent on staff for toileting and required substantial assistance from staff for bathing and personal hygiene. During a review of Resident 23's physician orders dated 1/12/2026 indicated Oxygen at two liters per minute via nasal cannula (medical device used to deliver oxygen to the respiratory system) to keep oxygen saturation at or above 92% every shift for COPD. During a concurrent observation and interview on 1/21/2026 at 1:26 p.m. with Licensed Vocational Nurse (LVN) 4 in Resident 23's room, Resident 23 was observed on four liters of oxygen via nasal cannula. LVN 4 stated Resident 23 should be on two liters of oxygen as per physician orders. LVN 4 stated oxygen should be administered as ordered by physician. LVN 4 stated administering more oxygen than ordered can have a negative effect on residents' respiratory system, and places residents at risk of carbon dioxide and oxygen imbalances. During an interview on 1/23/2026 at 9:30 a.m. with the Director of Nursing (DON), the DON stated staff should follow physician orders for oxygen administration because the physicians' assessments of residents and their diagnoses determine orders that are clinically appropriate for the resident. The DON stated residents with COPD are at risk for carbon dioxide retention and decreased breathing drive when receiving oxygen therapy and should not be receiving more oxygen than ordered. During a review of facility policy and procedure (P&P) titled Oxygen Therapy dated 10/10/2025, the P&P indicated, Administer oxygen and obtain oxygen saturation levels as ordered by the provider.

Based on interview and record review, the facility failed to:Ensure one of one sampled resident (Resident 6) was evaluated by a physician initially in the first 90 days of admission and document his visit in resident's clinical records.This deficient practice had the potential for Resident 6's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment.Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), muscle weakness, and neuralgia (intense, sharp, or stabbing pain caused by damage, irritation, or compression of nerve).During a review of Resident 6's History and Physical (H&P), dated 7/20/2025, the H&P indicated, Resident 6 had the capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/2/2025, the MDS indicated, Resident 6 was independent (decisions consistent/reasonable) on cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 6 had the ability to make self-understood and understand others. The MDS indicated, Resident 6 was dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing.During an interview on 1/20/2026 at 10:01 a.m., with Resident 6, Resident 6 stated she had not seen her physician in the facility for 4 months. Resident 6 stated she would like to see her physician so she could discuss her multiple medical conditions.During a concurrent interview and record review on 1/21/2026 at 2:15 p.m., with the Director of Nursing (DON), Resident 6's clinical records were reviewed. The DON stated Resident 6 was readmitted to the facility on 11/2025 for skilled care services (high-level medical, nursing, or rehabilitative treatments that must be performed by licensed professionals such as nurses or therapist under doctor's supervision). The DON stated there was no initial comprehensive visit by Resident 6's physician within the first 30 days of readmission. The DON stated Resident was last visited by her physician on 7/20/2025. The DON stated Resident 6 was visited by a Nurse Practitioner ([NP] - a nurse who has advanced clinical education and training) not by a physician on 11/26/2025, 12/7/2025, and 1/4/2026. The DON stated physician should come and visit resident monthly and as needed. The DON stated physician visit is necessary so he could review the condition of the resident and adjust the plan of care as necessary.During a review of the facility's policy and procedure (P&P) titled, Physician Services and Visits, dated 11/11/2025, the P&P indicated, Physician services shall include but are not limited to resident evaluation including a written report of a physical examination within 5 days prior to admission or within 72 hours following admission. The P&P indicated for the first 90 days, the initial visit must be conducted by attending physician.

Based upon observation, interview and record review, the facility failed to: 1.Ensure appropriate medication treatment was administered for one of six sampled residents (Resident 25) who was observed yelling loudly throughout various shifts for 4 days. This deficient practice had the potential to result in escalation of behavioral issues.Findings: During a review of Resident 25's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 25's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 25's history and physical (H&P) form, dated 11/26/2025/2025, the H&P indicated Resident 25 did not have the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/1/2025, the MDS indicated Resident 25's cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 25 was dependent on 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 an observation, on 01/20/2026 at 9:32 a.m., of Resident 25, Resident 25 was observed lying in bed, yelling and screaming in his room, while looking up at the ceiling. Resident 25 did not appear to be in any distress. Resident 25 was unable to be interviewed. During an observation, on 01/20/2026 at 2:07 p.m., of Resident 25, Resident 25 continued to be observed yelling and screaming in his room throughout various work shifts. Resident 25 did not appear to be in any type distress. During an observation, on 01/21/2026 at 12:00 p.m., of Resident 25, Resident 25 was observed yelling and screaming every 3 to 5 minutes while in his room. Resident 25 had been yelling since 7:30 a.m. During a record review of Resident 25's January 2026 Medication Administration Record (MAR), the MAR indicated Resident 25 had a physician's order for Ativan 0.5 milligrams (mg) 1 tablet every 6 hours as needed for anxiety manifested by constant screaming with a start date of 1/13/2026. The MAR also non-pharmacological interventions had been attempted but was ineffective. The MAR indicated Resident 25's medication had not been administered since the start date. During a concurrent interview and record review, on 01/22/2026 at 12:10 p.m., with Registered Nurse 2 (RN 2), RN 2 stated the protocol for a resident who constantly yells after non-pharmacological interventions were ineffective was to administer medication to a resident. RN 2 stated although Resident 25 had been constantly yelling and screaming for 3 days, no medication was administered to him. RN 2 stated Resident 25 should have had medication administered as ordered. RN 2 stated the risk of not administering medication when a resident displays behavioral issues could result in disturbing other residents and cause altercations. During a review of the facility's policy and procedures (P&P), titled Behavior/Psychoactive Drug Management, dated 11/14/2025, the P&P indicated, The Facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents.

Based on observation, interview and record review, the facility failed to ensure medications were administered at the time of preparation for one of three sampled residents (Resident 27). This failure had the potential to place resident at risk for medication errors. Findings: During a review of Resident 27's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/11/2023 and was readmitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 27's History and Physical (H&P) dated 11/8/2025, the H&P indicated the resident did not have the capacity to understand or make decisions. During a review of Resident 27's Minimum Data Set (MDS- a resident assessment tool), the MDS indicated Resident 27 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 27 was dependent on staff for eating, toileting and bathing. During a concurrent observation and interview on 1/22/2026 at 8:05 a.m. with Registered Nurse (RN) 2 in front of Resident 27's room, a medication cup with four unlabeled medications was observed on RN 2's medication cart. RN 2 stated the medications in cup were for Resident 27, but Family Member (FM) 1 requested medications to be administered after breakfast. RN 2 placed the medication cup with unlabeled medications back into medication cart. During a concurrent observation and interview on 1/22/2026 at 9:00 a.m., RN 2 was observed preparing Resident 27's medications and took out the unlabeled medication cup from the medication cart. RN 2 stated she will use the medications she prepared at 8:00 a.m. and continued to prepare the rest of the medications that were to be given at this time.During an interview on 1/22/2026 at 12:30 p.m. with RN 2, RN 2 stated she should not have stored unlabeled medications prepared for Resident 27. RN 2 stated per facility policy medications should be administered right after preparation. RN 2 stated administering medications that were prepared an hour in advance and unlabeled places resident at risk for medication errors. During a concurrent interview and record review on 1/23/2026 at 9:22 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines dated November 2021 was reviewed. The P&P indicated Medications are administered at the time they are prepared. The DON stated administering unlabeled medications an hour after preparation places residents at risk for medication errors.

Based on observation, interview and record review, the facility failed to ensure medications were secured and visible to registered nurse administering medications for one of three sampled residents (Resident 27). This deficient practice had the potential to result in safety issues such as unauthorized resident access to medications and medication errors. Findings: During a review of Resident 27's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/11/2023 and was readmitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 27's History and Physical (H&P) dated 11/8/2025, the H&P indicated the resident did not have the capacity to understand or make decisions. During a review of Resident 27's Minimum Data Set (MDS- a resident assessment tool), the MDS indicated Resident 27 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 27 was dependent on staff for eating, toileting and bathing. During an observation on 1/22/2026 at 8:00 a.m. in front of Resident 27's room, a cup with four medications was observed on top of medication cart with no nursing staff or licensed personnel present. Registered Nurse (RN) 2 was observed coming out of Director of Nursing's (DON) office at 8:05 a.m. and returned to medication cart. During an interview on 1/22/2026 at 12:30 p.m. with RN 2, RN 2 stated she left Resident 27's medications unsupervised on top of medication cart while she went into the DON's office. RN 2 stated medications should never be left unattended or out of nursing staff's line of sight. RN 2 stated medications left unattended can be accessed by ambulatory residents walking around the facility and places residents at risk for medication errors. During an interview on 1/23/2026 at 9:22 a.m. with the DON, the DON stated skilled nurses need to make sure medications are always secured and never left unattended. The DON stated there was a risk of another resident taking medication, switching medications or medication errors when medications are left unattended and out of nursing staff's line of sight. During a review of facility policy and procedure (P&P) titled, Medication Administration - General Guidelines dated November 2021, indicated During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 38) was referred to Dental service for readjustment of his dentures.This deficient practice had the potential to result in inability to chew food and weight loss for Resident 38.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included low back pain, chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and bipolar disorder (sometimes called manic-depressive disorder, mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 38's History and Physical (H&P), dated 1/12/2026, the H&P indicated, Resident 38 can make needs known but could not make medical decisions.During a review of Resident 38's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/6/2026, the MDS indicated, Resident 38's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor). The MDS indicated, Resident 38 had the ability to make self-understood and understand others. The MDS indicated, Resident 38 required setup assistance (helper assists only prior to or following the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 38's care plan, titled Risk for oral infections related to edentulism and denture use, dated 1/11/2026, indicated goal for resident to manage his oral health effectively and maintain proper nutrition, until next reviews in 3 months. The care plan intervention included to coordinate with Social Service Director to arrange for regular dental check-ups to monitor the condition of dentures and oral tissues.During a concurrent observation and interview on 1/20/2026 at 9:33 a.m., in Resident 38's room, Resident 38 had no upper and lower dentures. Resident 38 stated he does not use his dentures because it falls out and does not fit properly. Resident 38 stated he informed the staff 2 weeks ago about the problem of his dentures. Resident 38 stated he had a hard time eating without his dentures.During an interview on 1/21/2026 at 11:17 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 38 refused to wear his dentures because it was loose.During an interview on 1/21/2026 at 11:20 a.m., with the Social Service Director (SSD), the SSD stated the facility has outside dental provider that comes to see residents regularly. The SSD stated dental services are one of the ancillaries (secondary/supplementary) services provided by the facility to all residents. The SSD stated she was not aware that Resident 38 had a problem with his dentures. The SSD stated Resident 38 was last seen by the dentist on 12/5/2025 and recommended to have a new full upper and lower dentures when eligible. The SSD stated Resident 38's could have been referred to the dentist for denture adjustment or reline. The SSD stated ill-fitting dentures could result on resident's not properly to eat that would lead to weight loss.During an interview on 1/21/2026 at 1:20 p.m., with the Director of Nursing (DON), the DON stated loose fitting dentures could cause discomfort to the resident.During a review of the facility's policy and procedure (P&P) titled, Oral Healthcare and Dental Services, dated 7/14/2017, the P&P indicated, The facility will provide oral healthcare and dental services for preventive care and treatment.During a review of the facility's Social Service Coordinator Job Description, the Social Service Coordinator Job Description indicated, to arrange ancillary services that have been determined necessary to maintain the resident's concrete needs.

Based on interview and record review, the facility failed to:Ensure smoking assessment was completed accurately for one of one sampled resident (Resident 38).This deficient practice had the potential to place Resident 38 at risk for injury and inadequate care planning.Findings:During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 38's diagnoses included low back pain, chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and bipolar disorder (sometimes called manic-depressive disorder, mood swings that range from the lows of depression to elevated periods of emotional highs), and nicotine (cigarette) dependence.During a review of Resident 38's History and Physical (H&P), dated 1/12/2026, the H&P indicated, Resident 38 can make needs known but could not make medical decisions.During a review of Resident 38's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/6/2026, the MDS indicated, Resident 38's cognitive (ability to think and reason) skills for daily decision making were moderately impaired (decisions poor). The MDS indicated, Resident 38 had the ability to make self-understood and understand others. The MDS indicated, Resident 38 required setup assistance (helper assists only prior to or following the activity) from staff with oral hygiene, toileting hygiene, and upper and lower body dressing. During a review of Resident 38's care plan, titled Risk for injury related to smoking, resident is an assisted smoker requiring supervision, dated 1/11/2026, indicated goal for resident not to suffer injury from unsafe smoking practices, until next reviews in 3 months. The care plan intervention included to conduct smoking safety evaluation on admission and as needed.During an interview on 1/21/2026 at 1:15 p.m., with Activity Assistant 1 (AA 1), AA 1 stated Resident 38 needed supervision during smoking.During a concurrent interview and record review on 1/22/2026 at 10:41 a.m., with the Minimum Data Set Nurse (MDSN), Resident 38's Smoking and Safety assessment, dated 1/11/2026, was reviewed. The MDSN stated Resident 38's Smoking and Safety assessment, indicated Resident 38 is an independent smoker. The MDSN stated Resident 38's Smoking and Safety assessment was not completed accurately. The MDSN stated there should be a checked mark on Smoking and Safety assessment number 6 (balance problems while sitting or standing) and number 14 (unable to light tobacco or other smoking products safely). The MDSN stated Resident 38 needs to be supervised during smoking because he has poor cognition. The MDSN stated it is important to complete the Smoking and Safety assessment accurately for the safety of the resident and the facility.During an interview on 1/23/2026 at 9:11 a.m., with the Director of Nursing (DON), the DON stated Smoking and Safety assessment is a tool to identify the status of the resident if he could smoke cigarette safely. The DON stated inaccurate smoking assessment of resident could lead to fire.During a review of the facility's policy and procedure (P&P) titled, Smoking by Residents, dated 8/18/2023, the P&P indicated, The facility will accommodate residents who smoke and will take reasonable precautions by providing a safe environment and protecting the non-smoking residents.

Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (a written plan of care developed by the resident's medical provider, the interdisciplinary team ([IDT] group of healthcare professionals working together to provide residents with needed care), and the resident to help resident achieve his or her treatment goals) was developed and implemented for the safe storage of smoking materials (cigarettes and lighters) for three of three sampled residents (Residents 1, 2 and 3), who were smokers by failing to ensure: 1). Resident 1 did not have a cigarette lighter in her purse on 7/2/2024 at 1:45 p.m. 2). Resident 2 did not have a lighter on her wheelchair seat while in the room, on 7/2/2024 at 1:50 p.m. 3). Resident 3 was not holding a lighter while coming out of his room on 7/2/2024 at 2 p.m. 4). Its Nursing Manual-Resident Rights, titled, Smoking Residents, which indicated the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke, was implemented. These failures had the potential for Residents 1, 2, and 3 to turn on the lighters, cause a fire and affect the health, safety, and wellbeing of all 56 residents in the facility, staff and visitors and result in serious injuries, hospitalization , and death. On 7/3/2024 at 4:32 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 the Administrator 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 56 residents in the facility including staffs and visitors. On 7/5/2024 at 4 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 7/5/2024 at 4:18 p.m. in the presence of the Administrator, DON, and Clinical consultant. The IJRP included the following immediate actions: 1). On 7/3/24, the Administrator Immediately removed the lighter from Residents 1, 2 and 3. 2). On 7/3/2024, the DON/designee immediately reassessed and completed the Smoking Safety Evaluations for Residents 1, 2, and 3 who smoked and included in the assessment, the safe storage of their smoking paraphernalia (material), the supervision and/or assistance required during smoking. Person-centered care plans were updated to address residents' current assessments including their supervision needs, and safe storage of smoking materials. 3). On 7/3/24, the Administrator met with Residents 1, 2, and 3 and discussed the Smoking Policy and Procedures including the process for safe storage and safekeeping of smoking materials. The smoking materials will be kept in a locked box and will be supervised by the activity and nursing staff. 4). Resident 3 will be supervised by the activity/nursing staff during smoking outside smoking scheduled times. 5). On 7/3/2024, the DON/designee conducted an audit of current residents who smoke to ensure accurate Smoking Safety Evaluations and Person-Centered Care Plans were in placed, including assessment for safe storage of smoking materials, supervision or assistance required during smoking. There were 12 residents that smoke. 12 out 12 residents identified as smokers, would be supervised by the facility staff during smoking break. These residents' smoking materials will be kept in a locked box by the Activity Department in daytime and at the nurse's station after office hours. Person centered care plans have been updated to reflect residents' smoking needs. 6). On 7/3/2024, the Administrator/Designee conducted rounds and observations on current residents to identify any other residents who kept smoking materials in their possession and ensure safekeeping. 7). On 7/3/2024, the DON/Designee conducted rounds and observation in the smoking area to ensure that residents who required supervision while smoking, were supervised. 8). On 7/3/2024, the Administrator/DON initiated in -service education to the Licensed Nurses, Certified Nurse Assistants (CNA), Department Managers and the rest of the facility staff on the Smoking Policy and Procedures, with emphasis on: -Accurate Smoking Safety Evaluations and Person -Centered Care Plans -Monitoring and safe storage of smoking materials for the residents. Smoking paraphernalia will be kept in the locked box in the activity department during activity hours and at the nursing station thereafter. -Residents who smoke will be supervised and assisted by the designated staff during smoking. This education was completed 7/4/2024. Staff who were on leave or were unscheduled, will be provided with education by the DON or designee upon return to work. 9). During morning Clinical Meetings on Mondays to Fridays, the IDT will review residents newly admitted /readmitted , residents due for quarterly assessments and residents with significant change in condition. The review was to ensure that Smoking Safety Evaluations and Person-Centered Care Plans were accurately completed for those residents who currently smoke, and those who have expressed the desire to smoke. Identified concerns will be immediately addressed and reported to the Administrator and DON for resolution, as warranted. 10). The Department Managers will conduct rounds and observe residents who smoke, weekly for 4 weeks, then bimonthly for 2 months, to ensure residents who smoke adhere to smoking policy and procedures. 11). Lighting and smoking materials were safely stored according to the residents' care plan and residents were provided supervision/assistance by the staff accordingly. Identified concerns during the observation will be immediately addressed and reported to the Administrator and DON for resolution, as warranted. 12). The Administrator and DON will present the results of the Smoking Monitoring Audits to the Quality Assurance and Performance Improvement Committee for monthly review, for the next 3 months and quarterly thereafter, until substantial compliance is achieved. The Administrator and DON were responsible for monitoring and sustaining compliance. Findings: a). During a concurrent observation and interview on 7/2/2024 at 1:45 p.m., Resident 1 was observed sitting on her bed with a cigarette lighter in her purse. Resident 1 stated cigarette breaks were scheduled several times a day and she did not have to ask for a lighter or cigarette from anyone since she already had hers. Resident 1 stated she was unsupervised during some cigarette breaks. Resident 1 stated staff did not check her belongings for the presence of cigarettes or lighters. Resident 1 stated she would feel horrible (fearful) if someone stole her lighter and set a fire, in the facility. During a concurrent interview and record review on 7/3/2024 at 1:40 p.m. with the DON, Resident 1 ' s Smoking and Safety form dated 6/5/2024 and Resident 1 ' s care plan titled Risk for injury related to smoking dated 6/5/2024 were reviewed. The DON stated Resident 1 ' s Smoking and Safety form indicated Resident 1 was able to smoke cigarettes without supervision but did not indicate how the smoking materials will be stored. The DON stated Resident 1 ' s care plan titled Risk for injury related to smoking, indicated Resident 1 was an assisted smoker and required supervision. The DON stated the care plan interventions did not indicate how Resident 1 ' s cigarettes and lighter will be stored. The DON stated the care plan and smoking, and safety form were misleading, and staff could not implement appropriate interventions to prevent negative outcomes due to the inconsistency of the documents. The DON stated the care plan did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 1 ' s Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included schizoaffective disorder (a mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), generalized anxiety disorder (persistent worrying), and nicotine dependence (addiction of). A review of Resident 1 ' s care plan titled Risk for injury related to smoking, dated 6/5/2024, indicated Resident 1 was an assisted smoker and required supervision. The care plan interventions indicated staff will enforce (implement) supervised smoking hours during scheduled times in the designated smoking patio. A review of Resident 1 ' s IDT Conference Review, dated 6/10/2024, indicated the purpose of the conference was to ensure Resident 1 smoked safely. The IDT goals indicated staff will keep offering Resident 1 an apron (burn protector for smokers) and encourage it ' s (apron) use. The interventions indicated staff will enforce the facility ' s smoking hours and supervise residents while smoking. The IDT Conference Review did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 1 ' s Minimum Data Set ([MDS] an assessment and care planning tool), dated 6/12/2024, indicated Resident 1 had clear speech and had the ability to express ideas and wants, and understood. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and upper body dressing. 2). During an observation and interview on 7/2/2024 at 1:50 p.m., Resident 2 was observed lying in bed and a wheelchair next to his bed. An orange cigarette lighter was observed on the seat of the wheelchair. Resident 2 stated he kept his cigarettes and lighter and smoked as needed without staff ' s supervision. Resident 2 stated he would feel horrible if someone stole his cigarette lighter and use the lighter to start a fire in the facility. During a concurrent interview and record review on 7/3/2024 at 1:45 p.m. with the DON, Resident 2 ' s IDT Conference Review, dated 1/16/24 was reviewed. The DON stated the IDT conference review goals and outcomes indicated staff will give Resident 2 smoking related material per facility ' s protocol and supervise the resident per his smoking assessment. The DON stated smoking materials were supposed to be stored by the activities department. The DON stated all residents were supposed to be supervised during smoking to prevent burn related injuries. The DON stated the care plan did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 2 ' s Admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnosis of metabolic encephalopathy (alteration in consciousness due to brain dysfunction), urinary tract infection ([UTI] infection in urinary system, which may include kidneys, ureters, bladder, or urethra), and unsteadiness on feet. A review of Resident 2 ' s IDT Conference Review, dated 1/16/2024, indicated Resident 2 was safe to smoke independently. The IDT Conference Review indicated staff will explain the facility ' s smoking policy, store smoking related materials per facility policy and supervise Resident 2, per the smoking assessment. A review of Resident 2 ' s Smoking and Safety form dated 4/20/2024, indicated Resident 2 used tobacco and required assistance and supervision when smoking. The Smoking and Safety form indicated staff will apply a smoking apron on Resident 2, extinguish (blow out) the resident ' s cigarette, and refer to the IDT, if Resident 2 was deemed unsafe to smoke. The form did not indicate how Resident 2 ' s cigarettes and lighter were stored. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had a clear speech and had the ability to express ideas and wants, and understood. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and personal hygiene. A review of Resident 2 ' s care plan titled, Risk for injury related to smoking, an assisted smoker requiring supervision, and refusing to wear an apron, dated 7/1/2024, indicated staff will keep offering and encouraging Resident 2, to use an apron, to protect the resident. The care plan interventions indicated staff will enforce supervised smoking hours at scheduled times in the designated smoking patio. The care plan interventions indicated staff will light Resident 2 ' s cigarette and bring the cigarette to his mouth for assistance. The care plan did not indicate how Resident 2 ' s cigarettes and lighter were stored. 3). During an observation and interview on 7/2/2024 at 2 p.m., Resident 3 was observed coming out of his room, holding a lighter. Resident 3 refused to answer what could happen if he lost his cigarette lighter and/or someone stole his cigarette lighter. During an observation on 7/2/2024 at 3:45 p.m., in the smoking patio, Resident 3 was observed smoking a cigarette by himself, and unsupervised. During a concurrent interview and record review on 7/3/2024 at 1:55 p.m. with the DON, Resident 3 ' s Smoking Safety Evaluation, dated 6/6/2024 was reviewed. The DON stated, the Smoking Safety Evaluation indicated Resident 3 smoked cigarettes and required supervision during designated smoking times. The DON stated the Activity ' s Department kept the lighters and cigarettes in an unlocked, unsecured tacklebox (utility box). The DON stated she was unaware if residents were stealing cigarettes and lighters from the tacklebox. The DON stated unsecured cigarettes and lighters were a safety concern in case residents light cigarettes and smoked in a room where other residents might be using oxygen. A review of Resident 3 ' s Admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3 ' s admitting diagnoses included schizoaffective disorder, suicidal ideations (act of thinking about or a state of preoccupation with taking one's own life) and homicidal ideations (a thought pattern characterized by the desire to kill another person or persons, along with a mental plan for a method of doing it). A review of Resident 3 ' s Smoking Safety form, dated 6/6/2024, indicated Resident 3 utilized (used) cigarettes and supervision was required during designated smoking times. A review of Resident 3 ' s MDS, dated [DATE] indicated Resident 3 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 3 was independent with eating, toileting, and personal hygiene. A review of Resident 3 ' s IDT Conference Review, dated 6/14/2024, indicated Resident 3 was safe to smoke independently. The IDT Conference Review indicated staff interventions included to store smoking materials per facility protocols, explain facility smoking policy to Resident 3, and assist Resident 3 to and from the designated smoking area. A review of Resident 3 ' s care plan titled At risk for injury related to smoking, an assisted smoker requiring supervision and refusing to wear apron, dated 6/14/2024, indicated staff will enforce supervised smoking hours in the designated smoking patio. The care plan did not indicate if Resident 3 required his cigarettes and lighter stored. A review of the facility ' s Nursing Manual-Resident Rights, titled, Smoking Residents, dated 8/18/2023, indicated the licensed nurse will assess residents who express a desire to smoke upon admission, quarterly, annually and upon significant change of condition, and present to the interdisciplinary team (IDT) for review. The manual indicated, the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoked.

Based on interview and record review, the facility failed to: 1. Ensure Resident 1 was being monitored for wandering (a person that roams around and becomes lost or confused about their location) throughout the facility. 2. Ensure staff followed Resident 1's Care Plan (CP) titled Resident is an elopement risk/wanderer related to dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person ' s ability to perform everyday activities) with intervention requiring a sitter for constant monitoring for safety purposes. 3. Ensure staff followed Resident 1's CP titled Risk for harm, other directed behavior potentially causing harm (episodic). Resident 1 enters other residents rooms, takes, and moves their personal items. 4. Follow their policy and procedure (P&P), titled, Reporting Abuse, indicated the facility will ensure residents are free from physical harm. These deficient practices resulted in Resident 1 sustaining a hematoma (a bruise) under the right eye. During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), Type 2 diabetes mellitus ([DM] - a disease characterized by an impairment of the body's ability to control blood sugar levels), and dementia. During a review of Resident 1's History and Physical (H&P), dated 2/18/2024, the H&P indicated, Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] resident assessment and care screening tool), dated 2/18/2024, the MDS indicated, Resident 1 had wandering behavior. The MDS indicated, Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing (the ability to dress and undress above the waist), and lower body dressing (the ability to dress and undress below the waist). During a review of Resident 2's Admission Record, the Admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), depression (feeling sadness and loss of interest), and chronic obstructive pulmonary disease ([COPD] - a group of lung disease conditions that causes breathing difficulties). During a review of Resident 2's History and Physical (H&P), dated 1/11/2024, the H&P indicated, Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] resident assessment and care screening tool), dated 3/4/2024, the MDS indicated, Resident 2 needs supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene and toileting hygiene. During a review of Resident 3's Admission Record, the Admission Record indicated, Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of Type 2 diabetes mellitus ([DM] - a disease characterized by an impairment of the body ' s ability to control blood sugar levels), end stage renal disease (a medical condition in which a person ' s kidneys cease functioning on a permanent basis leading to the need for a regular course of long term dialysis or a kidney (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) transplant to maintain life), and right eye blindness (lack of vision). During a review of Resident 3's History and Physical (H&P), dated 10/4/2023, the H&P indicated, Resident 3 had the capacity to understand and make decisions. During a review of Resident 1's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff after a resident has a change of condition), dated 3/13/2024 at 6:30 p.m., the SBAR indicated CNA 1 saw Resident 2 on his wheelchair hitting Resident 1 who was lying on the bed of Resident 2 with a wooden back scratcher. The SBAR indicated Resident 1 sustained a hematoma (bad bruise that happens when an injury causes blood to collect and pool under the skin) on the right eye. During a review of Resident 1's Wound Assessment, dated 3/13/2024, the Wound Assessment indicated Resident 2 had hematoma on right periorbital area (around the eye) with intervention to cleanse with normal saline, pat dry, leave open to air and apply cold compress thereafter. During a review of Resident 1's Psychiatric Evaluation, dated 2/21/2024, the Psychiatric Evaluation indicated Resident 2 had assigned sitter due to confused behavior, restless, agitation and unable to follow commands. During a review of Resident 1's CP, titled The resident is an elopement risk/wanderer related to dementia, dated 12/20/2023 and revised on 3/4/2024, with goal of resident ' s safety will be maintained through the review date. The CP intervention indicated the resident is capable of being redirected. She requires a sitter for constant monitoring. During a review of Resident 1's CP, titled Risk for harm-directed behavior potentially causing harm (episodic) she enters other resident ' s rooms and rummages through their belongings. This behavior puts her in harm ' s way, dated 3/10/2024 and revised on 3/13/2024, the CP intervention indicated if wandering or pacing, initiate visual supervision during acute episode. During a review of Resident 1's emergency room (ER General Acute Care Hospital (GAHC) report, dated 3/13/2024, the GAHC report indicated Resident 1 had a diagnosis of periorbital ecchymosis of right eye (bruising and discoloration around a person ' s eye). During an interview on 3/15/2024 at 12:03 p.m. with Resident 3, stated he remembers the incident that happened with Resident 1 and Resident 2. Resident 3 stated his roommate Resident 2 just came back from smoking patio and entered the room screaming and yelling and informing Resident 1 to get out of his bed and room. Resident 3 stated he heard Resident 1 telling Resident 2 to stop hitting her. Resident 3 stated definitely Resident 2 was hitting Resident 1 with something and then someone came and grab Resident 1 outside of the room. Resident 3 stated he is blind but can recognized the voice of Resident 1 because she screams a lot. Resident 3 stated that night Resident 1 came to their room twice. Resident 3 stated the nurse were aware of Resident 1 ' s behavior of going into their room but they don ' t do anything about it. During a phone interview 3/15/2024 at 12:38 p.m., with LVN 2, LVN 2 stated Resident 1 had a sitter assigned to her the morning shift on 3/13/2024 but no assigned sitter that night. LVN 2 stated he did not know the reason why Resident 1 had no sitter that evening. LVN 2 stated she was passing medication to other residents when the incident happened. LVN 2 stated the incident could had been avoided if the facility had provided a sitter that could keep an eye on Resident 1 whereabouts especially Resident 1 had a wandering behavior and goes to other residents room. During an interview on 3/15/2024 at 1:12 p.m., with LVN 1, LVN 1 stated the incident between Resident 1 and Resident 2 happened on 3/13/2024 at 6:30 p.m. and was witnessed by CNA 1. LVN 1 stated it was essential for Resident 1 to have a sitter so they can follow, monitor, and redirect her behavior. LVN 2 stated Resident 2 had an anxiety (is an emotion characterized by feelings of tension and worried thoughts) behavior and easily get agitated. LVN 2 stated there were a sitter provided to Resident 2 on 3/13/2024 day shift but not on evening shift. During an interview on 3/15/2024 at 2:10 p.m., with the Director of Nursing (DON), the DON stated the facility provides only a sitter to Resident 1 only if they have an extra nurse. DON stated sitter is responsible for monitoring resident to prevent accidents and to redirect residents behavior from wandering into other residents room. DON stated safety is the paramount goal of the facility to prevent any accident of residents. DON stated interventions for wandering residents includes redirection of behavior, 1:1 monitoring (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act), and frequent visual checks monitoring. DON stated frequent visual checks meaning you have to check the resident more frequently like every hour. DON stated the facility did not provide visual monitoring for Resident 1 because the incident happened. DON stated it was the facility ' s responsibility to provide 1:1 monitoring for resident. DON stated when a resident was put on 1:1 monitoring, staff should observe resident, redirect resident and staff should be always with resident. DON stated constant monitoring means all the time (24 hours, 7 days a week). DON could not provide visual monitoring logs of Resident 1 ' s whereabouts. DON stated the facility must provide appropriate supervision to meet the needs of the residents. DON stated regardless of any situation, all residents have the right to be free from abuse. During an interview on 3/15/2024 at 2:45 p.m., with the Director of Staff Development (DSD), DSD stated she is responsible for assigning a sitter for Resident 1. DSD stated she provides only a sitter for Resident 1 only if necessary and to accommodate the staff who are on modified light duty (an offer of a work assignment made to an employee who is recovering from an injury, and who has received clearance from a physician to return to work with specific medical limitations). DSD stated a sitter was provided to Resident 2 on 3/13/2024 at day shift and no sitter provided at evening shift because there were no modified light duty staff available. During an interview on 3/15/2024 at 3:21 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she witnessed the incident of Resident 1 and 2. CNA 1 stated she was in other residents room, and she heard a voice coming from Resident 2 ' s room and she immediately responded. CNA 1 stated she saw Resident 2 sitting on his wheelchair inside his room and Resident 1 was lying on Resident 2's bed awake and yelling for help. CNA 1 stated she saw Resident 2 hitting Resident 1 on her right side of her face with a wooden back scratcher. CNA 1 stated she saw Resident 1 with a big bruise around her right eye and slight bleeding on her right side of the face. CNA 1 stated she put herself in front of Resident 2 to block him from further hitting Resident 1. During an interview on 3/15/2024 at 3:45 p.m., with the Administrator (ADM), the ADM stated he was informed about the incident that Resident 2 struck Resident 1 with a wooden back scratcher. ADM stated Resident 1 sustained a big bruise on her right eye and it was a big concern and was considered as major bodily injury. ADM stated the behavior of Resident 1 should had been redirected by the staff before she went to Resident 2 ' s room. ADM stated the facility failed to keep track of Resident 1 ' s whereabouts to prevent her from going to Resident 2 ' s room and it was unfortunate for Resident 1 got physically abused by Resident 2. During an interview on 3/18/2024 at 10:17 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she was assigned to Resident 1 on 3/13/2024 at evening shift. CNA 2 stated she was busy feeding and passing dinner trays to other residents when the incident happened. CNA 2 stated Resident 1 had a behavior of screaming and yelling and it needs two staff to talk to her and was not easy to redirect her behavior. CNA 2 stated she had seen Resident 1 in the past going to Resident 2 ' s room but Resident 1 had a sitter that follows her. During an interview and concurrent record review on 3/18/2024 at 10:57 a.m., with the Minimum Data Set Nurse (MDS Nurse), the CP titled The resident is an elopement risk/wanderer related to dementia and Risk for harm-directed behavior potentially causing harm (episodic) she enters other resident ' s rooms and rummages through their belongings. This behavior puts her in harm ' s way, were reviewed. MDS Nurse stated the CP goal for Resident 1 for safety to be maintained were not met. MDS Nurse stated visual monitoring means to monitor resident every hour. MDS Nurse stated all nurses were responsible in visual monitoring. During an interview and concurrent record review on 3/18/2024 at 11:20 a.m. with the DON, the daily staff assignment sheet from 3/1/2024 to 3/14/2024 were reviewed. The DON stated the facility did not provide a sitter to Resident 1 on the following days: 3/1/2024 7-3 shift, 3-11 shift, 11-7 shift. 3/2/2024 3-11 shift and 11-7 shift. 3/3/2024 3-11 shift and 11-7 shift. 3/4/2024 3-11 shift and 11-7 shift. 3/5/2024 3-11 shift and 11-7 shift. 3/6/2024 7-3 shift, 3-11 shift, 11-7 shift. 3/7/2024 7-3 shift, 3-11 shift, 11-7 shift. 3/8/2024 3-11 shift and 11-7 shift. 3/9/2024 7-3 shift, 3-11 shift, 11-7 shift. 3/10/2024 11-7 shift 3/11/2024 3-11 shift and 11-7 shift. 3/12/2024 3-11 shift and 11-7 shift. 3/13/2024 3-11 shift 3/14/2024 7-3 shift and 11-7 shift. During an interview on 3/18/2024 at 1:50 p.m., with the ADM, the ADM stated there were lapse within that specific time period when Resident 1 entered Resident 2 ' s room. ADM stated there were some sorts of lack of supervision provided to Resident 1 in that period. ADM stated since Resident 1 sustained an injury, the facility did not prevent Resident 1 from physical abuse by Resident 2. ADM stated constant monitoring means to know where the resident at all the time to make sure she is safe. During a review of the facility's Policy and Procedure (P&P) titled, Reporting Abuse, dated 1/8/2014, the P&P indicated The facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. During a review of the facility's P&P titled, Abuse-Prevention, Screening, and Training Program, dated 7/2018, the P&P indicated The facility conducts resident pre-admission, admission and ongoing assessments and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict or neglect. During a review of the facility's undated P&P titled, Wandering and Elopement, the P&P indicated To enhance the safety of residents of the facility. During a review of the facility ' s P&P titled, Resident Rights-Quality of Life, dated 3/2017, the P&P indicated To ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident ' s comprehensive assessment and plan of care. During a review of the facility ' s P&P titled, Resident Safety, dated 4/15/2021, the P&P indicated To provide a safe and hazard free environment. The IDT will establish a person-centered observation or monitoring systems for the resident to address the identified risk factors.

Based on interview and record review, the facility failed to provide necessary care to a resident who was residing in the isolation area (an area that keeps residents with certain medical conditions separate from other people while they receive medical care) due to the corona virus ([COVID-19] deadly virus that easily spreads from person to person) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses monitored (checked) Resident 1 ' s vital signs (measurementsof the body's most basic functions such as blood pressure [pressure of the circulating blood against the walls of the blood vessels], temperature [measurement of the heat inside the body], pulse (the rate at which the heart beats), respiration (breathing rate) and oxygen saturation (the measure of how much oxygen is traveling through your body) every four (4) hours for COVID-19 symptoms. 2. Ensure licensed nurses implemented Resident 1 ' s care plan titled At risk for COVID-19, dated [DATE], to monitor (check) the resident ' s vital signs every 4 hours. These deficient practices resulted in Resident 1 becoming unresponsive and later expiring (dying) on [DATE] at 11:50 a.m., at the facility, seven (7) hours after the last vital signs were checked on [DATE] at 4:30 a.m. Findings: 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 that included dysphagia (difficulty swallowing), diabetes (abnormal blood sugar) and dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 1 ' s care plan titled At risk for COVID-19 dated [DATE], the care plan interventions indicated staff will monitor Resident 1 for signs and symptoms of COVID-19 including respiratory rate, lung sounds, vital signs and oxygen saturation, every four (4) hours. During a review of Resident 1 ' s history and physical (H/P) dated [DATE], the H/P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated [DATE], the MDS indicated, Resident 1 had the ability to understand and be understood by others usually. The MDS indicated Resident 1 required limited assistance (the resident was highly involved in activity, staff provided guided maneuvering of limbs or other non-weight bearing assistance) for bed mobility. The MDS indicated, Resident 1 required extensive assistance (the resident was involved in activity, staff provided weight bearing support) for transfer, dressing, toilet use, and locomotion (moving between locations). During a review of Resident 1 ' s physician order dated [DATE], the physician order indicated monitor the resident ' s temperature, pulse, respiration, blood pressure, and oxygen saturation every 4 hours for COVID-19 screening/monitor for 10 days. During an interview on [DATE], at 2:08 p.m., Certified Nurse Assistant (CNA) 2 stated on [DATE] Resident 1 expired in the morning. CNA 2 stated she (CNA 2) attempted to feed Resident 1 breakfast (morning), but the resident only ate three bites of food and refused to eat more. CNA 2 stated, the facility had so many staffing problems and she sometimes worked in the isolation area (designated area for COVID-19 positive residents) without a designated licensed nurse. CNA 2 stated licensed nurses were responsible for checking the residents ' vital signs. During an interview on [DATE] at 1:20 p. m., Licensed Vocational Nurse (LVN) 1 stated on [DATE](during the day shift, 7a.m to 3p.m. shift), the facility called her (LVN 1) to work because the assigned LVN called off (did not report to work). LVN 1 stated, she clocked in to work at 10:30 a.m., (on [DATE]), went to Resident 1 ' s room at approximately 10:50 a.m., and found the resident unresponsive. LVN 1 stated, she verified Resident 1 ' s code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) in his chart and started cardiopulmonary resuscitation ([CPR] aprocedure designed to restore normal breathing after a person ' s heart stops beating) while another staff called 911(a telephone number used to contact the emergency services). During an interview on [DATE] at 1:20 p.m., LVN 1 stated, she did not know which licensed nurse was assigned to Resident 1 before her shift that started at 10:30a.m. (on [DATE]). LVN 1 stated CNA 2 was assigned to Resident 1 but CNA 2 left the faciity on [DATE] at approximately10:30 a.m., before the end of her shift because she was sick. LVN 1 stated she did not receive report from anyone about Resident 1 prior to starting her shift. LVN 1 also stated licensed nurses were responsible for checking residents ' vital signs every 4 hours in the isolation area. During an interview on [DATE] at 2:10 p.m., with the Director of Staff Development (DSD), the DSD stated, Resident 1 was diagnosed with COVID-19 on [DATE]. The DSD stated vital signs for all COVID-19 positive residents in the isolation area (designated area for COVID-19 positive residents) were supposed to be checked by the licensed nurses every four hours. During a concurrent interview and record review of Resident 1 ' s Medication Administration Record (MAR) dated [DATE] on [DATE] at 2:30 p. m., with the Infection Preventionist (IP) the IP stated the MAR indicated, to monitor Resident 1 ' s vital signs such as temperature, pulse, respirations, and oxygen saturation every 4 hours. The IP stated Resident 1 ' s vital signs were not taken and not recorded on [DATE] at 8 a. m., when they (licensed nurses) were supposed to have been taken. The IP stated according to the MAR, Resident 1 ' s vital signs were last taken was on [DATE] at 4:30 a.m. and again at 11:30a.m., (7 hours later), when the resident was found unresponsive. During an interview on [DATE] at 9:15 a. m., the DSD stated on [DATE] the assigned LVN called off and LVN 4 was supposed to monitor residents in the isolation area, until LVN 1 arrived at the facility. During an interview on [DATE] at 9:50 a. m., LVN 4 stated, when Resident 1 expired in the facility on [DATE] (at 11:50 a.m.), he (LVN 4) was working in Station 1 and Resident 1 was in Station 2 (non-isolation area). LVN 4 stated, he did not take care of Resident 1 and did not check the resident ' s vital signs at any point on [DATE]. During an interview on [DATE] at 2pm, the IP stated it was important to monitor Resident 1 ' s vital signs every 4 hours. The IP stated if Resident 1 ' s vital signs were checked every 4 hours, nurses could have intervened promptly on [DATE] at 11:30a.m., when the resident was found unresponsive. During a review of the facility ' s policy and procedure (P&P) titled Obtaining Vital Signs, dated [DATE], the P &P indicated vital signs will be taken as ordered by the physician, and before giving medication or treatments when there were conditional parameters of administration. During a review of the facility ' s infection control P&P for mitigating COVID-19, with a revision date of [DATE], the P&P indicated resident ' s positive for COVID-19 with or without symptoms will be isolated (separating residents with a contagious disease from people who are not sick) and their vital signs taken and recorded in the resident ' s clinical record every 4 hours, the resident will be observed for worsening or improvement of symptoms of COVID-19.

Based on observation, interview and record review, the facility failed to follow its policy to ensure one of three sampled residents (Resident 1), who had a high risk for falls and was on a low air loss ((LAL) mattress utilized for its unique ability to minimize maceration (oversaturation of the skin due to a prolonged exposure to moisture) and heat build-up) mattress had used appropriate interventions to prevent falls and injuries while utilizing a LAL mattress as per the manufactures' guidelines. Resident 1 fell out of the bed onto the floor, while care was being provided, and sustained facial/head injuries. The facility's staff failed to follow the Nurse Practitioner ((NP) is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose illness and disease, prescribe medication and formulate treatment plans) orders to transfer Resident 1 to the emergency room via 911 (emergency services), which resulted in a delay in diagnosis, care and treatment. These deficient practices resulted in Resident 1 falling from an elevated bed, sustaining facial bruising (bleeding under the skin due to trauma) over the right eye through the bridge of the nose and under the left eye, subdural hematoma (pool of blood between the brain and its outermost covering), [MEDICATION NAME] hemorrhage (ruptured blood vessel causing bleeding inside the brain), facial fracture (bones of the face broken), basilar skull fracture (break of a bone in the base of the skull), and an odontoid cervical fractures (break of the second bone of the neck). Resident 1 required a transfer to general acute care hospital 1 (GACH 1) from [DATE] through [DATE] (22 days); undergoing neck surgery on [DATE] to repair the neck fracture with screws; on [DATE] Resident 1 required a [MEDICAL CONDITION] (incision in the windpipe made to relieve an obstruction to breathing) placement due to [MEDICAL CONDITION] (inability to breathe). Resident 1 was transferred to GACH 2 on [DATE] through [DATE] (29 days) and expired on [DATE] at 2:28 a.m. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was 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 [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated [DATE], indicated Resident 1 was severely impaired in cognitive skills (thought process) and required an extensive assist of a one-person physical assist in turning side to side, positioning self while in bed, toilet use and personal hygiene. A review of Resident 1's care plan titled, Fall Risk Prevention and Management, dated [DATE], indicated Resident 1 was at risk for falls and injury related to poor balance, lack of awareness, communication and combativeness (fighting). The goal was to provide a safe environment that minimized complications associated with falls. The staffs' interventions included to keep Resident 1's bed low, use of bilateral (both sides) floor mats and to provide an environment that supports minimized hazards over which the facility had control. A review of Resident 1's Physician 1's order, dated [DATE] and timed at 5:40 p.m., indicated to provide Resident 1 with a LAL mattress for skin integrity management, bed at the lowest position with bilateral floor mats and safety precautions. A review of Resident 1's Fall Risk Data Collection, dated [DATE], indicated Resident 1 had a score of 14 (a score of 10 or greater indicated a high risk for falls). A review of Resident 1's nursing progress notes, dated [DATE] and timed at 10:30 a.m., indicated that Certified Nurse Assistant 1 (CNA 1) was noted calling for help from Resident 1's room. The note indicated that Resident 1 was observed on the floor mat facing down and was able to state in her native language that she was in pain. A review of the facility's Therapy Post-Fall Screen, dated [DATE], indicated that on [DATE] at 10:30 a.m., Resident 1 slid from the mattress during care. The report indicated that a bump on Resident 1's right eyebrow was noted after the resident hit her head on the side of the bed. The report indicated the contributing factor to Resident 1's fall was poor caregiver bed mobility during care and slippery mattress. A review of an untimed physician's telephone order, dated [DATE], indicated to transfer Resident 1 to GACH 1 for fall evaluation and a CT-scan (computed tomography scan makes use of computer-processed combinations of many X-ray measurements taken from different angles to diagnose injuries to body structures) with a 7-day bed hold. A review of the facility's document, dated [DATE] and titled, Resident Transfer Record, indicated Resident 1 was transferred to GACH 1 for fall evaluation and CT-scan. A review of Emergency Department 1's (ED 1) triage note, dated [DATE] and timed at 2:12 p.m., indicated Resident 1 was admitted to the hospital for a fall that occurred in a nursing home when the resident fell out of bed while being changed and hitting her face on a chair. A review of the GACH 1's physical exam, dated [DATE], indicated Resident 1 had large amount of facial bruising mainly on the right eye extending to the nose and the underside of the left eye. The exam indicated Resident 1's [DIAGNOSES REDACTED]. A review of GACH 2's History and Physical (H/P) indicated Resident 1 was admitted to GACH 2 on [DATE] from GACH 1 following a trauma to the head and neck after a fall at the nursing home. The H/P indicated that Resident 1 underwent neck repair to stabilize the fracture on [DATE]. The report indicated Resident 1 developed [MEDICAL CONDITION] (a condition in which not enough oxygen passes from the lungs into the blood, or when your lungs cannot properly remove carbon [MEDICATION NAME] from the blood) requiring a respiratory tube placement and was placed on a ventilator (a machine that assist and stimulates breathing). On [DATE] at 1:49 p.m., during a concurrent interview and record review of Resident 1's clinical record, Licensed Vocational Nurse 1 (LVN 1) stated on [DATE], she was called by CNA 1 to Resident 1's room and found Resident 1 facing down on the floor mat with the bed in a high position. LVN 1 stated upon turning Resident 1 over, she observed blood on Resident 1's teeth and a bump on her forehead. LVN 1 stated that CNA 1 notified her (LVN 1) that the resident had rolled off the bed to the floor during activities of daily living ((ADL) daily self-care activities such as bathing, dressing, and grooming) care. LVN 1 stated that Resident 1 was lying on a LAL mattress with the bed in a high position. On [DATE] at 2:10 p.m., during a concurrent interview and record review of Resident 1's clinical record, Registered Nurse 1 (RN 1) stated that on [DATE], at approximately 10:30 a.m., during care, CNA 1 was calling for help and upon entering the room, she saw Resident 1 facing down on the floor on top of the floor mat. RN 1 stated during the initial assessment, Resident 1 had a bump to the right side of her forehead and was bleeding from the mouth. RN 1 stated Resident 1 required total care and had weakness on her left side. On [DATE] at 2:35 p.m., during a concurrent interview and record review of Resident 1's physical therapy (PT) assessment, the Director of Rehabilitation (DOR) stated that Resident 1 was paralyzed on the right side of the upper and lower extremities and was weak on the left upper and lower extremities, but was able to initiate task, but not complete task. The DOR stated Resident 1 was totally dependent on staff for care. On [DATE] at 3:05 p.m., during an interview, CNA 2 stated Resident 1 required a two-person physical assist due to her inability to move on one side and weakness on the other side. CNA 2 stated it was difficult to clean and provide care to Resident 1 by herself. On [DATE] at 3:40 p.m., during an interview, CNA 3, who cared for Resident 1 in the past but not on the date of the fall incident, stated Resident 1 was a two-person physical assist due to her paralysis. On [DATE] at 4:59 p.m., during an observation, Resident 1 was observed in the GACH's Intensive Care Unit (ICU) with a cervical collar (medical device used to support neck injuries) on, breathing with the assistance of a ventilator, a urinary catheter (tube inserted into the bladder to drain urine freely), and receiving intravenous (into the vein) medications. Resident 1's right facial area and bilateral arms were discolored, dark purple and red. On [DATE] at 7:25 a.m., CNA 1 stated on [DATE] at approximately 10:30 a.m., she went to change Resident 1's adult brief and draw sheets (a sheet that is placed in such a way that it can be taken from under a patient without disturbing the bedclothes). Resident 1 was on a LAL mattress with the bed in a high position to assist her (CNA 1) in changing the resident. CNA 1 stated there were no side rails and the mattress was in floatation (distributes body weight evenly to minimize prolonged pressure in one area) mode. CNA 1 stated that Resident 1 rolled off the bed while she was changing her adult brief and landed on the floor face down. On [DATE] at 8:49 a.m., during a subsequent interview, CNA 1 stated that on [DATE] approximately at 10:30 a.m., during care, Resident 1 was turned on the left side in the middle of the bed facing the door. CNA 1 stated that she was changing Resident 1's adult brief when the resident rolled over and slid off the bed because the LAL mattress was slippery. CNA 1 stated that the bed was elevated and there was no sheet on the LAL mattress and no side rails for Resident 1 to hold on for safety. CNA 1 stated Resident 1 rolled off the bed and landed on the floor face down hitting her head. CNA 1 stated there was blood on Resident 1's mouth and the resident complained of pain. According to CNA 1, She was never instructed to have another staff when turning Resident 1, if so, she would have asked for help when caring for a resident on a LAL mattress, who had no side rails to prevent falls and injuries. CNA 1 stated after Resident 1 fell , Resident 1 had an episode of vomiting and she notified RN 1. On [DATE] at 10:10 a.m., during a concurrent interview and record review, RN 1 stated she did not document Resident 1's teeth were bleeding after the fall, or that the right side of the forehead bump was increasing in size, and that the resident was throwing up. RN 1 stated that the NP texted her cell phone and ordered to transfer the resident to the emergency room (ER) for further evaluation. RN 1 stated that she did not consider Resident 1's injury severe enough to be transferred via 911 (emergency transport) and sent the resident via regular ambulance. RN 1 stated Resident 1's fall happened at 10:30 a.m., on [DATE] and Resident 1 was not transferred to GACH 1 until 1:30 p.m., three hours later by non-emergent ambulance service. On [DATE] at 9:50 a.m., during a telephone interview, the NP stated that RN 1 informed her that Resident 1 was stable and doing well. The NP stated she informed the facility's staff to send Resident 1 to the hospital via 911 to the emergency room for evaluation and for a CT scan to be done. The NP indicated that the facility staff should have followed her orders and sent Resident 1 via 911 as she ordered. The NP stated that she was not informed of Resident 1's bump to the head. On [DATE] at 12:35 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated Resident 1 had a LAL mattress slid off the bed in the presence of CNA 1. The DON stated a LAL mattress was slippery and caused the resident to slide off the bed when CNA 1 failed to use an appropriate technique, such as taking the mattress off floatation mode and utilizing a two-person assist when she was providing care. The DON stated CNA 1 should have placed the resident in the middle of the bed, pulled Resident 1 towards her, and then turn the resident to the side utilizing a two-person assist. A review of the GACH 2's Progress Note, dated [DATE], indicated Resident 1 was pronounced deceased without respirations (breathing) and circulation at 2:28 a.m. on [DATE]. A review of the LAL mattress's manual provided by the facility and titled, Operations Manual,'' with revision date of [DATE], indicated to press the autofirm button during patients' care to quickly inflate the air mattress to the maximum pressure which facilitates nursing care. The autofirm system will automatically return to the previous mode 30 minutes after the autofirm mode was in operation. According to the operation manual, the LAL mattresses have soft edges that may collapse when patients roll to that edge. A review of the facility's policy, revised [DATE] and titled, Emergency Care-General, indicated the purpose of the policy was to ensure emergency treatment was provided to residents, staff, or visitors who sustain injury while in the facility. The policy indicated that if an individual has fallen, assess the limbs for good body alignment, cover individual and summon help and request that someone call 911 if indicated. A review of the facility's policy titled, Falls Management Program, revised date of [DATE], indicated the purpose of the policy was to provide residents with a hazard free environment. It also indicated licensed nurses would assess residents and review care plans for appropriateness. A review of the facility's policy titled, Bed Safety, dated ,[DATE] indicated that the DON will inspect bed frames, side rails, and all types of mattresses upon admission when a resident requires side rails, and/or all types of mattresses. The DON will take immediate action to correct any safety risk identified involving the bed, mattresses or side rails.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents, who was a high risk for falls (Resident 1) received adequate supervision and assistance while using the toilet, by failing to wait for the resident to finish using the bathroom and provide assistance when the resident was calling for help. This deficient practice resulted in Resident 1 having an unwitnessed fall and sustaining a right arm fracture (broken bone) that required admission to a general acute care hospital (GACH) for two (2) days. It also resulted in Resident 1 being unable to use her right hand for activities of eating. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's care plan, dated 1/4/18, indicated Resident 1 was at risk for falls due to limited mobility, poor balance, and lack of awareness, decreased endurance, unsteady gait, and paralysis (inability to move one side of the body). The staff's interventions indicated to remind the resident to use the call light, provide assistance with activity of daily living (ADL) as needed, and encourage the use of the assistive devices A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 7/9/18, indicated the resident had severe impairment in cognitive (thought process) skills. The resident had a Brief Intervention of Mental Status (BIMS) score of 3 (0-7=severe impairment). According to the MDS, Resident 1 required two or more 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. Resident 1 used a walker or wheelchair to ease movement. The MDS also indicated Resident 1 was always incontinent (inability to control) of bowel function and received scheduled pain medications. A review of Resident 1's fall risk assessment, dated 7/18/18, indicated the resident scored 13 (10 or greater = high risk for falls). A review of another care plan, dated 7/19/18, indicated Resident 1 was at risk for falls due to limited mobility, lack of awareness, decreased endurance, unsteady gait, paralysis and forgets to call or wait for assistance. The staff's interventions indicated reminding the resident to use the call light and encouraging the use assistive devices. A review of Resident 1's history and physical (H/P), dated 7/20/18, indicated the resident had a fluctuating capacity to understand and make decisions. A review of a Nurses Note, dated 7/20/18, indicated Resident 1 was incontinent of bladder, and was assisted to the bathroom for urination. A review of a nurses note, dated 7/21 through 7/22/18, indicated Resident 1 was receiving bladder and bowel training program and the resident was assisted to the bathroom as needed. A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR), dated 8/6/18, and timed 5 p.m., indicated the resident's left hand (3rd and 4th fingers) was caught in between the wheelchair while propelling her wheelchair. It also indicated Resident 1's hand was discolored, and the resident complained of left hand pain, with pain level of 5/10 (10 being the worst pain possible and 0 with no pain). A review of Resident 1's Physician Order, dated 8/6/18, indicated an order to obtain a left hand x-ray (process of taking pictures to diagnose a broken bone) on 8/7/18. A review of the x-ray report, dated 8/7/18, showed [MEDICAL CONDITION] shaft of the 5th metacarpal (broken 5th finger) and a mild displacement of the distal fragment. A review of a Pain Assessment Flow Sheet, dated 8/6/18, indicated Resident 1 had pain level of 5 out of 10 (a score of 5 -7 = moderate pain) to the left hand. It also indicated the resident received [MEDICATION NAME] 50 milligrams (mg) by mouth, repositioning, relaxation techniques and distraction for pain management. A review of Resident 1's Physician Orders, dated 8/8/18, indicated the following: apply a left hand immobilizer to the resident's left fractured hand, no weight bearing (NWB) on the left hand and to wear sling when out of bed to enforce the NWB status. A review of a SBAR, dated 8/8/18, and timed at 3:50 p.m., two days after sustaining a left fractured hand, indicated Resident 1 was found on the floor, lying on her back. The SBAR indicated Resident 1 complained of a pain level of 10 out of 10 (a pain scale of 0 -10, 0 =no pain, 10 = severe pain) to the shoulder and back. According to the SBAR, the resident refused to be lifted from the floor. A review of a Post Fall Assessment, report dated 8/8/18, indicated Resident 1 had right shoulder and back pain 10/10 and that no first aid was provided. According to this record, four (4) paramedics had to move Resident 1 from the floor. A review of an undated Physician's Discharge Summary, indicated Resident 1 was transferred to a GACH following an unwitnessed fall and complain of right shoulder and back pain level of 10/10. It also indicated the resident's needs could not be met in the facility. A review of the GACH's x-ray report, dated 8/8/18, of the right wrist showed non-displaced distal radial of ulnar fractures (broken right arm). A review of the facility's interview record, dated 8/9/18, indicated Resident 1 was assisted to the bathroom by Certified Nursing Assistant 1 (CNA 1) and minutes later the resident was screaming for help. It indicated CNA 1 found the resident on the floor. According to the interview record, Resident 1 stated that she was scared of hitting her head and used both of her arms to block her head during the fall. Resident 1 refused to be touched due to severe pain to the right shoulder. A review of the facility's follow-up report, dated 8/9/18, indicated on 8/8/18, at 3:30 p.m., Resident 1 had an unwitnessed fall that resulted in a right arm fracture. A review of Resident 1's GACH record titled, Physical Examination, dated 8/9/18, indicated the resident fell , complained of right upper extremity pain, and the x-ray results indicated the resident sustained [REDACTED]. A review of Resident 1's GACH record titled, Discharge Summaries, dated 8/10/18, indicated the resident was admitted on [DATE] and discharged on [DATE]. The record indicated Resident 1 fell and had a right arm fracture. According to this report, Resident 1 would have a right arm placed in a cast for two (2) weeks. On 8/15/18 at 9 a.m., during a concurrent observation and interview, Resident 1 was observed in a wheelchair with a right arm sling. Resident 1 stated that on 8/8/18, at approximately 4 p.m., CNA 1 assisted her to the toilet and left her there. The resident stated her back and legs were hurting from seating on the toilet too long, so she screamed for help, but no one came. Resident 1 stated she was trying to get up, but fell through the door and hurt her back, arm and wrist. The resident stated CNA 1 left her on the toilet and did not return to check on her. According to Resident 1, if CNA 1 waited for her when she was using the bathroom or came to help as soon as she screamed, she would not have broken her right arm. On 8/15/18 at 10 a.m., during an interview, the Director of Nursing (DON) stated on 8/8/18, Resident 1 was screaming for help from the bathroom after falling. The DON stated that CNA 1 left the resident in the bathroom and instructed her to call for help, but the resident forgot to call. According to the DON, Resident 1 had a splint to the left hand following a previous accident, which had limited the resident's mobility. On 8/15/18 at 11:26 a.m., during an interview, Physical Therapist 1 (PT 1) stated that on 8/8/18, at approximately 5 p.m. Resident 1 was found on the floor, lying on her right arm, with her body in the next room while her feet were in the bathroom. PT 1 stated that Resident 1 had a left hand cast and sling. According to PT 1, Resident 1 required staff's assistance for transfers because she had a left hand fracture, and could not use the left arm and required assistance. PT 1 stated that the staff was aware the resident required assistance with activities including transfers (on and off the toilet). On 8/15/18 at 11:40 a.m., during an interview, the resident council president (Resident 2) stated that in the council meetings, answering call lights was always a topic for discussion, because the staff took too long to respond to call lights. On 8/15/18 at 12 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that CNA 1 was not standing by the bathroom door after Resident 1 was left unassisted in the bathroom. According to LVN 1, Resident 1 already had a fracture and splint on the left hand and relied on the staff for assistance, CNA 1 should have stayed by the door and assisted Resident 1. On 9/19/18 at 1:40 p.m., during a telephone interview, CNA 1 stated she assisted Resident 1 to the bathroom, left the resident on the toilet, and went to the Nurses' Station, which was located around the corner from the resident's room. CNA 1 stated that the resident was supposed to call her for assistance, but did not. According to CNA 1, Resident 1 would not have fallen, if the she had waited for the resident to finish using the bathroom. CNA 1 stated she should not have left the resident unattended, especially since she required staff's assistance. A review of the facility's policy and procedure titled, Fall Management Program, with a revised date of 11/7/16, indicated the purpose was to provide a safe environment that minimize complications from falls. It also indicated the facility would implement fall management program that supports providing an environment hazards free.

Based on observation, interview, and record review, the facility failed to ensure residents who were at high risk for falls had fall prevention measures in place and receive care in accordance with residents' plan of care for four of five sampled residents (Residents 1, 3, 4, and 5). A. Certified Nursing Assistant (CNA 1) left Resident 1 unattended in the bathroom B. Resident 3 only had one floor mat, call light and bedside table were not within reach. C. Resident 4's floor mats were away from the bed, table and water pitcher were not within reach. D. Resident 5 only had one floor mat, her table, water pitcher and call light were not within reach. These deficient practices resulted in Resident 1 having an unwitnessed fall that resulted in a right arm fracture (broken bone) and the potential to result in falls and injuries Residents 3, 4 and 5. Findings: a. A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's care plan, dated 1/4/18, indicated Resident 1 was at risk for falls due to limited mobility, poor balance, and lack of awareness, decreased endurance, unsteady gait (way of walking), and paralysis (inability to move one side of the body). The staff's interventions indicated to remind the resident to use the call light, provide assistance with activities of daily living ((ADLs) routine activities people do every day without assistance, such as dressing, eating, toileting, grooming) as needed, and encourage the use of the assistive devices (any device that is designed, made, or adapted to assist a person perform a particular task; such as canes, crutches, walkers, and wheel chairs). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 7/9/18, indicated the resident had severe impairment in cognitive (thought process) skills. The resident had a Brief Intervention of Mental Status (BIMS) score of 3 (0-7=severe impairment). According to the MDS, Resident 1 required two or more 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. Resident 1 used a walker or wheelchair to ease movement. The MDS also indicated Resident 1 was always incontinent (inability to control) of bowel function and received scheduled pain medications. A review of Resident 1's fall risk assessment, dated 7/18/18, indicated the resident scored 13 (10 or greater = high risk for falls). A review of another care plan, dated 7/19/18, indicated Resident 1 was at risk for falls due to limited mobility, lack of awareness, decreased endurance, unsteady gait, paralysis and forgets to call or wait for assistance. The staff's interventions indicated reminding the resident to use the call light and encouraging the use assistive devices. A review of Resident 1's history and physical (H/P), dated 7/20/18, indicated the resident had a fluctuating capacity to understand and make decisions. A review of a Nurses Note, dated 7/20/18, indicated Resident 1 was incontinent of bladder, and was assisted to the bathroom for urination. A review of a nurses note, dated 7/21 through 7/22/18, indicated Resident 1 was receiving bladder and bowel training program and the resident was assisted to the bathroom as needed. A review of Resident 1's Situation, Background, Assessment and Recommendation ((SBAR) communication tool used between licensed staff), dated 8/6/18, and timed 5 p.m., indicated the resident's left hand (3rd and 4th fingers) was caught in between the wheelchair while propelling her wheelchair. It also indicated Resident 1's hand was discolored, and the resident complained of left hand pain, with pain level of 5/10 (10 being the worst pain possible and 0 with no pain). A review of Resident 1's Physician Order, dated 8/6/18, indicated an order to obtain a left hand x-ray (process of taking pictures to diagnose a broken bone) on 8/7/18. A review of the x-ray report, dated 8/7/18, showed [MEDICAL CONDITION] shaft of the 5th metacarpal (broken 5th finger) and a mild displacement of the distal fragment. A review of a Pain Assessment Flow Sheet, dated 8/6/18, indicated Resident 1 had pain of 5/10 (moderate pain = 5-7) to the left hand. It also indicated the resident received [MEDICATION NAME] (opioid pain medication used to treat moderate to moderately severe pain) 50 mg by mouth, repositioning, relaxation techniques and distraction for pain management. A review of Resident 1's Physician Orders, dated 8/8/18, indicated the following: apply a left hand immobilizer (used to prevent, restrict, or reduce normal movement in the body, a limb, or a joint) to the resident's left fractured hand, no weight bearing (NWB) on the left hand and to wear sling when out of bed to enforce the NWB status. A review of a SBAR, dated 8/8/18, and timed at 3:50 p.m., two days after sustaining a left fractured hand, indicated Resident 1 was found on the floor, lying on her back. The SBAR indicated Resident 1 complained of a pain level of 10/10 to the shoulder and back. According to the SBAR, the resident refused to be lifted from the floor. A review of a Post Fall Assessment, report dated 8/8/18, indicated Resident 1 had right shoulder and back pain 10/10 and that no first aid (assistance given to any person suffering a sudden illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery) was provided. According to this record, four (4) paramedics had to move Resident 1 from the floor. A review of Resident 1's undated Physician's Discharge Summary, indicated Resident 1 was transferred from the facility to the GACH following an unwitnessed fall and complaints of right shoulder and back pain level of 10 out of 10. It also indicated the resident's needs could not be met in the facility. A review of the GACH's x-ray report, dated 8/8/18, of the right wrist showed non-displaced distal radial of ulnar fractures (broken right arm). A review of the facility's interview record, dated 8/9/18, indicated Resident 1 was assisted to the bathroom by Certified Nursing Assistant 1 (CNA 1) and minutes later the resident was screaming for help. It indicated CNA 1 found the resident on the floor. According to the interview record, Resident 1 stated that she was scared of hitting her head and used both of her arms to block her head during the fall. Resident 1 refused to be touched due to severe pain to the right shoulder. A review of the facility's follow-up report, dated 8/9/18, indicated on 8/8/18, at 3:30 p.m., Resident 1 had an unwitnessed fall that resulted in a right arm fracture. A review of Resident 1's GACH record titled, Physical Examination, dated 8/9/18, indicated the resident fell , complained of right upper extremity pain, and the x-ray results indicated the resident sustained [REDACTED]. A review of Resident 1's GACH record titled, Discharge Summaries, dated 8/10/18, indicated the resident was admitted on [DATE] and discharged on [DATE]. The record indicated Resident 1 fell and had a right arm fracture. According to this report, Resident 1 would have a right arm placed in a cast for two (2) weeks. On 8/15/18 at 9 a.m., during a concurrent observation and interview, Resident 1 was observed in a wheelchair with a right arm sling. Resident 1 stated that on 8/8/18, at approximately 4 p.m., CNA 1 assisted her to the toilet and left her there. The resident stated her back and legs were hurting from seating on the toilet too long, so she screamed for help, but no one came. Resident 1 stated she was trying to get up, but fell through the door and hurt her back, arm and wrist. The resident stated CNA 1 left her on the toilet and did not return to check on her. According to Resident 1, if CNA 1 waited for her when she was using the bathroom or came to help as soon as she screamed, she would not have broken her right arm. On 8/15/18 at 10 a.m., during an interview, the Director of Nursing (DON) stated on 8/8/18, Resident 1 was screaming for help from the bathroom after falling. The DON stated that CNA 1 left the resident in the bathroom and instructed her to call for help, but the resident forgot to call. According to the DON, Resident 1 had a splint to the left hand following a previous accident, which had limited the resident's mobility. On 8/15/18 at 11:26 a.m., during an interview, Physical Therapist 1 (PT 1) stated that on 8/8/18, at approximately 5 p.m. Resident 1 was found on the floor, lying on her right arm, with her body in the next room while her feet were in the bathroom. PT 1 stated that Resident 1 had a left hand cast and sling. According to PT 1, Resident 1 required staff's assistance for transfers because she had a left hand fracture, and could not use the left arm and required standby assistance. PT 1 stated that the staff was aware the resident required assistance with activities including transfers (on and off the toilet). On 8/15/18 at 11:40 a.m., during an interview, the resident council president (Resident 2) stated that in the council meetings, answering call lights was always a topic for discussion, because the staff took too long to respond to call lights. On 8/15/18 at 12 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that CNA 1 was not standing by the bathroom door after Resident 1 was left unassisted in the bathroom. According to LVN 1, Resident 1 already had a fracture and splint on the left hand and relied on the staff for assistance, CNA 1 should have stayed by the door and assisted Resident 1. On 9/19/18 at 1:40 p.m., during a telephone interview, CNA 1 stated she assisted Resident 1 to the bathroom, left the resident on the toilet, and went to the Nurses' Station, which was located around the corner from the resident's room. CNA 1 stated that the resident was supposed to call her for assistance, but did not. According to CNA 1, Resident 1 would not have fallen, if the she had waited for the resident to finish using the bathroom. CNA 1 stated she should not have left the resident unattended, especially since she required staff's assistance. b. A review of Resident 3's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], with an original admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 3's H/P, dated 12/25/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 3's physician's orders [REDACTED]. A review of Resident 3's care plan, with a revised date of 6/19/18, indicated the resident was at risk for falls due to limited mobility, lack of awareness, unsteady gait, visual and communication problems, and a history of falls. The staff's interventions indicated: to provide a hazard free environment, low bed and the use of floor mats. A review of Resident 3's fall risk assessment, dated 7/27/18, indicated the resident had a fall risk score of 13 (high risk = 10 or greater). A review of Resident 3's MDS, dated [DATE], indicated the resident had severe impairment in cognitive skills. The MDS indicated Resident 3 required staff 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 used a walker or wheelchair to ease movement. A review of a special need lists, dated 8/2/18, indicated Resident 3 had floor mats. On 8/15/18 at 8:35 a.m., during a concurrent observation and interview, Resident 3 was in bed; his remote control and bedside table were not within reach. The resident's call light was on the floor. CNA 3 stated the resident's belongings should be within reach for easy access and fall prevention. CNA 3 also stated Resident 3 only had one floor mat and should have had 2. c. A review of Resident 4's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], with an original admission date of [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's fall risk assessment, dated 4/30/18, indicated the resident had a score of 15. A review of Resident 4's H/P, dated 7/4/18, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 4's physician's orders [REDACTED]. A review of Resident 4's care plan, with a revised date of 5/18, indicated the resident was at risk for falls due to limited mobility, poor balance and unsteady gait. The staff's interventions included the use of bilateral floor mats and to provide a safe environment. A review of another care plan, dated 8/2/18, indicated Resident 4 was at risk for falls due to limited mobility, poor balance, unsteady gait and a history of falls. The staff's interventions included to provide an environment that minimizes hazards over which the facility had control of, place call light within reach, and placing the resident's bed in the lowest position. A review of Resident 4's MDS, dated [DATE], indicated the resident had severe impairment in cognitive skills. The MDS also indicated Resident 4 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 4 used a wheelchair to ease movement. A review of a special need lists, dated 8/2/18, indicated Resident 4 was supposed to have a floor mat. On 8/15/18 at 8:35 a.m., during a concurrent observation and interview, Resident 4's floor mats were away from the bed. LVN 1 stated that the floor mats were supposed to be closer to the resident's bed to prevent injury if the resident fell . LVN 1 also stated that the water pitcher on the bedside table should always be within Resident 4's reach to prevent fall and injury. d. A review of Resident 5's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], with an original admission date of [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's H/P, dated 1/5/18, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 5's physician's orders [REDACTED]. It however did not indicated the use of a floor mat. A review of Resident 5's care plan, dated of 1/3/18, indicated the resident was at risk for falls due to limited mobility, poor balance, lack of awareness, unsteady gait, communication problems, and a history of falls. The staff's interventions indicated: to provide a hazard free environment, low bed and the use of floor mats. A review of Resident 5's fall risk assessment, dated 1/3/18, indicated the resident had a score of 12. A review of Resident 5's MDS, dated [DATE], indicated the resident had severe impairment in cognitive skills. The MDS also indicated Resident 5 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 5 used a wheelchair to ease movement. A review of a special need list, dated 8/2/18, indicated Resident 5 was supposed to have a floor mat. On 8/15/18 at 8:50 a.m., during a concurrent observation and interview, Resident 5 was in bed, the bed was elevated, the bed side table, away from the resident and there was only one floor mat next to her bed. LVN 2 stated that the bed should always be in the lowest position and the resident's bed side table in reach to prevent falls. LVN 2 also stated that it was the nurses' responsible to notify the physician and get orders for a floor mat and other fall preventive devices for residents who were at risk for falls. According to LVN 2, floor mats were stored in the maintenance department and the nurses had to requests for them. On 8/15/18 at 9:19 a.m., during a concurrent observation of the maintenance storage room, and interview, no mats were observed in the storage area. The Maintenance Supervisor (MS) stated that there were no mats in storage and that he would order more floor mats for the residents. On 8/15/18 at 10 a.m., during an interview, the Environment Supervisor (ES) stated that no staff had notified him that floor mats were out. According to ES, he should have ordered more mats before they ran out. A review of the facility's policy and procedure titled, Fall Management Program, with a revised date of 11/7/16, indicated the purpose was to provide a safe environment that minimize complications from falls. It also indicated the facility would implement fall management program that supports providing an environment hazards free. A review of the facility undated policy and procedure titled, Comprehensive Person-Centered Care Planning indicated the care plan will be implemented using the necessary combination of problem specific care plans.

Based on interview and record review, the facility failed to implement a resident's plan of care to ensure one of three sampled residents (Resident 2) received adequate supervision and monitoring to prevent abuse to other residents (Residents 1 and 3). This deficient practice resulted in Resident 2 physically and verbally abusing Residents 1 and 3 and had the potential to affect other residents in the facility. Findings: a. A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P) record, dated 3/24/18, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Situation Background Assessment Recommendation ((SBAR) nurses' internal communication tool), dated 3/27/18, indicated Resident 1 informed the facility's social services director (SSD) that Resident 2 slapped him approximately four (4) to six (6) days prior. The SBAR indicated Resident 1 requested for a room change because he did not want to be in the same room as his abuser (Resident 2). A review of the Interview Record, dated 3/27/18, Resident 1 was moved to another room, after Resident 1 was in bed watching television (TV) and Resident 2 was talking too much. Resident 1 asked Resident 2 to shut up and Resident 2 slapped Resident 1 on the face. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 3/28/18, indicated the resident was able to understand and be understood by others. According to the MDS, Resident 1 required one or two staff's assistance with bed mobility, moving around the unit, dressing, toilet use and personal hygiene. On 4/5/18 at 1:05 p.m., during an interview, Resident 1 stated he was in bed watching TV and Resident 2 kept talking. Resident 1 stated when he told Resident 2 to shut up; Resident 2 walked towards him and slapped him on the left side of the face. Resident 1 also stated Resident 2 had a tendency of unplugging the TV. According to Resident 1, he was happy to have moved to another room, away from his abuser. b. A review of Resident 2's Admission Face sheet indicated the resident was admitted to the facility, on 11/6/17. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's H/P record, dated 11/14/17, indicated the resident had a fluctuating capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident was able to understand and be understood by others. According to the MDS, Resident 2 required staff's supervision with bed mobility, moving around the unit, dressing, toilet use and personal hygiene. A review of a care plan, dated 2/13/18, indicated Resident 2 had an episode of physical aggression without an apparent reason. The goal indicated Resident 2 would not have any episodes of physical aggression daily for three (3) months. The staff's interventions indicated the staff would assess the resident as needed; provide a calm and meaningful environment to the resident; medications as ordered and a psych evaluation (a psychiatrist to evaluate, specially trained physician in mental disorders) as indicated. A review of Resident 2's Mental Status Examination, dated 3/12/18, indicated the resident was agitated, combative and striking out at the staff. A review of the SBAR, dated 3/27/18, indicated Resident 2 was increasingly authoritative, manipulative and a danger to others. It also indicated Resident 2 always followed his own rules stating, This is my house and I make my own rules. According to the SBAR, the resident was aggressive, abusive and alleged to have slapped his roommate (Resident 1). A review of Resident 2's care plan, dated 3/27/18, addressed the resident's behavior problems related to increased episodes of authoritarianism and danger to others. The staff's interventions included to monitor the resident's behavior and determine its cause, intervene as needed to protect the rights and safety of others, and to remove the resident from the situation and take to another location. The care plan did not address other specific interventions such as, close supervision or extra precautions to prevent Resident 2 from hitting other residents. A review of the nurses notes, from 3/28/18 through 3/30/18, indicated Resident 2 was authoritative, manipulative and a danger to others. It also indicated the resident was telling his roommates (Residents 1 and 3) to get out of his room, entering other resident's rooms and unplugging the TV. The nurse's notes also indicated Resident 2 asked other residents to leave their rooms because it was his house. A review of another care plan, dated 3/31/18, indicated Resident 2 was being physically aggressive without a reason. The staff's interventions indicated the resident would have a psych (psychiatrist; physician trained in mental health) evaluation. A review of Resident 2's nurse's note, dated 3/31/18, indicated the resident was accused of hitting Resident 3 with a water pitcher. A review of the facility's Incident and Accident Report Form, dated 3/31/18, indicated Resident 3 reported that he was hit on the right arm by his roommate (Resident 2) with a water pitcher. This report indicated on 3/31/18, at 8:30 p.m., LVN 1 heard a scream from Resident 3's room while Resident 3 was calling for help. The report indicated LVN 1 observed Resident 2 about to strike Resident 3 on the face with a water pitcher. The note indicated Resident 3 raised his right hand to block his face and the pitcher landed on his hand. According to this report, Resident 2 stated, It's my house, get out of my house. On 4/4/18, at 12:35 p.m., during an interview, the facility's Director of Nursing (DON) stated that Resident 2 unplugged the TV and when Resident 1 asked why he did, Resident 2 hit Resident 1 with a water pitcher. The DON stated that Resident 2 was okay in the mornings and would become agitated in the evenings. According to the DON, Resident 2 was okay as long as no resident came close to his space. At 3 p.m., on 4/4/18, during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 2 was aggressive and did not want anyone going into his room. On 4/5/18, at 1:31 p.m., during an interview a Licensed Vocational Nurse 1 (LVN 1) stated Resident 2 would always unplugged the TV and was agitated at nighttime. According to LVN 1, the resident was re-directed. On 4/5/18, at 1:45 p.m., during an interview, CNA 1 stated Resident 2 was possessive, aggressive and agitated when someone got in what he claimed, was his space. CNA 1 stated Resident 2 did not like the TV loud and would ask that the staff should get his roommates out of his room. According to CNA 1, Resident 3 liked the TV loud, which caused Resident 2 to become physically aggressive. According to CNA 1, the staff was aware of Resident 2's aggressive and authoritative tendencies and would try to re-direct the resident each time. On 4/5/18, at 2 p.m., during an interview, the facility's administrator (ADM) stated if he had known of Resident 2's authoritative and aggressive behavior, he would have ensured the resident was monitored closely. On 4/5/18, at 3 p.m., during an interview CNA 2, stated Resident 2 was possessive, aggressive and did not want anyone in his room. According to CNA 2, Resident 2 always tried hitting and stopping the staff from entering his room. CNA 2 also stated the nurses were aware of Resident 2's behavior. On 4/5/18, at 4:05 p.m., during an interview, CNA 3 stated Resident 2 was upset when the lights were turned on to assist roommates and would turn the lights and TV off. CNA 3 stated the staff would plug the TV on each time Resident 2 unplugged it. According to CNA 3, Resident 3 would yell at the staff too. A review of Resident 1's clinical records, Resident 1 was transferred to another room after the incident. However, Resident 2 remained in the same room with his other roommate (Resident 3), where he continued to exhibit aggressive behavior. A review of Resident 2's clinical record indicated there was no documentation to indicate that the facility had immediately implemented effective interventions to ensure further abuse did not occur after Resident 2 allegedly slapped Resident 1, which led to Resident 3 being physically abused by Resident 2. c. A review of Resident 3's Admission Face sheet indicated the resident was admitted to the facility on [DATE], with an original admission date of [DATE]. Resident 3 had [DIAGNOSES REDACTED]. A review of Resident 3's H/P record, dated 2/1818, indicated the resident had a fluctuating capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE], indicated the resident was able to understand and be understood by others. According to the MDS, Resident 3 required two staff's assistance with bed mobility, moving around the unit, dressing, eating, toilet use and personal hygiene. The MDS also indicated Resident 3 used a walker for mobility. On 4/4/18, at 1:10 p.m., during an interview, Resident 3 stated that Resident 2 was okay during the day but very violent at night. Resident 3 stated Resident 2 had been aggressive for six months and that the night nurses knew about it. Resident 3 also stated the night nurses used to tell Resident 2 to knock it off. Resident 3 stated that he required assistance to get up out of bed and Resident 2 would always get in his face telling him to get out of the room. Resident 3 stated he was watching TV and Resident 2 asked him to turn it off. According to Resident 3, Resident 2 unplugged the TV, and when Resident 1 told him not to do so, he hit him with a water pitcher. Resident 3 stated he became scared because he could not defend himself. Resident 3 stated he asked the nurse to call the police for his safety. He also stated his right hand was bruised and hurt. Resident 1 stated Resident 2's whole mind changed each time the TV was turned on. Resident 3 stated Resident 2 would cursed the staff and other residents regularly. A review of the facility's policy titled, Abuse Prevention Program, with a revised date of 9/2017, indicated the purpose of the policy was to ensure the health, safety and comfort of residents by preventing abuse and mistreatment. This policy defined physical abuse as hitting, slapping or controlling behavior through corporal punishment. A review of the facility's policy titled Dementia Care, with a revised date of 10/2017, indicated the facility would provide a person-centered, comprehensive and interdisciplinary care that reflected best practice standards for meeting health, psychosocial and behavioral needs of residents with dementia. This policy also indicated the staff would thoroughly evaluate new or worsening behaviors exhibited by a resident, intervene in a timely and appropriate manner to address the resident's behaviors.

Based on interview and record review, the facility failed to follow its policies regarding abuse prevention for one of three sampled residents (Resident 2). Resident 2, had a behavior of being physically and verbally aggressive and physically abused Residents 1 and 3. Resident 2 slapped Resident 1 and tried to hit Resident 3 in the face with a water pitcher (crossed referenced to F689). This failure resulted in continued emotional and physical distress to Residents 1 and 3 and had the potential to affect other residents in the facility. Findings: a. A review of Resident 1's Admission Face sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's history and physical (H/P) record, dated 3/24/18, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Situation Background Assessment Recommendation ((SBAR) nurses internal communication tool), dated 3/27/18, indicated Resident 1 informed the facility's Social Services Director (SSD) that Resident 2 slapped him approximately four (4) to six (6) days prior. The SBAR indicated Resident 1 requested for a room change because he did not want to be in the same room as his abuser (Resident 2). A review of Resident 1's Interview Record, dated 3/27/18, indicated the resident requested for a room change. When the SSD asked Resident 1 why, he alleged Resident 2 slapped him on the left side of his cheek about four to six days prior. The interview record indicated Resident 1 was in bed watching television (TV) and Resident 2 was talking too much. Resident 1 asked Resident 2 to shut up and Resident 2 slapped Resident 1 on the face. According to the interview record, Resident 1 was moved to another room. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 3/28/18, indicated the resident was able to understand and be understood by others. According to the MDS, Resident 1 required one or two staff's assistance with bed mobility, moving around the unit, dressing, toilet use and personal hygiene. On 4/5/18, at 1:05 p.m., during an interview, Resident 1 stated he was in bed watching TV and Resident 2 kept talking. Resident 1 stated when he told Resident 2 to shut up; Resident 2 walked towards him and slapped him on the left side of the face. Resident 1 stated Resident 2 had a tendency of unplugging the TV. Resident 1 stated he was happy to have moved to another room, away from Resident 2. On 4/5/18 at 1:20 p.m., during an interview, Resident 3 stated Resident 2 was nice during the day, but dangerous at nighttime. Resident 3 stated Resident 2 always turned the TV off claiming it belonged to him. On 4/5/18 at 1:49 p.m., during an interview, the SSD stated on 3/27/18, Resident 1 requested for a room change because Resident 2 slapped the resident on the face. The SSD stated Resident 1 told her the incident was not reported the day it happened because Resident 1 did not want to get anyone in trouble. b. A review of Resident 2's Admission Face sheet indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's H/P record, dated 11/14/17, indicated the resident had a fluctuating capacity to understand and make decisions. A review of a care plan, dated 11/16/17, addressed Resident 2's impaired decision-making related to dementia (confusion/memory loss). The staff's interventions included giving medications as ordered. A review of Resident 2's MDS, dated [DATE], indicated the resident was able to understand and be understood by others. According to the MDS, Resident 2 required staff's supervision with bed mobility, moving around the unit, dressing, toilet use and personal hygiene. A review of a care plan, dated 2/13/18, indicated Resident 2 had an episode of physical aggression without an apparent reason. The goal indicated Resident 2 would not have any episodes of physical aggression daily for three (3) months. The staff's interventions indicated the staff would assess the resident as needed; provide a calm and meaningful environment to the resident; medications as ordered and a psych evaluation (a psychiatrist to evaluate, specially trained physician in mental disorders) as indicated. A review of the nurses' note, dated 2/14/18 and timed at 2 p.m., indicated Resident 2 was monitored for two episodes of aggressive behavior. A review of the nurses' notes, dated 2/16/18, and untimed, indicated Resident 2 had aggressive behavior. A review of Resident 2's Mental Status Examination, dated 3/12/18, indicated the resident was agitated, combative and striking out at the staff. A review of an Incident/Accident Report Form, dated 3/27/18, indicated Resident 1 stated that Resident 2 had slapped him four to six days prior, approximately at 2 p.m., while he was lying in bed watching television (TV). Resident 1 stated he told Resident 2 to shut up when Resident 2 asked him to turn down the TV and then Resident 2 slapped him. A review of the SBAR (Situational, Background, Assessment and Recommendation (an internal communication)), dated 3/27/18, indicated Resident 2 was increasingly authoritative, manipulative and a danger to others. It also indicated Resident 2 always followed his own rules stating, This is my house and I make my own rules. According to the SBAR, the resident was aggressive, abusive and had alleged to have slapped his roommate (Resident 1). A review of Resident 2's care plan, dated 3/27/18, addressed the resident's behavior problems related to increased episodes of authoritarianism and danger to others. The staff's interventions included to monitor the resident's behavior and determine its cause, intervene as needed to protect the rights and safety of others, and to remove the resident from the situation and take to another location. The care plan did not address other specific interventions to prevent Resident 2 from hitting other residents. A review of nurses' notes, from 3/28/18 through 3/30/18, indicated Resident 2 was authoritative, manipulative and a danger to others. The notes indicated the resident was telling his roommate (Resident 3) and previous roommate (Resident 1) to get out of his room, entering other resident's rooms and unplugging the TV. The nurses' notes also indicated Resident 2 asked other residents to leave their rooms because it was his house. A review of another care plan, dated 3/31/18, indicated Resident 2 was being physically aggressive without a reason. The staff's interventions indicated the resident would have a psych evaluation. A review of Resident 2's nurses' note, dated 3/31/18, and timed at 8:30 p.m., indicated the resident was accused of hitting Resident 3 with a water pitcher. A review of the facility's Incident and Accident Report Form, dated 3/31/18, indicated Resident 3 reported that he was hit on the right arm by his roommate (Resident 2) with a water pitcher. This report indicated on 3/31/18, at 8:30 p.m., Licensed Vocational Nurse 1 (LVN 1) heard a scream from Resident 3's room while Resident 3 was calling for help. The report indicated LVN 1 observed Resident 2 about to strike Resident 3 on the face with a water pitcher. The note indicated Resident 3 raised his right hand to block his face and the pitcher landed on his hand. According to this report, Resident 2 stated, It's my house, get out of my house. The report indicated Resident 2 was verbally aggressive towards the staff. On 4/4/18, at 12:35 p.m., during an interview, the Director of Nursing (DON) stated that Resident 2 unplugged the TV and when Resident 3 asked why he did it, Resident 2 hit Resident 3 with a water pitcher. The DON stated that Resident 2 was okay in the mornings and would become agitated in the evenings. According to the DON, Resident 2 was okay as long as no resident came in his space. On 4/4/18, at 3 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 2 was aggressive and did not want anyone going into his room. On 4/5/18, at 1:31 p.m., during an interview a Licensed Vocational Nurse 1 (LVN 1) stated Resident 2 always unplugged the TV and was agitated at nighttime. According to LVN 1, the resident was re-directed. On 4/5/18 at 1:45 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 2 was possessive, aggressive and agitated when someone got in what he claimed, was his space. CNA 1 stated Resident 2 did not like the TV loud and would ask that the staff should get his roommates out of his room. According to CNA 1, Resident 3 liked the TV loud, which caused Resident 2 to become physically aggressive. According to CNA 1, the staff were aware of Resident 2's aggressive and authoritative tendencies and would try to re-direct the resident each time. On 4/5/18 at 2 p.m., during an interview, the facility's administrator (ADM) stated if he had known of Resident 2's authoritative and aggressive behavior, he would have ensured the resident was monitored closely. On 4/5/18 at 3 p.m., during an interview, CNA 2 stated Resident 2 was possessive, aggressive and did not want anyone in his room. According to CNA 2, Resident 2 would try to hit and stop the staff from entering his room. CNA 2 also stated the nurses were aware of Resident 2's behavior. On 4/5/18 at 4:05 p.m., during an interview, CNA 3 stated Resident 2 was upset when the lights were turned on to assist the roommates with care and would turn the lights and TV off. CNA 3 stated the staff would plug the TV on each time Resident 2 unplugged it. According to CNA 3, Resident 3 would yell at the staff as well. According to the clinical records, Resident 1 was transferred to another room after the incident was reported to the SSD. However, Resident 2 remained in the same room with the other roommate (Resident 3), where he continued to exhibit aggressive behavior. A review of Resident 2's medical record indicated there was no documentation to indicate that the facility had immediately implemented effective interventions to ensure further abuse did not occur after Resident 2 slapped Resident 1. c. A review of Resident 3's Admission Face sheet indicated the resident was admitted to the facility on [DATE], with an original admission date of [DATE]. Resident 3 had [DIAGNOSES REDACTED]. A review of Resident 3's H/P record, dated 2/1818, indicated the resident had a fluctuating capacity to understand and make decisions. A review of Resident 3's MDS, dated [DATE], indicated the resident was able to understand and be understood by others. According to the MDS, Resident 3 required two staff's assistance with bed mobility, moving around the unit, dressing, eating, toilet use and personal hygiene. The MDS also indicated Resident 3 used a walker for mobility. On 4/4/18, at 1:10 p.m., during an interview, Resident 3 stated that Resident 2 was ok during the day but very violent at night. Resident 3 stated Resident 2 had been aggressive for six months and that the night nurses knew about it. Resident 3 also stated the night nurses used to tell Resident 2 to knock it off. Resident 3 stated that he required assistance to get up out of bed and Resident 2 would always get in his face telling him to get out of the room. Resident 3 stated he was watching TV and Resident 2 asked him to turn the TV off. According to Resident 3, Resident 2 unplugged the TV, and when Resident 1 told him not to do so, he hit him with a water pitcher. Resident 3 stated he became scared because he could not defend himself. Resident 3 stated he asked the nurse to call the police for his safety. He also stated his right hand was bruised and hurt. Resident 1 stated Resident 2's whole mind changed each time the TV was turned on. Resident 3 stated Resident 2 would curse the staff and other residents regularly. A review of the facility's policy titled, Abuse Prevention Program, with a revised date of 9/2017, indicated the purpose of the policy was to ensure the health, safety and comfort of residents by preventing abuse and mistreatment. This policy defined physical abuse as hitting, slapping or controlling behavior through corporal punishment. A review of the facility's policy titled, Dementia Care, with a revised date of 10/2017, indicated the staff would thoroughly evaluate new or worsening behaviors exhibited by a resident, intervene in a timely and appropriate manner to address the resident's behaviors. According to this policy, the interventions would be monitored regularly for efficacy, risk and benefits.

Based on observation, interview and record review, the facility failed to ensure LVN 1 immediately initiated CPR for one of 14 sampled residents (9) who was found unresponsive, breathless and pulseless, in accordance with the facility's policy and professional standards of care. This resulted in a delay in the initiation of CPR and caused Resident 9, to not receive the full benefit of CPR (Cardio [MEDICAL CONDITION] resucitation) to affect her chance of survival. Consequently, the resident did not survive and expired. Additionally, the facility's licensed nurses LVN 1, 4, 5, 6, RN 1 and the DSD failed to demonstrate knowledge regarding the proper protocol for the initiation of CPR. This deficient practice has the potential to result in a delay in the response time and provision of necessary care during a life threatening/emergent situation and has the potential to result in not honoring the resident's wishes to be resuscitated (Full code), which could cause anxiety to the family and not afford the resident the chance to survive. For Resident RSR, RN 1 failed to flush the resident's right upper arm peripherally inserted central catheter (PICC-a form of intravenous access that extends to the superior vena cava that stays in place and dwells within the veins for days or weeks) to ensure patency prior to administering the antibiotic infusion. Findings: During an initial tour of the facility on [DATE], at 7:55 p.m., the paramedics arrived to the facility, entered Resident 9's room and took over CPR efforts on Resident 9. According to the admission record, Resident 9 was a [AGE] year-old female, who was admitted to the facility on [DATE], from a general acute care hospital (GACH). The resident had [DIAGNOSES REDACTED].). A review of the full Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated [DATE], indicated Resident 9 was able to express her ideas and wants, had clear speech and was able to understand others. According to the MDS, the resident's memory was moderately impaired but she had the ability to recall. The MDS indicated Resident 9 was receiving oxygen therapy. The Physician order [REDACTED].) dated [DATE], indicated Resident 9 wished an attempt of cardiopulmonary resuscitation (CPR) and full treatment for [REDACTED]. A physician's orders [REDACTED]. Resident 9 had a care plan developed on [DATE], for ineffective airway clearance, with interventions that included: assess as an indication of respiratory distress as shortness of breath (SOB), wheezing, coughing and notify the doctor accordingly. Elevate the head of the bed as indicated for SOB to help with breathing. Give oxygen inhalation as indicated, and give breathing treatment as ordered. According to the History and Physical (H&P) dated, [DATE], Resident 9 had shortness of breath on exertion and had the capacity to understand and make decisions. The physicians order also indicated Resident 9 was admitted to hospice on [DATE]. A review of the hospice nurses' notes dated [DATE], at 4:20 p.m., indicated Resident 9 was sitting in her wheelchair alert, oriented and coherent. The resident had a productive cough with slight congestion and unlabored breathing. A review of the nurses notes [DATE], at 7:55 p.m., indicated on [DATE], at 4:30 p.m., Resident 9 was sitting in her wheelchair in no form of distress. At 5:00 p.m., the Hospice nurse assessed the resident and obtained an oxygen saturation reading of 92 % (normal range ,[DATE] for [MEDICAL CONDITION] diagnosis) The resident denied shortness of breath. According to LVN 1 at 6 p.m., the resident looked tired and was assisted back to bed. At 7 p.m., the resident was asleep. At 7:55 p.m., Resident 9's face was drooping and she seemed unresponsive and had no pulse. LVN 1 then shook the resident and tried to wake her, but the resident remained unresponsive. LVN 1 then ran towards the nurses station and called for everyone's attention. LVN 1 informed the charge nurse to grab the crash cart. The DON called 911 and the rest of the nursing team started CPR. The paramedics arrived to the facility and took over CPR. Resident 9 was transferred to a GACH. On [DATE] at 8:15 p.m., the DON was questoined regarding Resident 9's activity prior to the paramedics' arrival. The DON stated twice that LVN 1 ran to the nurses station to inform her that Resident 9 was not breathing. During an interview on [DATE], at 8:30 p.m., LVN 1 stated at 6:30 p.m., Resident 9's oxygen saturation level was assessed as 87%. The resident was wearing oxygen. A review of the resident's Hospice flowsheet indciated the previous resident's oxygen saturation levels were as follows: 1. [DATE], [DATE] and [DATE]. the resident's oxygen saturation mesured 96 %, while on 2L of oxygen therapy- 2. On [DATE], the resident's oxygen level measured 92% - 3. On [DATE] the resident's oxygen level measured as 95%- According to the University of Michigan, for most [MEDICAL CONDITION] patients, the oxygen saturation goal is range between ,[DATE]%. Dufring an interveiw with LVN 1 on [DATE], at 7:45 p.m., LVN 1 stated she observed the resident to be unresponsive and not breathing due to the color of her face and her mouth was twisted. LVN 1 shook the resident, called out her name and checked her radial pulse but the resident remained unresponsive. LVN 1 ran right away to the nurses' station to call for help. LVN 1 obtained an emergency kit (E-kit-an emergency medication kit used in long term facilities) and returned to the resident's room. LVN 1 stated that CPR was initiated for Resident 9 by LVN 2. When LVN 1 was asked why she did not start CPR efforts herself when Resident 9 was found to be non-responsive, she stated that she had ran to get help and to retrieve the crash cart. During an interview on [DATE], at 9 p.m., the DON stated that she was called by LVN 1 who stated to her that Resident 9 did not look good. The DON was asked how did she and the staff become aware that the resident was in distress. The DON stated LVN 1 ran to the nurses station to inform the staff. When the DON was asked who initiated CPR? She stated LVN 2 initiated CPR. During a tour of the facility on [DATE] at 9:54 p.m., the Director of Staff Development (DSD) was observed standing in a corner on the south side of the patio reading the facility's CPR policy. He quickly folded the policy and placed the policy in his pocket. During an interview on [DATE] at 8:05 p.m. and 10 p.m., LVN 2 stated he was alerted that Resident 9 was not breathing. When he arrived to Resident 9's room there was no licensed staff physically touching the resident at that time. LVN 2 observed the resident to be breathless and initiated CPR with chest compressions. LVN 1 and the DON had entered the room after his arrival. LVN 7 entered the resident's room with the crash cart. During an interview on [DATE] at 10:15 p.m., RN 1 was asked when a resident is found unresponsive and breathless what should be done, RN 1 stated she would make sure that the resident is not a full code, get the crash cart and then initiate CPR. During an interview on [DATE], at 10:25 p.m., the Director of Staff Development (DSD) was asked when a resident is found unresponsive and breathless what should be done? The DSD stated he would call for help, obtain the crash cart, check the resident vital signs (measurements taken that indicate the status of the body's life-sustaining functions which includes body temperature, blood pressure, pulse (heart rate), and respiratory rate), hold the resident's shoulders and shout are you ok, wait for the crash cart, proceed with taking the vital signs and if the resident does not respond then start CPR immediately. During an interviews on [DATE] at 12:35 p.m., the DON was asked when a resident is found unresponsive and breathless what should be done? The DON stated she would shake the resident a little bit, check for a pulse, if resident is pulseless then check the residents medical record to see if the resident is A DNR or a full code, obtain the crash cart and then perform CPR. The DON was asked how does the nursing staff determine which residents have a DNR or a full code status during an emergency. The DON stated the nursing staff would have to look in the resident's medical records and check for a POLST form before performing CPR. The DON was asked what would happen if a resident does not have a POLST in their medical records? The DON stated residents who do not have a POLST in their medical record are automatically considered a full code. The DON further stated if a licensed nurse is unable to locate a resident's POLST the nurse would call the family and instruct another licensed nurse to perform CPR, while attempting to call the family. During an interview on [DATE], at 11:10 p.m., LVN 5 was asked when a resident is found unresponsive and breathless what should be done? LVN 5 stated she would check the resident's vital signs, call a Code Blue, call out for help, check the resident's medical record to ensure if the resident is a DNR or a full code, then initiate CPR. During an interview on [DATE], at 12:20 p.m., LVN 6 was asked when a resident is found unresponsive and breathless what should be done? LVN 6 stated yell for help, stay with the resident, when help arrives they would be able to determine the code status of the resident, then start CPR. LVN 6 stated that waiting for the code status of a resident during an emergency would be done in a timely manner in less than a minute if possible. During an interview on [DATE] at 12:41 p.m., the DON stated Resident 9 had expired at the GACH on [DATE]. The facility's policy dated [DATE], and titled, Cardiopulmonary Resuscitation indicated CPR is instituted in cases of recognized cardiac and/or [MEDICAL CONDITION] arrest until medical emergency personnel are available to take over the resuscitation efforts. The first of facility personnel to arrive and find a resident with any of the above conditions will identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling out their name; Respond to the resident immediately and send available staff to call a code blue; commence one person CPR, according to current practice; check the resident's airway for breathing and circulation and begin CPR; if alone, perform resuscitation for one minute before leaving the resident to call for help. (This policy does not include the most recent changes from the American Heart Association). According to the Vocational Practice Act 2518.6 Performance Standards; a licensed vocational nurse shall safeguard the patient's health and safety by actions that include maintaining current knowledge and skills for safe and competent practice. Because of the facility's failure to ensure LVN 1 responded immediately to begin CPR for Resident 9 who was unresponsive, breathless and in need of immediate emergent care and was a full code, and to ensure LVN 1, 4, 5, 6, RN 1 and the DSD were properly trained in when to initiate CPR according to professional standards which entails to respond to life threatening medical emergency situations in a timely and effective manner. An immediate jeopardy was called on [DATE] at 1:15 p.m., with the administrator and the Director of Nurses. The administrator presented an acceptable plan of correction action to the surveyor on [DATE], which consisted of the following: Staff will be provided one-to-one in-service by the DON on emergency procedures in accordance with the facility's policies. This in-service will begin immediately and be completed by [DATE], then on a bi-monthly basis. The facility initiated in-services immediately which included: a. In-Services will be initiated on [DATE], from 4 p.m. - 5:30 p.m., and continued through [DATE], regarding the facility's policy titiled Responding to an Unresponsive resident Vs. Activating CPR. which entails to check the resident's armband prior to initiating CPR. If the resident is not wearing a pink armband institute CPR once cardiopulmonary arrest is recognized to sustain or support a resident's cardiopulmonary functions until medical emergency personnel are available to take over the resuscitation efforts. b. In-Service will be initiated on [DATE], at 4 p.m. thru 5:30 p.m. and continued through [DATE], regarding the facility's policy titled, Advance Directives, which entails that during an emergency staff will be able to make decisions by identifying residents with a pink wristband. This will indicate a DNR code status and a white wristband will indicate a Full Code. c. The admission licensed nurse will verify and clarify the residents code status on admission. d. Licensed nurses will conduct daily rounds to assess each resident's condition and making sure the proper code status identification is in place. Any findings will be reported to immediate supervisor for prompt intervention. e. The DON and designee will conduct an in-service to all licensed staff regarding full code responses bi-monthly. On [DATE], at 10 p.m., the surveyor met with the administrator and the director of nurses (DON) and informed them the immediate jeopardy was lifted.

Based on observation, interview, and record review, the facility failed to ensure Resident 1, who was assessed as requiring a two-person assist during transfers, was transferred utilizing two persons with a gait belt for one of 14 sampled residents (1). On April 8, 2013, at approximately 11:00 a.m., the restorative nursing assistant ((RNA 1) a nursing assistant trained to help nurses in restoring mobility to residents) transferred Resident 1 by himself without using a gait belt. At 5:00 p.m., the licensed vocational nurse (LVN 9) was informed by a certified nursing assistant (CNA 1) that there was a bump on Resident 1's left thigh. The physician was notified and an x-ray of the left leg was done which showed a left displaced (to shift from the usual place or position) diaphyseal (a bone break that occurs along the shaft of a long bone) of the distal femur (end of the thigh bone) fracture. Resident 1 was transferred to a general acute care hospital (GACH) for surgery. Findings: On May 8, 2013, at 11:14 a.m., Resident 1 was observed lying in bed awake, alert, and confused. Resident 1 had a dressing extending from her left thigh to the knee and was wearing a left knee immobilizer (device to prevent movement). According to Resident 1's clinical record, she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk assessment dated [DATE], indicated the resident had a score of 13 (total score of 10 or above represents a high risk for falls). There was a care plan, titled, "Activities of Daily Living" (ADL) dated January 8, 2013. The goal was for Resident 1 to demonstrate minimal complications related to decreased ADL performance. The interventions included to provide ADL care as needed, turn and reposition as ordered, and monitor for changes in self performance of ADLs. The interventions did not address how the resident would be transferred from one surface to another surface (bed to chair, wheelchair to bed etc.). The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated January 11, 2013, indicated the resident was moderately impaired in her cognitive skills for daily decision making and had short-term and long-term memory problems. According to the MDS, Resident 1 had impairment for range of motion (the distance and direction a joint can move to its full potential) on both sides of the upper (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot). The MDS also indicated she required extensive assistance with two-person assist with bed mobility and transferring. On April 23, 2013, at 8:25 a.m., during an interview with RNA 1 he stated that he transferred Resident 1 from the bed to the wheelchair by himself on April 8, 2013 at approximately 11:00 a.m. When RNA 1 was asked how he transferred the resident, he stated that he set the resident on the edge of the bed, placed the resident's arms around his neck, and grabbed onto the resident's pants to maneuver her into the wheelchair. When RNA 1 was asked why he grabbed onto Resident 1's pants to move her he stated, "I forgot my gait belt at home." On April 23, 2013, at 9:23 a.m., during an interview the occupational therapist (OT) stated Resident 1 was bed bound and was totally dependent on staff for transfers. He also stated the resident was unable to assist or follow instructions during transfer, therefore, Resident 1 required a two-person assist at all times. On April 23, 2013, at 9:30 a.m., during an interview with the physical therapy (PT) director, she stated Resident 1 was totally dependent and that she cannot assist with transfers due to her cognitive impairment. She also stated Resident 1 requires a two-person assist. On April 23, 2013, at 11:35 a.m., during a telephone interview with CNA 2, she stated that she was in the room when RNA 1 transferred Resident 1 from her bed to the wheelchair, however, did not help RNA 1 with the transfer. When asked why she did not help with the transfer she stated that Resident 1 was too heavy for her and RNA 1 did not ask her to help him because he said he could do it himself. The Nurses Notes dated April 8, 2013, at 5:00 p.m., indicated LVN 9 was informed by CNA 1 that there was a bump on Resident 1's left thigh. The site was assessed as being hard, warm, and tender to the touch with no signs or symptoms of pain at the site, and Resident 1's physician was called and ordered a "stat" (at once) x-ray of the left leg, which was carried out. On April 8, 2013, at 7:20 p.m., the left hip x-ray from the skilled nursing facility (SNF) result indicated a displaced fracture of the distal femur. The Nurse's Notes dated April 9, 2013, at 7:20 a.m., indicated Resident 1's physician called to the SNF and ordered to transfer Resident 1 to the GACH due to an acute distal femur fracture. The History and Physical (H & P) from the GACH dated April 9, 2013, indicated Resident 1 had a displaced left femur fracture and was scheduled for surgical repair. Another H & P dated April 11, 2013, indicated Resident 1 had an open reduction and internal fixation ((ORIF) a method of surgically repairing a fractured bone by using screws and plates or a rod to stabilize the bone). The SNF Nurses Notes (notes) indicated Resident 1 was readmitted to the facility on [DATE], at 1:10 p.m. The notes dated April 20, 2013, at 10 a.m., indicated Resident 1's left femur surgical site had a small amount of fresh blood, was swollen and warm to the touch. The physician was notified and ordered to transfer the resident back to the GACH. The SNF Nurses Notes (notes) indicated the resident was readmitted on [DATE], at 12:30 p.m., with a surgical incision on her left thigh that had 28 staples. The notes dated April 22, 2013, at 7 a.m. indicated the licensed nurse spoke to the physician and obtained an order for [REDACTED]. At 11:00 a.m., Resident 1's physician was notified of the left hip x-ray result showing the proximal fixation device was unattached from the bone and left knee and to transfer Resident 1 back to the GACH. The H&P from the GACH dated April 23, 2013, indicated Resident 1's femur was detached from the fixation device and the resident was admitted for an orthopedic (bone specialty doctor) for evaluation. This was Resident 1's third trip to the GACH, and second admission after the incident on April 8, 2013. The Orthopedic Consultation Report dated April 24, 2013, indicated Resident 1 had a loss of fixation (detached) on the fracture following a twisting injury. The Operative Report dated April 29, 2013, indicated Resident 1 underwent a second ORIF surgery. The SNF Nurses Notes dated April 30, 2013, at 8:45 p.m., indicated Resident 1 was readmitted to the facility. On April 23, 2013, at 12:45 p.m., during an interview, the director of staff development (DSD) stated that RNA 1 should not have transferred Resident 1 by himself. She also stated that all the RNAs and CNAs are supposed to use their gait belt when transferring a resident because of safety reasons and that each staff was given a gait belt to use. When the DSD was asked when the nursing staff were in-serviced regarding the use and application of the gait belt, she stated, "About 3 to 4 months ago." Also, when asked how the RNAs and CNAs know which resident should be a one or two-person assist she stated that before the incident with Resident 1's fracture, there was no system in place to help the nursing staff identify which residents required one or two-person assist, so they had to use their own judgment. A review of the In-Service Meeting Minutes dated on December 4, 2012, topic titled "Gait Belt: use and application", indicated RNA 1 attended the in-service. The In-Service Minutes document also indicated a gait belt will be part of the uniform and to be used at all times while on duty. According to the facility's undated policy and procedure titled, "Policy and Procedure for Use of Transfer Belts", the health and safety of resident and personnel, all facilities will implement the use of transfer belts/gait belts for transferring and ambulating residents to reduce incidents of employee and resident injury. The facility's policy and procedure titled, "Transfer", dated January 12, 2012, indicated the general transferring principles include the following: 1. If you need extra help, ask for it. 2. Explain procedures to resident. 3. Know the residents abilities and limitations. 4. Use good body mechanics. 5. If not contraindicated, use a gait belt during transfers. 6. If the resident must hold onto you during a transfer, have him hold onto your forearms, not your neck or waist.

Based on observation, interview, and record review, the facility staff failed to follow its policies to ensure one of 14 sample residents (Resident 11), who had a history of [REDACTED]. and prevent him from leaving the facility unattended. This deficient practice resulted in Resident 11 leaving the facility unattended, and without receiving his morning medications, including insulin, which may cause unstable blood sugar levels and a risk for falls. He was declared missing by the facility administrator, and was found after nine hours, with a contusion (bruise or injury without breaking the skin) to his elbow, and elevated blood sugar and ketone levels (occurs when the body cannot use the glucose as a fuel source because there is little or no insulin, and fat is used for fuel instead). He was sent to the hospital for an evaluation, and eventually discharged to a locked-down psychiatric facility. Findings: On February 10, 2013, between the hours of 12:00 p.m. and 12:30 p.m., the administrator reported to the survey team that Resident 11, an [AGE] year old male, was missing from the facility grounds. He had notified the police, physician, and the resident's family member. A review of Resident 11's closed record containing documentation detailing his prior stay in the facility, revealed a form titled," Elopement Risk Evaluation," dated January 22, 2013. Documentation by the licensed nurse indicated that the resident was assessed as a moderate risk for elopement, and required care planning. The admission record revealed that he was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. The care plan for Wandering/Elopement dated January 23, 2013, indicated that Resident 11 wandered related to unfamiliarity with his new environment. The goals included that the resident will not wander out of the facility, will demonstrate awareness of safety needs, and will be free from injury related to wandering. The interventions included to evaluate the resident's wandering pattern, emotional status, provide emotional support and meaningful activity, and utilize validation techniques to understand emotions behind attempts to leave the facility. The January 23, 2013, care plan had an intervention selection of, "Use Measures to Provide for Safety," however it was left blank. The care plan did not indicate that a Wander Guard had been applied to Resident 11, nor that one-to-one monitoring was attempted, as indicated in the "Wandering and Elopement" policy to ensure residents who had the behavior of wandering were safe. A review of the Licensed Nurse's Notes (notes) dated January 29, 2013, at 7 a.m., that were located in the closed record, indicated that the resident was awake, and alert with periods of confusion and forgetfulness. The notes indicated the resident was pacing back and forth, and kept saying, "I want to go back to my home," and "I don't want any more medications." The resident was noted to be hyper verbal, was trying to leave the facility, resisted care, and was un-cooperative with the staff. The physician was notified and the resident was transferred to the acute psychiatric medical center by ambulance for further evaluation and treatment as needed, according to the documentation. A review of the physician's admission orders [REDACTED]'s ability to use blood sugar). The Admission Insulin Orders dated February 7, 2013, indicated the resident was to have his blood sugar checked via fingerstick every morning before breakfast. The "Admission History and Physical" (H&P) written by the physician dated February 7, 2013, indicated that Resident 11 had a fluctuating capacity to understand and make decisions, and had "homicidal" thoughts. The H&P indicated that Resident 11 had additional [DIAGNOSES REDACTED]. The previous elopement history of Resident 11 was not incorporated in the readmission assessment signed by the Registered Nurse (RN), dated February 7, 2013. The Comprehensive Resident Admission assessment dated [DATE], was also inaccurate, as documented. It indicated that Resident 11 was alert, oriented to time, place, and person. The assessment under Section 7E indicated that the resident was cognitively intact, and had competent decision making capability. The assessment also erroneously indicated that the resident had no past history of wandering or exiting the facility without the needed supervision. The Licensed Nurse's Notes for Resident 11's current admission revealed the following documentation on February 9, 2013, the day he eloped from the facility: At 8:30 a.m., a licensed nurse saw Resident 11 outside the facility door zipping his sweater. She told the resident to come inside because the weather was cold. The resident followed her inside of the facility, and he sat on the couch in the front lobby (the front lobby couch was observed located next to the front door leading to the sidewalk and street). There was no documentation to indicate that the licensed nurse reported the resident's behavior to the Director of Nursing (DON) during this time. There was also no documented evidence that she had communicated to other nursing staff to alert them of Resident 11's behavior or that the resident was monitored or supervised closely to prevent him from leaving the facility unattended. Further review of the Licensed Nurse's Notes revealed that at 9 am, the medication nurse for Resident 11 went to his room to administer his medications; however he was not in his room. The lobby was searched, and staff were asked to help in the search for Resident 11. The supervisor and DON were notified. On February 9, 2013, the following interviews were conducted with facility staff regarding Resident 11's elopement. At 9:30 am, Employee 4 stated that he assisted Resident 11 with grooming during the morning, before breakfast, and then assisted the resident to the dining room. Employee 4 then went to another resident and was not aware of what time the resident left the facility. At 9:47 a.m., Employee 11 stated that she saw the resident wandering around the facility at about 8:15 a.m. She stated that most of the time the resident was looking outside, and the resident was right by the facility front door sitting on the couch. Employee 11 stated that she was unaware the resident was missing until a certified nursing assistant (CNA) notified her. She said she did not know that Resident 11 was an elopement risk. At 10:42 a.m., Employee 6 stated that when he went to pass the 9 a.m. medications for Resident 11, the resident was not in his room. He stated that he did not know the resident was an elopement risk. When asked if he knew why the resident was discharged from the facility within the month, he stated,"No." When asked if the resident received his 9 a.m. medications including his insulin, Employee 6 stated no, because the resident was missing when it was time to administer the medications. When asked if the resident had his blood sugar checked in the morning, prior to breakfast, Employee 6 stated, "maybe". Documentation on Resident 11's medication administration record (MAR) for February 9, 2013, revealed that Resident 11 did not receive the following medications: [REDACTED] Aspirin 81 milligrams (mg) - One tablet by mouth daily, for a Cerebral Vascular Accident ((CVA) or a stroke - a disruption in oxygen supply to the brain) treatment. Glyburide 2.5 mg by mouth daily (for diabetics to control blood sugar). Zoloft 25 mg by mouth daily. (for persons who are depressed). Risperdal .5 mg by mouth twice a day. (for the treatment of [REDACTED]. At 2 p.m., during an interview with the DON, when asked for an update on the resident's status, she was unable to provide additional information except that which was documented in the clinical record. At 2:12 p.m., during an interview with Employee 1, he stated he was informed that the resident was missing at about 11 am. He stated that the resident was oriented to person and place and as far as he knew, was not an elopement risk. At 2:20 p.m., during an interview with Employee 3, he stated that the resident was in his office at about 7 a.m. on February 9, 2013. He stated that the resident was alert, responsive, and was stating that he wanted to go home, and offered him twenty dollars to assist him in getting home. At 6:05 p.m., the facility administrator stated that Resident 11 had been located at the residence of a next of kin, but left the residence and was missing. However, according to the administrator, within the hour the resident was located again. On February 9, 2013, at 6:40 p.m., an interview was conducted with a fire fighter from Los Angeles County via phone with the surveyor. The fire fighter stated that Resident 11 was located in Los Angeles and had an abrasion to the right elbow and minor scratches to the right knee. A copy of the report of the hospitalization for the evening of February 9, 2013, was requested from the DON. On February 10, 2013, at 7 a.m., the administrator stated Resident 11 was currently at the acute care hospital. The administrator was questioned about the resident's previous January 29, 2013, attempt to leave the facility, and when stopped from leaving, becoming so agitated that he had to be sent out for psychiatric evaluation and treatment. The administrator stated he was not aware of the reason the resident was hospitalized or what was documented in his clinical record by the treating/discharging physician until after the resident eloped from the facility on February 9, 2013. He stated he was surprised of what the physician had documented in the discharge orders about Resident 11's current diagnosis/behavior. The administrator stated he had never observed Resident 11 display any of the behaviors documented by the in-resident physician. He stated he did not expect Resident 11 to return to the facility after his discharge. The labwork results from the general acute care hospital (GACH) dated February 9, 2013, drawn at 9:30 p.m.,m revealed he had elevated blood glucose of 175 ( reference range 70 to 110), and urine glucose of 500 (reference range is negative). A review of the Urgent Care Physicians Report/Orders from the GACH dated February 9, 2013, indicated that Resident 11 had a contusion to the right elbow. The Urgent Care Nursing Record documentation indicated the resident had schizophrenia, altered mental status, and was gravely disabled. He was cleared to be transferred to a locked-down geriatric psychiatric unit by ambulance. The current care plan developed by the facility in expectation of Resident 11's return, dated February 9, 2013, titled," Wandering/Elopement", revealed that the care plan interventions had not been updated in accordance with their policies. Safety measures such as an alarm, Wander Guard, or other measures to prevent the resident from leaving the facility unattended and ensure his safety, were again left blank. A review of two facility policies titled, "Wandering and Elopement," dated December 1, 2012, and January 1, 2012, revealed the following: The purpose of the policy is to enhance the safety of residents of the facility, and to prevent residents from leaving the facility without following proper procedures. The policy indicated that while respecting resident's rights facility staff must also act to ensure their health and safety. The policy indicated that the facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The procedures included: lV. Residents with a history of wandering or who the IDT (Interdisciplinary Team) have assessed to be at risk for wandering or elopement will have a photograph maintained in their medical record. The policy indicated the following procedure: 1. Residents will be assessed by the interdisciplinary team (IDT) to determine their risk of wandering/elopement. This assessment will take place upon admission, quarterly, and when behavior changes. A. If the resident appears likely to wander or elope, the facility staff should provide diversions and increase monitoring of the resident. The facility may institute one-to-one staffing until the resident's risk of wandering/elopement subsides. ll. If this is not adequate, the IDT may consider outfitting the resident with an alert device (Wander Guard). In such cases, the licensed nurse will contact the attending physician and the responsible party for a physician order [REDACTED]. B. Nursing Staff will update the resident's Care Plan to include interventions to prevent wandering/elopement, including, but not limited to the following: Outfitting the resident with an alert bracelet (Wander Guard) Assigning the resident to a room away from commonly utilized exits: Placing a sign on resident's room with his/her name in large letters: Placing a, "stop" sign on exit doors: Engaging the resident in supervised group activities; Assigning the resident to a supervised dining program Distracting the resident with items he/she enjoys A review of the clinical record for Resident 11 revealed no photograph of the resident. There was no documentation that the facility staff provided diversions and increased monitoring of Resident 11 after he told staff he wanted to go home, and after he was found outside of the facility in the morning, and when he was in the lobby on the couch next to the exit. There was no documentation by facility staff that the resident was considered for on one-to -one monitoring after he was found outside the facility prior to him leaving unattended, to ensure his safety, as well as the safety of others, as indicated in the facility policy, and since his physician documented that he was "homicidal".