Every finding on record at Lighthouse Healthcare Center

Based on observation, interviews and a review of records, the facility failed to ensure one of three residents (Resident 1) was assisted when she requested to get up into her wheelchair. This deficient practice caused Resident 1 to feel frustrated and had the potential to negatively affect her psychosocial well being. Findings: During a concurrent observation and interview on 8/25/2026 at 1:14 p.m., in Resident 1's room, Resident 1 was observed lying in bed with a blanket, and her wheelchair was positioned next to the bed. Resident 1 stated, I like to get up to my wheelchair every day between 9 a.m. and 10 a.m. Resident 1 reported that the nurse did not want to get her up on this day (8/25/2026). Resident 1 stated, I asked her to get me up and she said no. Resident 1 stated, I feel offended because I like to get up every day. I have the right to get up from bed. Resident 1 stated, It is already 1:00 p.m. I do not want to get up now; it is too late. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included functional quadriplegia (a clinical designation describing a profound loss of mobility affecting all four limbs), muscle weakness (reduced strength in one or more muscles) and hypertension (HTN-high blood pressure). During a review of Resident 1's History and Physical examination (H&P) dated 5/13/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/27/2026, the MDS indicated Resident 1 had moderate cognitive impairment. Resident 1 was dependent on staff for assistance with Activities of Daily Living (ADLs) such as dressing, toilet use, transfer and mobility. During a review of Resident's 1 care plan titled, ADL self-care performance deficit related to impaired mobility, dated 2/10/2025, one of the interventions indicated to encourage Resident 1 to get up in a wheelchair daily as tolerated, talk to the resident while giving care. During an interview on 8/25/2026 at 2:37 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated that Resident 1 can communicate her needs. CNA 2 stated that Resident 1 cannot stand and required nursing staff assistance to transfer to her wheelchair. CNA 2 stated that after breakfast, Resident 1 asked to be gotten up on the wheelchair. CNA 2 stated she told Resident 1 yes as she was walking out of the room. CNA 2 stated this may have been a misunderstanding, as Resident 1 may not have heard her and thought she was ignored. CNA 2 stated that when she returned to Resident 1's room later (time not specified), Resident 1 no longer wanted to get up. CNA 2 stated that it was important to communicate with residents face-to-face so they can clearly understand directions. CNA 2 further stated that Resident 1 has the right to get out of bed and it was the nurses' responsibility to assist her. CNA 2 stated that failing to do so can cause Resident 1 to feel ignored, angry, and anxious. During an interview on 8/25/2026 at 4:19 p.m., with the Director of Nursing (DON), the DON stated that residents have the right to get up whenever they chose. The DON stated the nurses must be ready to assist the residents. The DON stated that when nurses communicate with residents, they must ensure the residents understand what is being communicated. The DON stated that Resident 1 may feel ignored and may believe the nurses had no intention of helping her. During a review of facility's policy and procedures (P&P) titled, Residents right, dated 5/1/2023, the P&P indicated the facility must treated each resident with respect and dignity and care for each resident in a manner and in an environment, that enhance of his or her quality of life, recognize each resident individually. The facility staff should encourage residents to participate in planning their daily care routines, including ADLs. During a review of facility's P&P titled, Privacy and Dignity, dated 5/1/2018, the P&P indicated staff should focus on residents as individual when they speak to them, and address residents as individuals when providing care and services.

Based on interview and record review, the facility failed to notify the Power of Attorney (POA, a legal document that lets one person, act on their behalf) for health care decisions, during Changes of Condition (COC- a noticeable or measurable deviation in a person's physical, mental, or functional health status compared to their normal baseline), for one of 4 residents' (Resident 1).This failure violated the resident's instructions and the resident representative's rights provided by the state law and resulted in the resident's POA for healthcare decisions not aware of the residents changes in medical condition. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (a general loss of brain function), malignant neoplasm of endometrium (cancer starting in the inner lining of the uterus), and hypertension (occurs when the force of blood pushing against your artery walls is consistently too high). Resident 1 had a POA.During a review of Resident 1's Advance Health Care Directive Form (a legal document that lets you state your medical treatment preferences in advance and name someone to make decisions for you if you become unable to speak or decide for yourself), dated 4/8/2022, the Advance Health Care Directive Form indicated FM 1, as the POA/ designated agent for health care decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/5/2026, the MDS indicated Resident 1 had clear speech, difficulty communicating some words or finishing thoughts but is able if prompted or given time, and responds adequately to simple, direct communication only. The MDS indicated Resident 1 was dependent on staff for personal hygiene, toileting hygiene and shower/bathe self.During a review of Resident 1's Change of Condition, dated 4/28/2026, 5/13/2026, 5/14/2026, 6/9/2026, 6/10/2026, 7/4/2026 and Resident 1's Progress Notes dated 4/28/2026, 5/14/2026, 6/10/2026, the COC and progress notes indicated Resident 1 was responsible and was made aware of the COCs. There were no documentation the healthcare decision maker was notified.During an interview on 7/27/2026 at 2 p.m., with the Registered Nurse (RN 1), the RN 1 stated staff failed to notify Resident 1's designated agent for health care decisions (FM1), of all the Resident 1's COCs, that resulted in FM 1 being unaware and uninformed of the resident's changes in condition.During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, dated 2/20/2026, the P&P indicated facility should promptly inform the resident and notify the resident's legal representative when the resident experience a change in condition.

Based on interview and record review, the facility failed to ensure, one of four sampled residents (Resident 1), did not develop pressure sores (injuries to the skin over bony areas), at the facility. The facility failed to: 1). Develop a baseline care plan (initial person-centered care plan within the first 48 hours of admission, that will provide instructions for care of the resident) with interventions to prevent Resident 1 from developing a skin breakdown. 2). Ensure the Certified Nurse Assistants (CNAs) conducted skin checks during showers and bed baths, as indicated in the facility's policy and procedure (P&P titled Skin Care Tips for CNAs. These failures resulted in Resident 1 acquiring a Stage 2 pressure sore (shallow, open wound where the top layer of skin and part of the underlying layer are damaged, exposing the dermis [middle layer of the skin]) on the sacral coccyx area (tailbone) on 5/18/2026, and deep tissue injuries (DTI- serious pressure-related injury-induced damage that affects tissues beneath the skin's surface, including muscles, bones, and subcutaneous (under skin) layers) on the left lateral (side) plantar (underside) near the fifth toe, left plantar heel, right medial (middle) midfoot, and right posterior (back) heel on 5/21/2026. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, muscle weakness (reduction in the strength of muscles) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Clinical admission Skin assessment dated [DATE], the admission skin assessment indicated Resident 1 had no skin issues identified. During a review of Resident 1's Braden Scale (a standardized tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers, or bedsores) dated 2/26/2026, the Braden scale indicated Resident 1 was at high risk for developing pressure sores. During a review of Resident 1's admission care plans on 2/26/2026, there was no care plan developed to address Resident 1 being at high risk for skin breakdown. During a review of Resident 1's Skin Check forms rom 2/26/2026 through 7/8/2026, there were no skin check forms available to demonstrate Resident 1's skin were visually assessed from 2/26/2026 through 7/8/2026. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/5/2026, the MDS indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent (helper does all the effort) on staff with activities of daily living (ADLs) such as, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/off footwear, personal hygiene. Resident 1 required substantial/maximal (helper does more than half) assistance chair/bed-to-chair transfer, tub and shower transfer, sit to stand. Resident 1 required supervision or touching (helper set up) in rolling left and right of the bed. During a review of Resident 1's Care Plan titled At risk for skin breakdown related to incontinence of bladder and bowel, dated 4/16/2026, the interventions indicated to encourage resident to reposition every 2 hours, maintain adequate hydration and nutrition, handle gently during care, weekly body check and during care. During a review of Resident 1's Nursing Weekly Summary (a document containing records of vital signs, skin assessments, bowel and bladder function, pain management, cognitive patterns, ADL function, and nutrition and hydration status) dated 5/6/2026 and 5/13/2026, the weekly summary indicated Resident 1 had a penis laceration (skin tear) present on admission 2/26/2026. No other wounds were indicated in the Nursing Weekly Summary. During a review of Resident 1's Change of Condition (COC), dated 5/18/2026 at 10:03 a.m., the COC indicated, Resident 1 had stage 2 sacral pressure ulcer, measured 6.5 centimeters (cm- unit of measurement [unspecified]) by 2 cm (unspecified), with a 0.1 cm depth (distance between the visible surface of the skin and the deepest point of the wound bed). During a review of Resident 1's COC, dated 5/21/2026 at 1:03 p.m., the COC indicated upon assessment, Resident 1 was observed with DTIs on the left lateral plantar area near fifth toe, left plantar heel, right medial midfoot, and right posterior heel. Resident 1's physician was notified of the resident's condition and ordered to transfer Resident 1 to a general acute care hospital (GACH) for evaluation and treatment. During a concurrent interview and record review on 7/7/2026 at 12:49 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's care plan titled At risk for skin breakdown related to incontinence of bladder and bowel, dated 4/16/2026, was reviewed. LVN 1 stated Resident 1 did not have a heel protector (device to offload pressure from the heels in residents with limited mobility) and the skin was not assessed daily. LVN 1 stated failing to reposition Resident 1 every two hours could contribute to the development of pressure sores. LVN 1 stated the care plan interventions did not include staff would reposition Resident 1 every two hours as Resident 1 was unable to reposition himself and was total dependent on staff with ADLs. LVN 1 stated staff should have assessed Resident 1's skin during ADL care and on shower days, document findings on the skin check form, and report concerns to licensed nurses. LVN 1 stated Resident 1 acquired stage 2 pressure to the sacral area at the facility. During an interview on 7/7/2026 at 2:30 p.m. with the Director of Nursing (DON), the DON stated it was important to reposition Resident 1 to prevent pressure sores.The facility had no proof that Resident 1 was repositioned and had no logs or documentation indicating that Resident 1 was repositioned every two hours. During a concurrent interview and record review on 7/8/2026 at 4:16 p.m. with the DON, Resident 1's care plan on admission [DATE]) was reviewed. The DON stated the facility did not create a baseline care plan addressing Resident 1 being at high risk for skin breakdown. The DON stated the facility have not performed Resident 1's skin check since 2/26/2026 through 7/8/2026. The DON stated Resident 1 developed sacral stage 2 sacral and DTI to both heels at the facility. The DON stated the Skin Check form was proof of skin assessments done. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer Prevention, dated 5/1/2018, the P&P indicated a licensed nurse should develop a care plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition. During a review of the facility's P&P titled, Positioning and Body Alignment, dated 5/1/2018, the P&P indicated a resident 's should be changed every 2 hours, or as otherwise indicated or ordered by Attending Physician. During a review of the facility's P&P titled, Skin Care Tips for CNAs, dated 6/15/2011, the P&P indicated to turn residents every 2 hours or more often as needed. Skin check must be done and any opening, discoloration, redness on skin, rashes, must be indicated on the Skin Report Form and be reported form to the charge nurse. During a review of the facility's P&P titled, Care Planning, dated 10/24/2022, the P&P indicated each resident's comprehensive care plan should describe the services that were to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being.

Based on interview and record review, the facility staff failed to maintain a complete and accurate resident medical records, for one of four residents (Resident 1). This failure resulted in resident medical records not available and not accessible when needed.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, muscle weakness (reduction in the strength of muscles) and dementia. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/5/2026, the MDS indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent (helper does all the effort) on staff with activities of daily living (ADLs) such as, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/off footwear, personal hygiene. Resident 1 required substantial/maximal (helper does more than half) assistance chair/bed-to-chair transfer, tub and shower transfer, sit to stand. Resident 1 required supervision or touching (helper set up) in rolling left and right of the bed. During a review of Resident 1's Skin Check forms rom 2/26/2026 through 7/8/2026, there were no skin check forms available to demonstrate Resident 1's skin were visually assessed from 2/26/2026 through 7/8/2026. During an interview on 7/7/2026 at 12:49 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated during Resident 1's ADL care and on shower days, staff should assess the resident's skin, document findings on the skin check form, and report concerns to licensed nurses. During an interview on 7/7/2026 at 1:46 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated that CNAs were required to check residents' skin daily and on shower days, document on the skin check form and give the skin check form to the nurse. During an interview on 7/7/2026 at 4:30 p.m. with the Director of Staff Development (DSD), the DSD stated CNAs use the skin check form, which includes a visual assessment of the resident's skin along with the resident's name and room number, while providing care, on shower days, and daily. The DSD stated that the completed skin check forms were kept in a binder for one week and then shredded. The DSD stated the facility did not keep (file in the resident's clinical records) all completed skin check forms from 2/26/2026 through 7/8/2026 due to the volume of paperwork that would need to be stored. During an interview on 7/8/2026 at 4:16 p.m. with the Director of Nursing (DON), the DON stated that the skin check forms that were discarded after one week of assessments should have been retained as part of Resident 1's medical record to serve as proof of skin assessments. The DON stated Resident 1's skin check form from 2/26/2026 through 7/8/2026 were not filed in the resident's clinical records. During a review of the facility's policy and procedure (P&P) titled, Record Content, dated 11/2017, the P&P indicated residents' health records retention period is 10 years after last day, following discharge or last day of treatment.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received adequate supervision and assistance devices to prevent accidents. The facility failed to: 1). Implement Resident 1's care plan titled, At high risk for falls and injuries related to diagnosis of quadriplegia (paralysis from the neck down, including legs, and arms) and dementia (a progressive state of decline in mental abilities), which indicated to use a hoyer lift (a mechanical device used to lift and/or transfer a person from place to place) during transfers. 2). Ensure Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/3/2026, indicated the resident required the use of a hoyer lift for transfers. 3). Implement its policy and procedure (P&P) titled, Transfer of Residents, which indicated mechanical lifts (hoyer lift) be used for non-weight bearing (unable to bear weights on one or more parts of the legs) residents. These failures resulted in Resident 1 hitting her left leg on a geri-chair (also known as a geriatric chair or medical recliner- a specialized seating device designed for patients with limited mobility) sustaining an acute (recent) nondisplaced fracture (a broken bone where the crack goes all the way through but the pieces stay lined up) on the proximal (a location near the center of the body) left tibia/fibula (long bone in the lower leg), medial (middle) malleolus (a bony projection with a shape likened to a hammer head, especially each of those on either sides of the ankle) and distal fibula (lower end of the two long bones in the lower leg), and was transferred to a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including quadriplegia (symptom of paralysis that affects all limbs and body from the neck down), rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness) and dementia. During a review of Resident 1's Physical Therapy evaluation and plan of treatment dated 10/27/2023, indicated Resident 1's level of function required maximum assistance with bed mobility and mechanical lift with transfer. During a review of Resident 1's History and Physical examination (H&P) dated 12/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Residents 1's MDS dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent (helper does all the effort) on staff with activities of daily living (ADLs) such as oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/off footwear, personal hygiene, chair/bed-to-chair transfer, tub and shower transfer. Resident 1 required substantial/maximal (helper does more than half) assistance in rolling left and right of the bed. The MDS did not indicate prior devices were used and had no mobility devices used in the last 7 days (from 4/3/2026). During a review of Residents 1's Fall Risk Evaluation, dated 4/3/2026, the assessment indicated Resident 1 was at high risk for potential falls. During a review of Resident 1's care plan titled, Requires use of geri-chair for out of bed activities, inability to tolerate use of wheelchair due to poor trunk control, revised 4/10/2026, the care plan interventions indicated to place Resident 1 in geri-chair for as tolerated for out of bed activities. The care plan had no interventions indicating the use of transfer equipment or number of staff's assistance during resident's transfer. During a review of Resident 1's care plan titled, At high risk for falls and injuries related to diagnosis quadriplegia, dementia, revised 4/10/2026, the care plan interventions indicated to use hoyer lift when transferring Resident 1. During a review of Resident 1's care plan titled, Resident has limited physical mobility and fluctuations in all ADLs related to contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), weakness, impaired mobility and requiring maximum assistance from the staff in all ADLs, revised 4/10/2026, the care plan had no interventions indicating the use of transfer equipment or number of staff needed during Resident 1's transfer. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 6/9/2026 at 3:15 a.m., the SBAR indicated Resident 1 was observed crying while laying in bed in a supine (lying flat on back) position. The SBAR indicated Resident 1 complained of pain to her foot rated at 6/10 (a numerical pain scale with 0 = no pain, 1-3= mild pain, 4-6 moderate pain, 7-8 = severe pain, 9-10 = worst pain possible), extending from the left knee to the foot. The SBAR indicated Resident 1's skin on the left foot was abnormally tight (unspecified), the resident could not move the left leg and cried uncontrollably when the left foot was lightly touched. During a review of Resident 1's Incident/ Accident Report (Non-Fall), dated 6/9/2026 at 10 a.m., the report indicated per resident, she hit her left leg on the geri-chair but did not report it. The report indicated the assigned Certified Nurse Assistant) CNA did not use a hoyer lift. During a review of the facility's Investigation Summary, conclusion report for Resident 1, dated 6/9/2026 at 10 a.m., the summary report indicated per Resident 1, on 6/8/2026, CNA 2 transferred the resident from the bed to a geri-chair by herself (CNA2) and hit Resident 1's leg on the chair. The report indicated it was an accident which resulted in Resident 1's injury. During a review of Resident 1's Radiology (xray, process of taking pictures to diagnose and treat diseases) Results Report dated 6/9/2026 at 3:36 p.m., the result indicated Resident 1 had an acute nondisplaced fracture on the proximal left tibia/fibula, medial malleolus and distal fibula. During a review of Resident 1's progress notes dated 6/9/2026, the progress notes indicated on 6/9/2026, around 6:29 p.m., Resident 1's physician was notified of Resident 1's x-ray result. Resident 1's physician ordered Resident 1's transfer to the GACH for evaluation and treatment. During a review of Resident 1's GACH Emergency Department (ED) admission record, dated 6/10/2026 at 4:49 a.m., the GACH ED record indicated a left tibia and fibula fracture at the extended-care facility (skilled nursing facility [Facility 1]), with left leg pain and swelling. During a review of Resident 1's GACH Orthopedic (a branch of medicine dealing with conditions affecting the bones or muscles) Surgery progress notes, dated 6/10/2026 at 4:05 p.m., the progress notes indicated Resident 1 had a minimally displaced left tibia shaft (the fracture along the central length of the tibia) and proximal (upper portion) fibula fracture. Resident 1 will be non-weight bearing and will be placed in a knee immobilizer (a brace or supportive device that prevents the knee from bending, protects injured tissues, and promotes proper healing). The progress notes indicated there were no plans for surgery on Resident 1. During an interview on 6/26/2026 at 9:35 a.m. with Resident 1 in her room, Resident 1 stated that when Certified Nurse Assistant (CNA) 2 carried her back to bed from the geri-chair (date unspecified), she was pushed to the side of the bed and twisted her foot. CNA 2 did not use a hoyer lift. During an interview on 6/26/2026 at 1:32 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 required a two-person assist during transfer, with the assistance of a hoyer lift. Resident 1's bilateral lower extremities were rigid (unable to bend) and Resident 1 could not stand. LVN 1 stated on 6/8/2026, around lunchtime, Resident 1 was seen in the activity room, on a geri-chair without a transfer sling (a specialized device used together with the hoyer lift to safely transfer individuals with limited mobility) under her back. LVN 1 stated she asked CNA 2 about Resident 1's sling and CNA 2 stated she did not use the hoyer lift in transferring Resident 1 from the bed to the geri-chair. LVN 1 stated later in the afternoon when Resident 1 was back to bed, Resident 1 complained of left knee pain (pain level unspecified). LVN 1 stated it was very important to follow Resident 1's care plan for safety and to prevent any injuries. During an interview on 6/26/2026 at 1:55 p.m. with CNA 2, CNA 2 stated on 6/8/2026 after providing Resident 1's ADL, she (CNA 2) transferred Resident 1 to the geri-chair by herself without using the hoyer lift. CNA 2 stated, I was able to carry her (Resident 1) to the geri-chair, and that was what I did. CNA 2 stated she did not know she was required to use the hoyer lift for the transfer. CNA 2 stated she did not remember seeing a picture of a hoyer lift posted at the door or at the headboard. CNA 2 stated CNA 4 assisted in transferring Resident 1 back to bed after lunch by carrying Resident 1 back to her bed. CNA 2 stated it was important to use proper equipment before transferring a resident to ensure patient safety and prevent falls or injuries. During an interview on 6/26/2026 at 2:26 p.m. with CNA 4, CNA 4 stated Resident 1 was in the geri-chair when CNA 2 asked him to help transfer Resident 1 back to bed. CNA 4 stated they (CNA 2 and CNA 4) did not use the hoyer lift because there was no sling under Resident 1. CNA 4 stated he held Resident 1 by the upper arms, and CNA 2 held the resident by her legs. CNA 4 stated Resident 1 required a hoyer lift during transfer, but because there was no sling placed under the resident, Resident 1 was carried back to her bed. CNA 4 stated it was not safe to carry Resident 1 back to bed, as the resident could fall or hit on something (unspecified). CNA 4 stated staff should use the hoyer lift to ensure residents' safety during transfers if residents were dependent on assistance. During a concurrent interview and record review on 6/26/2026 at 3:50 p.m. with the Registered Nurse (RN) 1, Resident 1's care plan titled, Resident has limited physical mobility and fluctuations in all ADLs related to contractures, weakness, impaired mobility and requiring maximum assistance from the staff in all ADLs, revised 4/10/2026, was reviewed. RN 1 stated the interventions did not indicate the use of hoyer lift during transfer or the number of persons required during the resident's transfer. RN 1 stated Resident 1 had contractures and could not bear weight on both feet. Resident 1 required a hoyer lift to be transferred to the geri-chair. RN 1 stated a hoyer lift sign was posted in Resident 1's room and there was no reason for CNA 2 to not know that Resident 1 required a hoyer lift during transfers. RN 1 stated charge nurses conduct a huddle to inform CNAs of all the residents' transfer needs. RN 1 stated failure to follow Resident 1's individualized care plan could result in injuries and/or fractures. During an interview on 6/26/2026 at 4:00 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 1's baseline was bed rest. Resident 1's mobility included full use of her upper extremities (parts of the body extending from the shoulders, arms, forearms, wrists, and hands) with no limitations, while her lower extremities were non-weight bearing. The DOR stated Resident 1 was dependent on assistance and it was important to use the hoyer lift to prevent her from getting hurt or falling during transfers. The DOR stated it was essential to maintain Resident 1's safety using the proper equipment for transfer. During a concurrent interview and record review on 7/8/2026 at 9:00 a.m., with LVN 4, the MDS dated [DATE], section GG (Section in MDS for Functional Abilities) on mobility devices and Resident 1's care plan titled, Requires use of geri-chair for out of bed activities; inability to tolerate use of wheelchair due to poor trunk control, dated 4/10/2026, were reviewed. LVN 4 stated Resident 1 required a mechanical lift transfer which was not accurately reflected in Resident 1's MDS section GG. LVN 4 stated nurses were required to use a hoyer lift for all residents who were dependent on staff assistance to prevent injuries. LVN 4 stated if staff had used the hoyer lift during Resident 1's transfer, it could have prevented the injury. LVN 4 stated the interventions in Resident 1's care plan did not specify the number of staff or the equipment required to safely transfer Resident 1 to the geri-chair and back to bed. LVN 4 stated that failure to develop the appropriate care plan interventions contributed to Resident 1's injury. During a review of facility's policy and procedure (P&P) titled, Transfer of Residents, dated 2/24/2026, the P&P indicated a licensed nurse and/ or the Director of Rehabilitation should assess and determine lifting and transfer requirements and the procedure to be used for each resident. The type of transfer should be recorded in the resident's care plan. The P&P indicated mechanical lifts are used for non-weight bearing residents. Residents must be lifted or transferred according to the determined need for staff assistance. Residents who required assistance in transferring may be transferred using a gait (manner of walking)/transfer belt or with a lift. During a review of the facility's P&P titled, Total Mechanical Lift, dated 5/1/2018, the P&P indicated the purpose of the policy was to use mechanical lift appropriately to facilitate transfer of residents. The P&P indicated to put sling under the resident, with at least two people present while residents are being transferred with mechanical lift. During a review of the facility's Certified Nursing Assistant (CNA) Job Description, dated 12/8/1998, the job description indicated CNA responsibilities and duties were to adhere to the facility's injury and illness prevention program, to consistently perform job duties in accordance with the facility's safe work practice and adhere to prescribed safety practices.

Based on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Unusual Occurrence (an unexpected event or accident that results in significant harm or requires significant additional measures) Reporting , which indicated the facility will report unusual occurrence by phone and in writing to the appropriate Stated or Federal agencies, within 24 hours, when one of three sampled residents (Resident 1), sustained fracture ( broken bone) on the left tibia/fibula (long bone in the lower leg), and distal fibula (lower end of the 2 long bones in the lower leg) on 6/8/2026. This failure delayed the investigation by the California Department of Public Health (CDPH) and placed Resident 1 and other residents at risk for potential neglect and abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including quadriplegia (symptom of paralysis that affects all limbs and body from the neck down), rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing pain, swelling, and stiffness) and dementia. During a review of Resident 1's History and Physical examination (H&P) dated 12/10/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Residents 1's MDS dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent (helper does all the effort) on staff with activities of daily living (ADLs) such as oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/off footwear, personal hygiene, chair/bed-to-chair transfer, tub and shower transfer. Resident 1 required substantial/maximal (helper does more than half) assistance in rolling left and right of the bed. The MDS did not indicate prior devices were used and had no mobility devices used in the last 7 days (from 4/3/2026). During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 6/9/2026 at 3:15 a.m., the SBAR indicated Resident 1 was crying while lying in bed in a supine (lying flat on back) position. The SBAR indicated Resident 1 complained of pain to her foot rated at 6/10 (a numerical pain scale with 0 = no pain, 1-3= mild pain, 4-6 moderate pain, 7-8 = severe pain, 9-10 = worst pain possible), extending from the left knee to the foot. The SBAR indicated Resident 1's skin on the left foot was abnormally tight (unspecified), the resident could not move the left leg and cried uncontrollably when the left foot was lightly touched. During a review of Resident 1's Incident/ Accident Report (Non-Fall), dated 6/9/2026 at 10 a.m., the report indicated per resident, she hit her left leg on the geri-chair (also known as a geriatric chair or medical recliner- a specialized seating device designed for patients with limited mobility) but did not report it. The report indicated the assigned CNA did not use a hoyer lift (a mechanical device used to lift and/or transfer a person from place to place). During a review of Resident 1's Radiology (Xray, process of taking pictures to diagnose and treat diseases) Results Report dated 6/9/2026 at 3:36 p.m., the result indicated Resident 1 had an acute nondisplaced fracture on the proximal left tibia/fibula, medial malleolus and distal fibula. During an interview on 6/26/2026 at 3:50 p.m. with Registered Nurse (RN) 1, RN 1 stated the facility conducted an internal investigation of Resident 1's left leg fracture but failed to report to the CDPH. RN 1 stated the facility should have reported the incident to CDPH to ensure Resident 1's safety. During an interview on 6/26/2026 at 4:50 p.m. with the Administrator (ADM), the ADM stated that when an incident occurs involving a resident's safety (Resident 1 sustaining a fracture), the facility was responsible for investigating and reporting the injury to CDPH within 24 hours. The ADM confirmed the facility did not report the incident involving Resident 1 to CDPH. During a review of facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 5/1/2018, the P&P indicated occurrences that affect the welfare, safety, or health of residents, employees, or visitors should be reported to the State and Federal agencies within 24 hours by telephone and then confirmed in writing.

Based on interview and record review, the facility failed to meet professional standards of quality, for one of three residents (Resident 1), by failing to: 1). Ensure Resident 1's pain level was reassessed and documented within one hour, after the pain medications were administered on 3/13/2026, 3/15/2026, 3/16/2026, 3/17/2026, 3/19/2026, 3/20/2026, 3/21/2026, 3/26/2026, 3/27/2026, 3/28/2026 and on 4/2/2026 and 4/3/2026.2). Clarify from Resident 1's physician, the orders of Tylenol (a pain-relieving medication), 500 milligrams ([mg], metric unit of measurement, used for medication dosage and/or amount) given for moderate pain and Tylenol 325 mg two (2) tablets (650 mg.) given for mild pain.3). Ensure the physician's order was complete with numerical pain scale (a numerical pain scale used in a facility with 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible) for mild, moderate and severe pain. These failures placed Resident 1 at risk of unresolved pain and the potential for poor quality care in pain management.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included Post-Traumatic Stress Disorder ([PTSD], a mental health condition triggered by experiencing or witnessing a terrifying event) and unspecified osteoarthritis (a degenerative joint disease where cartilage breaks down, causing pain, stiffness, and reduced mobility), unspecified (unknown) site. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 2/17/2026, the MDS indicated Resident 1 had moderate (not extreme) cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with Activities of Daily Living (ADLs) such as showering/bathing self and personal hygiene. During a review of Resident 1's Order Summary Report (a list of resident's orders), dated 4/7/2026, the Order Summary Report indicated Resident 1 had the following orders: Monitor pain every (q) shift and document using the 0-10 rating every shift for pain management. Ibuprofen Oral Tablet 200 mg, give 2 tablets orally every six (6) hours as needed (PRN) for pain at the back and shoulder. Tylenol Oral Tablet 325 mg, give 2 tablets by mouth every 6 hours PRN for mild pain. Tylenol Extra Strength Tablet 500 mg, give 1 tablet by mouth every eight (8) hours PRN for moderate pain, not to exceed three (3) grams ([g], a metric unit of mass and weight equal to one-thousandth of a kilogram) per 24 hours. During a concurrent interview and record review on 4/7/2026 at 1:41 p.m., with Licensed Vocational Nurse (LVN) 1, the following were reviewed:Resident 1's Medication Administration Record (MAR), for the month of 3/2026.Order Administration Notes, dated 3/13/2026, 3/19/2026, 3/20/2026, 3/21/2026, 3/26/2026, 3/27/2026, and 3/28/2026.Facility's policy and procedure (P&P) titled, Pain Management, dated 5/2022.LVN 1 stated the MAR indicated Resident 1 received Ibuprofen during the following dates and times, but the resident's pain level was not reassessed after 30 minutes to 1 hour, to see if the pain medication was effective or not. LVN 1 stated that staff should document when the reassessment occurred to determine what should be done if the pain medication was ineffective. 3/13/2026 at 9:11 a.m. - reassessed at 2:12 p.m.3/19/2026 at 9:42 a.m. - reassessed at 1:37 p.m.3/20/2026 at 10:16 a.m.- reassessed at 1:25 p.m. 3/20/2026 at 8:30 p.m. - reassessed on 3/21/2026 at 1:00 a.m.3/21/2026 at 9:18 a.m.- reassessed at 11:08 a.m. 3/21/2026 at 4:45 p.m. - reassessed at 6:43 p.m. 3/26/2026 at 5:00 p.m.- reassessed at 7:37 p.m.3/27/2026 at 5:00 p.m. - reassessed at 6:32 p.m.3/28/2026 at 4:00 p.m. - reassessed at 8:57 p.m.LVN 1 stated the facility's P&P indicated that pain reassessments should be documented within one hour of administration of pain medication. LVN 1 stated the staff ask the residents who are verbal to rate their pain using a scale of 1-10 (1, being little to no pain and 10 with excruciating pain). During a concurrent interview and record review on 4/7/2026 at 2:44 p.m., with LVN 2, Resident 1's MAR for the month of 4/2026 was reviewed. LVN 2 stated staff assessed Resident 1's pain level by asking Resident 1 to rate their pain on a scale of 1-10. LVN 2 stated staff do not ask residents to rate their pain as, mild, moderate, or severe. LVN 2 also stated Resident 1's Tylenol orders should have been clarified with Resident 1's physician. The current physician's order for Tylenol did not specify any pain level. The Tylenol order for mild pain was 650 mg and the Tylenol ordered for moderate pain was 500 mg. During a concurrent interview and record review on 4/7/2026 at 3:11 p.m., with the Registered Nurse (RN), Resident 1's MAR for the month of 3/2026 and 4/2026, were reviewed. RN stated the MAR indicated Resident 1 received Tylenol 500 mg on the following dates and time, but were not reassessed within one hour:3/13/2026 at 12:39 p.m.- reassessed at 9:45 p.m.3/15/2026 at 4:30 p.m. - reassessed at 7:56 p.m.3/16/2026 at 5:00 p.m. - reassessed at 9:24 p.m.3/17/2026 at 5:00 p.m. - reassessed at 7:30 p.m.4/3/2026 at 2:15 p.m. - reassessed at 3:32 p.m.RN stated not reassessing Resident 1's pain level timely (within 1 hour) after the Tylenol 500 mg. medications were administered on 3/13/2026, 3/15/2026, 3/16/2026, 3/17/2026 and on 4/3/2026, had the potential that Resident 1's pain was not resolved. RN stated, the MAR indicated, on 4/2/2026 at 10:45 a.m. and 6:59 p.m., the staff did not reassess and document Resident 1's pain level after the Ibuprofen medication was given. RN stated that Resident 1's Tylenol orders were not clarified with Resident 1's physician. RN stated Tylenol 325 mg is a standard order for mild pain, not moderate pain. The ordered should have been clarified with the physician because the resident's pain is subjective (based on feelings rather than verifiable facts). During a review of facility's P&P titled, Administration of Pain Medication, dated 5/1/2018, the P&P indicated to, review the physician order and administer the pain medications as ordered. During a review of facility's P&P titled, Pain Management, dated 5/2022, the P&P indicated, the licensed nurse should instruct the resident/and or surrogate regarding the pain scale (a tool used by healthcare professionals to quantify a patient's subjective pain intensity, typically ranging from 0 [no pain] to 10 [worst imaginable pain] utilized by the facility. The P&P indicated, the licensed nurse should administer pain medication as ordered and document on the MAR the drug, time of administration, dose, pain scale rating, and resident's response to medication within one hour.

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled Change of Condition Notification, revised 5/1/2018, for one of two sampled residents (Resident 1) when Resident 1's order for oral antibiotics was not transcribed or carried out, and staff failed to document 72-hour monitoring and develop a care plan for Resident 1's change of condition (COC) identified on 3/5/2026. These deficient practices placed Resident 1 at risk for complications from missed antibiotics, including worsening of a potential infection. This also placed Resident 1 at risk for developing unidentified complications requiring nursing or medical intervention.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included gastroesophageal reflux disease without esophagitis (GERD, a chronic condition where stomach acid frequently flows back into the esophagus, causing symptoms like heartburn, regurgitation, chest pain, and a sour taste). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 1 had moderate cognitive impairment (a decline in mental functioning, encompassing problems with memory, language, thinking, and judgment). The MDS indicated Resident 1 required set-up/clean-up assistance for eating and oral hygiene. During a review of Resident 1's Change of Condition (COC) assessment, dated 3/5/2026, the COC assessment indicated Resident 1 had a swollen right jaw related to her wisdom tooth. The COC assessment indicated Licensed Vocational Nurse (LVN) 2 notified Resident 1's physician and orders were received to refer Resident 1 to the dentist and monitor for 72-hours for acute (a condition that comes on suddenly, has severe symptoms, and usually lasts for a short period) changes. During a review of Resident 1's progress note, dated 3/5/2026 at 3:38 p.m., by the Social Services Assistant (SSA), the progress note indicated Resident 1 was referred to the dentist (Dentist 1). The progress note indicated the SSA transferred the phone call to LVN 2 for orders from Dentist 1. During a review of Resident 1's progress note, dated 3/5/2026 at 3:40 p.m., by LVN 2, the progress note indicated LVN 2 communicated with Dentist 1 regarding Resident 1's tooth. The progress note indicated Dentist 1 informed LVN 2 that orders for oral antibiotics were to be faxed to the facility as soon as possible. During a review of Resident 1's dentist order, dated 3/5/2026, the dentist order indicated an order by Dentist 1 to administer amoxicillin (an antibiotic) 500 milligrams every eight (8) hours for seven days. During an interview on 4/2/2026 at 1:02 p.m., with the Director of Social Services (DSS), the DSS stated Resident 1's dentist order, dated 3/5/2026, was faxed to the facility on 3/5/2026 at 3:47 p.m. During an interview on 4/2/2026 at 3:02 p.m., with Registered Nurse (RN) 1, RN 1 stated she was responsible for developing the care plan following a change of condition. RN 1 stated the care plan ensured continuity of care and outlined the care and services to be provided, including medications. RN 1 stated she was not made aware of Resident 1's change of condition and did not develop a care plan for monitoring or interventions. RN 1 stated 72-hour monitoring was also to be completed following a change of condition and stated this was not done because she was not aware of the change of condition. During an interview on 4/2/2026 at 3:24 p.m., with RN 2, RN 2 stated there was no documentation in Resident 1's medical record to indicate Resident 1's antibiotic order was transcribed into her record or carried out. RN 2 stated failure to transcribe and carry out the order was a delay in care and stated there was potential for infection or worsening infection. RN 2 stated there was no documentation in Resident 1's medical record indicating 72-hr monitoring was conducted related to Resident 1's change of condition. RN 2 stated 72-hour monitoring would also alert staff to follow-up on Resident 1's dentist's order to ensure it was transcribed and carried out timely. During a review of the facility's policy and procedure (P&P) titled Change of Condition Notification, revised 5/1/2018, the P&P indicated the licensed nurse was to document pertinent details of the incident and update the care plan to reflect the resident's status. The P&P indicated a licensed nurse was to document each shift for at least 72 hours.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen that affected 123 residents out of 125 sampled residents when: 1. One container that contained margarine, one opened bottle of whipped cream, one opened bottle of chocolate syrup, one box of dairy creamer, and one bag of parmesan cheese with no use by date (date the food item must be consumed by), were stored in the refrigerator. 2. The can opener was not maintained in a sanitary manner. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 123 of 125 residents who received food from the kitchen. Findings: During an observation during the initial kitchen tour on 6/2/2025 at 8:35 a.m., observed food items in the refrigerator with no opened date or use by date. Observed one container of margarine, one opened bottle of whipped cream, one opened bottle of chocolate syrup, one box of dairy creamer, and one bag of parmesan cheese with no label indicating the date those items were placed in the refrigerator and the date of when items must be used by. During an observation during the initial kitchen tour on 6/2/2025 at 9:00 a.m., observed a can opener attached to the food preparation table in the kitchen. The surface of the can opener was blackened and covered with black stains and dried residue. The area surrounding the can opener blade and gear were heavily stained with dark, hardened food debris. During an interview on 6/2/2025 at 9:10 a.m. with the Dietary Supervisor (DS), in the kitchen, the DS stated food items should be labeled with three dates. The DS stated food was labeled with a received date, opened date, and expiration date. The DS stated food items were labeled to identify if food was safe to consume. The DS stated when a food item was not labeled, the dietary staff would not know if the food was safe to consume. The DS stated refrigerators were checked daily. The DS stated when dietary staff checked the refrigerators, they were supposed to make sure all items were properly labeled, check the condition of the food, and check for expired items. During an interview on 6/2/2025 at 9:25 a.m. with the DS, the DS stated the can opener should be clean and kept in sanitary condition to prevent contamination and growth of harmful bacteria. The DS stated this had the potential for foodborne illness, placing residents at risk for harm. During a review of Food Code 2017, Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) Nonfood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. During a review of the facility's policy and procedure (P&P) titled Labeling and Dating of Foods, undated, the P&P indicated all food items in the refrigerator need to be labeled and dated. The P&P indicated food delivered to the facility needs to be marked with a received date. The P&P indicated newly opened food items need to be labeled with an open date and use by date. During a review of the facility's P&P titled Can Opener and Base, undated, the P&P indicated proper sanitation and maintenance of the can opener was important to sanitary food preparation. The P&P indicated The can opener must be thoroughly cleaned each work shift and when necessary, more frequently.

Based on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of 25 sampled residents (Resident 29 and 68) by failing to: 1. Ensure Resident 29 was bathed. 2. Keep Resident 68's fingernails clean and trimmed. These deficient practices had the potential to negatively impact Resident 29 and 68's quality of life and self-esteem. These deficient practices also had the potential to result in the development of infection. Findings: 1. During a review of Resident 29's admission Record (Face Sheet), the Face Sheet indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), generalized muscle weakness (lack of strength in many muscles throughout the body), and neuromuscular dysfunction of the bladder (lacking bladder control leading to difficulty empty the bladder). During a review of Resident 29's Minimum Data Set ([MDS], a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 29's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 29 was dependent on staff's assistance with toileting, bathing, and lower body dressing. The MDS indicated Resident 29 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). During a review of Resident 29's History and Physical (H&P), dated 5/6/2025, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's Care Plan titled, Activities of Daily Living (ADL) Self-Care Performance Deficit, dated 5/14/2025, the care plan indicated staff were to encourage Resident 29 to shower as scheduled and per Resident 29's preference. During an interview on 6/3/2025 at 8:58 a.m., with Resident 29, Resident 29 stated with the exception of two times, the certified nursing assistants (CNAs) did not bring him to the shower room nor give him a proper bed bath. Resident 29 stated the bed baths he received would not be considered an actual bed bath because the CNA would lightly wet the washcloth and wipe the washcloth on his body. Resident 29 stated the CNAs would not have a basin of water to rewet the washcloth nor would the CNAs rewet the washcloth in the sink. During an interview on 6/4/2025 at 8:28 a.m., with CNA 4, CNA 4 stated the residents follow a shower schedule, however, they can request to shower on any day. CNA 4 stated residents have the option to take a shower in the shower room or a bed bath in their room. CNA 4 stated when giving a bed bath, the CNA was responsible for grabbing a basin of water, fresh towels, and the resident's preferred soap. CNA 4 stated throughout the bed bath, new towels would be used in each section of the body being washed. CNA 4 stated providing perineal care (cleaning and maintenance of the genital and anal area) was very important, especially for a resident with an indwelling urinary catheter. CNA 4 stated perineal care was provided every day and during a resident's shower day. CNA 4 stated after a shower or bed bath was provided to a resident, the CNA was responsible for documenting on the resident's Task sheet on the electronic health record (eHR). During a concurrent interview and record review on 6/4/2025 at 8:39 a.m., with CNA 4, Resident 29's Bathing Task, dated May and June 2025 were reviewed. The Bathing Task indicated Resident 29 only had one documented shower on 5/13/2025. CNA 4 stated without documented showers, there was no way to prove Resident 29 received a shower or a bed bath. CNA 4 stated this was in issue because Resident 29 was at risk for infection due to the presence of the indwelling urinary catheter and bathing was essential to keep Resident 29 clean and free of dirt and bacteria. CNA 4 stated not only are showers essential for infection prevention, but showers were also important for Resident 29's self-esteem by feeling clean and not malodorous (smelling unpleasant). During an interview on 6/4/2025 at 2:34 p.m., with the Director of Nursing (DON), the DON stated all CNAs were expected to provide routine showers or bed baths to the residents. The DON stated a bed bath consisted of a water filled basin and towels to ensure the resident was clean. The DON stated the CNA was responsible for documenting in the resident's eHR after completing the bed bath to communicate to other staff members the date of the bath and the level of assistance the resident required. The DON stated Resident 29 should have been bathed either in the shower room or in his room. The DON stated bathing Resident 29 was essential for cleanliness, self-esteem, and infection prevention. The DON stated perineal care would also be provided during a bath and perineal care was essential for Resident 29 due to the presence of an indwelling urinary catheter. The DON stated not only was Resident 29 at risk for self-esteem issues, Resident 29 was also at risk for developing an infection. During a review of the facility's policy and procedure (P&P) titled, Showering a Resident, revised 5/1/2018, the P&P indicated, A shower bath is given to the residents to provide cleanliness, comfort, and to prevent body odors. 2. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), and muscle weakness. During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68's cognition was intact. The MDS indicated Resident 83 required moderate (helper does less than half the effort) assistance from staff for ADLs. During a concurrent observation and interview of 6/2/2025 at 9:52 a.m., in Resident 68's room, with Resident 68, the resident was observed with visibly long, irregular in shape fingernails. The fingernails had dark brown debris underneath and curled over the fingertips. Resident 68 stated her nails were dirty and too long. Resident 68 stated no one had cut and/or cleaned her nails in a while. During a concurrent observation and interview on 6/2/2025 at 3:30 p.m., in Resident 68's room, with CNA 3, Resident 68 was observed with a dark brown substance underneath her fingernails. CNA 3 stated Resident 68's fingernails were dirty and required cleaning and trimming. CNA 3 stated nail care was one of the CNA's responsibilities, which included observing the resident's nails and trimming and cleaning when long and dirty. CNA 3 stated residents' nails should be checked daily to ensure nails remain clean and neat. CNA 3 stated residents sometimes scratch their skin, and if they scratch hard enough, they could break the skin and create an open wound. CNA 3 stated if a resident had dirty fingernails and scratched themselves, this increased the risk of infection. CNA 3 stated having dirty fingernails was unsanitary because the residents use their hands to eat, and any bacteria present could be transferred to their mouth. CNA 3 stated if Resident 68 was to touch shared objects, bacteria from under her fingernails could be transferred to those items and potentially to other residents. During an interview on 6/5/2025 at 9:30 am., with the DON, the DON stated fingernail care was a part of the resident's ADLs routine. The DON stated if a resident had long and dirty fingernails, CNAs were expected to clean and trim them. The DON stated dirty fingernails was not acceptable, as they increase the risk of infection, especially if residents touch food or share items. During a review of P&P titled Grooming Care of the Fingernails and Toenails, revised 5/1/2018, the P&P indicated facility would provide nail care to keep residents' nails clean and trim. The P&P indicated CNAs would trim residents' fingernails.

b. During a review of Resident 29's admission Record (Face Sheet), the Face Sheet indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), generalized muscle weakness (lack of strength in many muscles throughout the body), and neuromuscular dysfunction of the bladder (lacking bladder control leading to difficulty empty the bladder). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29's cognition was moderately impaired, and the resident was dependent on staff's assistance for toileting, bathing, and lower body dressing. The MDS indicated Resident 29 had an indwelling urinary catheter. During an interview on 6/4/2025 at 8:54 a.m., Resident 29 stated the urinary catheter was not secured to his leg and that he often felt the tubing go under his genital area and his leg. Resident 29 stated when the tubing went underneath him, he would feel it poking him and would be very uncomfortable. Resident 29 stated at times the tubing felt like it was pulling, and he would have to try to readjust it. During a concurrent observation and interview on 6/4/2025 at 9:02 a.m., with TN 1 in Resident 29's room, Resident 29 was observed lying in bed with his urinary catheter exposed. Resident 29's indwelling urinary catheter exited from Resident 29's urethra (the tube that carries urine from the bladder out of the body) and the tubing was not secured to Resident 29's leg. TN 1 stated Resident 29's urinary catheter tubing should always be secured to his leg. TN 1 stated securing the tubing to Resident 29's leg offered protection from accidental pulling and dislodgement. TN 1 stated securing the tubing offered protection to Resident 29's genital area and legs to prevent any unnecessary pressure and poking. During an interview on 6/4/2025 at 2:42 p.m., the Director of Nursing (DON) stated indwelling urinary catheters should always be secured to the resident's leg. The DON stated Resident 29 was able to move around in bed and his urinary catheter could move under him or get stuck. The DON stated without the proper urinary catheter securement, Resident 29 was at risk of the urinary catheter pulling and dislodging which could be very painful. During a review of the facility's P&P titled, Catheter- Care of, revised 5/1/2018, the P&P indicated, Anchor the catheter with a leg strap to protect excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter. Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Residents 89 and 29) received the necessary care and services to maintain normal bladder function. Resident 89 did not receive daily urinary catheter care and Resident 29's urinary catheter was not secured with a leg strap. These deficient practices had the potential to result in a urinary tract infection (UTI- an infection in the bladder/urinary tract), urethral injury and / or unnecessary discomfort for Resident 89 and Resident 29. Findings: a. During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including retention of urine, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status, severe sepsis (a life-threatening blood infection) with septic shock ( a near-fatal condition that occurs with sepsis), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 89's Care Plan titled, Resident Requires Use of Foley Catheter, dated 10/18/2024, the care plan indicated the facility's interventions were to cleanse the foley catheter and urethral opening with normal saline daily or as needed. During a review of Resident 89's Minimum Data Set (MDS, a resident assessment tool), dated 5/16/2025, the MDS indicated Resident 89's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 89 was entirely dependent on staff for Activities of Daily Living and the resident had an indwelling catheter. During an observation made on 6/2/2025 at 10 a.m., in Resident 89's room, Resident 89 was in bed with his urinary catheter in place. During a concurrent interview and record review on 6/4/2025 at 9:41 a.m., with the Treatment Nurse (TN) 1, Resident 89's Physician's Orders, dated 4/2025 to 6/4/2025, and Resident 89's Treatment Administration Record (TAR), dated 4/2025 to 6/2/2025, were reviewed. The Physician's Orders indicated Resident 89 had a urinary catheter in place from 4/2025 to 6/4/2025. The Physician's Orders indicated there was no order for daily urinary catheter care since 4/2025. The TAR indicated there was no documentation of daily urinary catheter care since 4/2025. TN 1 stated the facility's normal practice to prevent the occurrence of UTI's was to ensure urinary catheter care was provided daily. This included the catheter bag was changed twice a week or as needed, and the resident's output was monitored and documented. TN 1 stated there was no documentation to indicate Resident 89 received daily urinary catheter care since 4/2025. TN 1 stated it was important to maintain documentation of daily urinary catheter care because the documentation served as proof that the task was completed. TN 1 stated if the care was not done daily, then there was potential for Resident 89 to develop a urinary catheter associated infection or a UTI. During a review of the facility's Policy and Procedure (P&P), titled, Catheter- Care Of, dated 5/1/2018, the P&P indicated the facility was to prevent catheter-associated urinary tract infections. The P&P indicated documentation of catheter care would be maintained in the resident's medical record.

Based on observation, interview and record review, the facility failed to ensure that its medication error rate was less than five percent (%). There were two medication errors out of 31 total opportunities which contributed to an overall medication error rate of 6.45% affecting two of five residents observed for medication administration (Resident 23 and Resident 60). Resident 23 and Resident 60 did not receive medications per Physician's Order, nor did the pharmacy have the medication available for Resident 23. The deficient practice of failing to administer medications in accordance with the physician's orders, including pharmacy not having the prescribed medication available, increased the risk that Residents 23 and 60 may have experienced medical complications possibly resulting in hospitalization. Cross Reference F755 Findings: a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was re-admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (an interruption in blood flow to the brain), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), and gastrostomy (g-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 23 was entirely dependent on staff for activities of daily living. During a review of the Physician's Order Summary Report, dated 6/3/2025, the Order Summary Report indicated Resident 23 was ordered isosorbide mononitrate (a medication used to prevent chest pain [angina] caused by coronary artery disease) oral tablet 30 milligrams (mg, unit of measurement) via g-tube one time a day for hypertensive (high blood pressure) heart disease on 5/20/2025. During a concurrent observation, interview, and record review on 6/3/2025 at 8:43 a.m. with LVN 1, Resident 23's isosorbide bubble pack was observed, Resident 23's isosorbide bubble pack medication label was reviewed and Resident 23's Physician Orders, dated 5/20/2025, were reviewed. The bubble pack had 11 tablets remaining out of the 31 doses dispensed. The bubble pack label indicated the contents of the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg extended release. The Physician's Orders indicated Resident 23 was ordered isosorbide mononitrate oral tablet 30 mg via g-tube one time a day on 5/20/2025. LVN 1 stated she did not notice the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg extended release and stated extended-release medication was not to be crushed and administered via g-tube unless prescribed by the physician. LVN 1 stated the order should have been clarified by the physician and the pharmacy should have been made aware. LVN 1 stated Resident 23's physician medication order of isosorbide mononitrate oral tablet 30 mg was not prepared or ordered as prescribed, which could have placed Resident 23 at risk for a sudden drop in blood pressure and, or decreased heart rate. During a concurrent interview and record review at 6/3/2025 at 8:45 a.m. with LVN 1, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated Resident 23 received 14 doses of isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 1 stated the only supply of isosorbide mononitrate oral tablet 30 mg was the extended-release dose. LVN 1 stated she was Resident 23's assigned nurse the day before (6/2/2025) and stated she crushed and administered Resident 23's isosorbide mononitrate oral tablet 30 mg extended-release dose via g-tube. LVN 1 stated she did not notice the physician orders did not match the labeling on the bubble pack supply of isosorbide for the five times she had administered it since 5/20/2025. During a concurrent interview and record review on 6/4/2025 at 11:11 a.m. with LVN 2, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated LVN 2 administered six doses of the 14 doses of Resident 23's isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 2 stated she crushed and administered the medication that was dispensed by the pharmacy (isosorbide mononitrate oral tablet 30 mg extended release) and did not notice the physician's orders did not match the labeling on the bubble pack supply for the six times she had administered it since 5/20/2025. LVN 2 stated by not comparing the bubble pack supply to the physician's order, and by crushing the extended-release dose of isosorbide, this placed Resident 23 at risk for death or hospitalization. During an interview on 6/3/2025 at 11:42 a.m. with Pharmacist 1, Pharmacist 1 stated the pharmacy had not delivered Resident 23's bubble pack supply of isosorbide mononitrate oral tablet 30 mg (immediate release) to the facility. Pharmacist 1 stated isosorbide mononitrate oral tablet 30 mg was only available in ER form and not in immediate release form. Pharmacist 1 stated the pharmacy delivered isosorbide mononitrate oral tablet 30 mg ER to the facility and the error was not noticed by the pharmacy technicians or the licensed nursing staff. During an interview on 6/4/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON stated she expected the pharmacy to communicate with the licensed nursing staff to make them aware the isosorbide mononitrate oral tablet 30 mg (immediate release) was not available so that the licensed nursing staff could call the physician. The DON stated she expected the licensed nurse to compare the medication bubble pack with the physician's order prior to the administration of medications. The DON stated if any issues were identified, then the licensed staff would have to communicate with the physician and the pharmacy. The DON stated once an ER medication was crushed, the medication was immediately released into the blood stream and the effects of the medication would start right away. The DON stated an ER medication was intended to be released slowly (over 12-24 hours) into the blood stream throughout the day. The DON stated this placed Resident 23 at risk for a hypotensive (low blood pressure) or bradycardic (slow heart rate) event because medication was crushed and not administered per the physician's order. b. During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was re-admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastrointestinal hemorrhage, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognitive skills for daily decision making were moderately impaired. During a concurrent observation and interview on 6/3/2025 at 7:45 a.m. with LVN 3, LVN 3's medication pass was observed. LVN 3 dispensed one metformin oral tablet 1000 mg in a medication cup. LVN 3 entered Resident 60's room and attempted to administer Resident 60 the tablet without his breakfast tray or food. During a concurrent interview and record review on 6/3/2025 at 7:50 a.m. with LVN 3, Resident 60's eMAR, dated 6/3/2025, was reviewed. The eMAR indicated Resident 60 was to receive the dose of metformin with food or a meal. LVN 3 stated she should have waited until Resident 60's breakfast tray was delivered to administer the medication. LVN 3 stated the administration of the metformin would have placed Resident 60 at risk for gastric upset and it did not align with the physician's order. During a review of Resident 60's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated Resident 60 was ordered metformin oral tablet 1000 mg one time a day by mouth and to give with food or meal. During an interview on 6/4/2025 at 12:10 p.m., the DON stated she would have expected the licensed nurses to compare the medication bubble pack with the physician's order prior to administering medications. The DON stated metformin was usually administered with food because some medications were sensitive to gastric acid. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, dated 5/1/2018, the P&P indicated the licensed nurse was to administer medications per the order of the attending physician or licensed independent practitioner. The P&P also indicated the licensed nurse were to perform three checks [which include]: comparing the physician's order, pharmacy label and the medication administration record. The P&P indicated if any discrepancies were identified during the first, second and third check, it must be resolved prior to the administration of any medication. The P&P also indicated the licensed nurse were to perform three checks [which include]: comparing the physician's order, pharmacy label and the medication administration record. The P&P indicated if any discrepancies were identified during the first, second and third check, it must be resolved prior to the administration of any medication. The P&P indicated the licensed nurses were to keep in mind the seven rights of medication when administering medication: a. The right medication b. The right amount c. The right resident d. The right time e. The right route f. Right indication g Right outcome

Based on observation, interview, and record review, the licensed nursing staff failed to ensure a resident was free from significant medication errors when staff failed to ensure the following for one of six sampled residents (Resident 23): 1. Resident 23's blood pressure medication was administered as ordered when the licensed nursing staff crushed and administered isosorbide mononitrate (a blood pressure medication) oral tablet 30 milligrams (mg- a unit of measurement) extended-release (ER- a medication that is formulated so that the drug is released slowly over time) in place of the prescribed isosorbide mononitrate 30 mg immediate release (IR- medication that allows for immediate absorption) on 14 occasions. 2. The pharmacy supplied the facility the correct form and dose of isosorbide mononitrate oral 30 mg for Resident 23, as ordered. These failures resulted in 14 instances of improper administration over a two-week period, which had the potential to cause rapid release of the drug, leading to hypotension (low blood pressure) dizziness, and other adverse cardiovascular effects for Resident 23. Findings: 1a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (an interruption in blood flow to the brain), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), and gastrostomy (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 23's Minimum Data Set ([MDS], a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 23 was entirely dependent on staff for 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 23's Order Recap Report, dated 6/3/2025, the Order Recap Report indicated on 5/20/20205 Resident 23 was ordered isosorbide mononitrate (a blood pressure medication) oral tablet 30 milligrams (mg- a unit of measurement) via g-tube one time a day for hypertensive (high blood pressure) heart disease. During a concurrent observation and interview on 6/3/2025 at 8:40 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1's medication pass was observed. LVN 1 compared Resident 28's bubble pack, which was labeled as isosorbide mononitrate oral tablet 30 mg ER to Resident 28's Electronic Medication Administration Record (eMAR) and proceeded to place one pill from the bubble pack into a medication cup. LVN 1 proceeded to place the medication in a plastic medication bag to prepare to crush the tablet of isosorbide mononitrate oral tablet 30 mg ER. During a concurrent observation, interview, and record review on 6/3/2025 at 8:43 a.m. with LVN 1, Resident 23's isosorbide bubble pack was observed, Resident 23's isosorbide bubble pack medication label was reviewed and Resident 23's Physician Orders and eMAR, dated 6/3/2025, were reviewed. The bubble pack had 11 tablets remaining out of the 31 doses dispensed. The bubble pack label indicated the contents of the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg ER. The Physician Orders and eMAR indicated Resident 23 was ordered isosorbide mononitrate oral tablet 30 mg via g-tube one time a day. LVN 1 stated she did not notice the bubble pack contained doses of isosorbide mononitrate oral tablet 30 mg ER and stated ER medication was not to be crushed and administered via g-tube unless prescribed by the physician. LVN 1 stated the order should have been clarified by the physician and the pharmacy should have been made aware. LVN 1 stated Resident 23's physician medication order of isosorbide mononitrate oral tablet 30 mg was not prepared or ordered as prescribed, which could have placed Resident 23 at risk for a sudden drop in blood pressure and, or decreased heart rate. During a concurrent interview and record review at 6/3/2025 at 8:45 a.m. with LVN 1, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated Resident 23 received 14 doses of isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 1 stated the only supply of isosorbide mononitrate oral tablet 30 mg was the ER dose. LVN 1 stated she was Resident 23's assigned nurse on 6/2/2025 and stated she crushed and administered Resident 23's isosorbide mononitrate oral tablet 30 mg ER dose via g-tube. LVN 1 stated she did not notice the physician orders did not match the labeling on the bubble pack supply of isosorbide for the total of five times she administered the medication since 5/20/2025. During a concurrent interview and record review on 6/4/2025 at 11:11 a.m. with LVN 2, Resident 23's eMAR, dated 5/20/2025 to 6/3/2025, was reviewed. The eMAR indicated LVN 2 administered six doses of the 14 doses of Resident 23's isosorbide mononitrate oral tablet 30 mg via g-tube. LVN 2 stated she crushed and administered the medication that was dispensed by the pharmacy (isosorbide mononitrate oral tablet 30 mg ER) and did not notice the physician orders did not match the labeling on the bubble pack supply for the total of six times she administered the medication since 5/20/2025. LVN 2 stated this placed Resident 23 at risk for death or hospitalization by not comparing the bubble pack supply to the physician order and crushing the ER dose of isosorbide. 2a. During an interview on 6/3/2025 at 11:42 a.m. with Pharmacist 1, Pharmacist 1 stated the pharmacy had not delivered Resident 23's bubble pack supply of isosorbide mononitrate oral tablet 30 mg (IR) to the facility. Pharmacist 1 stated isosorbide mononitrate oral tablet 30 mg was only available in ER form and not in IR form. Pharmacist 1 stated the pharmacy delivered isosorbide mononitrate oral tablet 30 mg ER to the facility and the error was not noticed by the pharmacy technicians or the licensed nursing staff. During an interview on 6/4/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON stated she expected the pharmacy to communicate with the licensed nursing staff to make them aware the isosorbide mononitrate oral tablet 30 mg (IR) was not available so that the licensed nursing staff could call the physician. The DON stated she expected the licensed nurse to compare the medication bubble pack with the physician's order prior to the administration of medications. The DON stated if any issues were identified, then the licensed staff would have to communicate with the physician and the pharmacy. The DON stated once an ER medication was crushed, the medication was immediately released into the blood stream and the effects of the medication would start right away. The DON stated an ER medication was intended to be released slowly (over 12-24 hours) into the blood stream throughout the day. The DON stated this placed Resident 23 at risk for a hypotensive (low blood pressure) or bradycardic (slow heart rate) event because medication was crushed and not administered per the physician's order. During a review of the facility's Policy and Procedure (P&P), titled, Medication Administration, dated 5/1/2018, the P&P indicated the licensed nurse was to administer medications per the order of the attending physician or licensed independent practitioner. The P&P indicated the licensed nurse were to perform three checks [which include]: comparing the physician's order, pharmacy label and the medication administration record. The P&P indicated if any discrepancies were identified during the first, second and third check, it must be resolved prior to the administration of any medication. The P&P indicated the licensed nurses were to keep in mind the seven rights of medication when administering medication: a. The right medication b. The right amount c. The right resident d. The right time e. The right route f. Right indication g Right outcome

Based on observation, interview, and record review, the facility failed to honor a resident's preference regarding personal care by assigning a male certified nursing assistant (CNA) to provide showers to one of eight sampled residents (Resident 86) when the resident requested to have female CNAs assigned on her shower days. This failure resulted in a violation of Resident 86's personal dignity and right to make decisions about her care. Findings: During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension ([HTN] - high blood pressure), metabolic encephalopathy (brain dysfunction), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness (loss of muscle strength). During a review of Resident 86's Minimum Data Set ([MDS]- a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 86's cognition (ability to think and reason) was intact. The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes activity) from staff for 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 6/2/2025 at 11:41 a.m., with Resident 86, Resident 86 stated her scheduled shower days were twice a week, on Mondays and Thursdays. Resident 86 stated she repeatedly informed staff that she did not want a male staff to assist her with showers. Resident 86 stated despite her request male CNAs continue to be assigned to her. Resident 86 stated the most recent incident occurred two weeks ago and again on 6/2/2025. Resident 86 stated she felt uncomfortable and embarrassed. Resident 86 stated the facility did not respect her wishes or her privacy. During a concurrent observation and interview on 6/5/2025 at 7:30 a.m., with Resident 86, in Resident 86's room, Resident 86 was observed siting on her bed, visibly upset. Resident 86 stated she had once again been assigned a male CNA on her shower day. Resident 86 stated she felt embarrassed and experienced a loss of dignity due to the facility's continued disregard for her expressed preferences. During a concurrent observation and interview on 6/5/2025 at 7:35 a.m., with CNA 2, who was male, stated he had been assigned to assist Resident 86 on her most recent shower days and on 6/5/2025. CNA 2 stated he was not aware Resident 86 was uncomfortable receiving assistance from a male CNA during her showers. CNA 2 stated if the resident preferred a female CNA, it was the responsibility of the Director of Staff Development (DSD) to ensure such preferences were reflected in the daily assignment. During a concurrent interview and record review on 6/5/2025 at 7:50 a.m., with the DSD, the facility's staff assignment records titled Nursing Staffing Assignment and Sign in Sheet, dated 5/1/2025 through 6/5/2025, were reviewed. The staff assignment records indicated on 5/19/2025, 6/2/2025, and 6/5/2025, a male (CNA 2) was assigned to assist Resident 86 with her shower. The DSD stated she was aware of Resident 86's preference for female CNAs during showers, which had been communicated verbally by the resident, however she overlooked the CNA assignment and did not include any instructions or notations in the daily assignment sheet to ensure that the resident's preference was followed. The DSD stated this failure to honor the resident's preferences could lead to emotional distress and loss of dignity. During an interview on 6/5/2025 at 9:30 a.m., with the Director of Nursing (DON), the DON stated resident's preferences such as care preferences should be honored and clearly communicated during staff assignments. The DON stated repeated exposure to the male CNA, against the resident's preferences, could lead to emotional discomfort and that the resident's personal care preferences were not valued or respected. The DON stated this compromised the resident's well-being and quality of life. During a review of the facility's policy and procedure (P&P) titled Privacy and Dignity, revised 5/1/2018, the P&P indicated To ensure that care and services provided by the Facility promote and/or enhance privacy, dignity and overall quality of live. During a review of the facility's P&P titled Resident Rights, revised 5/1/2023, the P&P indicated the facility would protect the right of all residents at the facility. The P&P indicated The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on interview and record review, the facility failed to timely submit the referral for probate conservatorship (referral to the court to appoint a conservator [an appointed person to act or make decisions for a person who cannot make decisions for themselves]) for one of three sampled residents (Resident41), who did not have the capacity to make decisions. This deficient practice resulted in the delay in the process of obtaining a conservator, which resulted in the Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) overseeing Resident 41's care. Findings: During a review of Resident 41's admission Record (Face Sheet), the Face Sheet indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), cerebral infarction (loss of blood flow to a part of the brain), and schizophrenia (a mental illness that is characterized by disturbances in thought). The Face Sheet indicated the clinical IDT was Resident 41's responsible party. During a review of Resident 41's Minimum Data Set ([MDS], a resident assessment tool), dated 4/29/2025, the MDS indicated Resident 41's cognition (process of thinking) was severely impaired. The MDS indicated Resident 41 was dependent on staff's assistance with toileting, bathing, and putting on/taking off footwear. During a concurrent interview and record review on 6/3/2025 at 2:48 p.m., with the Social Services Director (SSD), Resident 41's History and Physical (H&P), dated 11/26/2024, was reviewed. The SSD stated Resident 41 did not have the capacity to understand and make decisions. The SSD stated Resident 41 did not have any family or friends involved in her care. The SSD stated since Resident 41 was assessed by their physician to not having the capacity to make medical decisions and no other person was involved in their care, the Resident 41 was supposed to be referred for probate conservatorship. The SSD stated while the referral was processed, the Resident 41's care would be overseen by the clinical IDT until a conservator was appointed. The SSD stated the process for appointing a conservator was a lengthy process and it was important to initiate the referral timely. During a concurrent interview and record review on 6/3/2025 at 2:54 p.m., with the SSD, Resident 41's IDT Conference Meeting, dated 2/27/2025, was reviewed. The SSD stated Resident 41's referral for probate conservatorship was made that day after the IDT met to discuss Resident 41's need for conservator. The SSD stated the process for appointing a conservator could be lengthy and the referral should be sent as soon as possible. The SSD stated three months was too long to wait to submit the referral for probate conservatorship. The SSD stated due to delaying the referral, the rest of the process for probate conservatorship was delayed, therefore the clinical IDT had overseen Resident 41's care for potentially a longer than necessary. During an interview on 6/4/2025 at 2:13 p.m., with the Director of Nursing (DON), the DON stated Resident 41 was unable to make medical decisions for herself, therefore was currently under the care of the clinical IDT. The DON stated Resident 41 was deemed to not having decision making capacity in November 2024 and should have been referred for probate conservatorship at that time. The DON stated once the social services department determined Resident 41 did not have any family or friends involved in her care, the process should have immediately started. The DON stated waiting three months to submit Resident 41's referral was too long and during those three months, Resident 41's referral could have been processed. The DON stated due to the delay; Resident 41 could have had a conservator appointed but instead stayed under the care of the clinical IDT. During a review of the facility's policy and procedure (P&P) titled, Bioethics Committee, revised 1/31/2025, the P&P indicated, A personal representative must be appointed for each resident lacking decision-making capacity and without a surrogate decision-maker. If the resident has no family or friends willing to participate in the Bioethics Committee meeting on his/her behalf, the Facility must find another person unaffiliated with the nursing home to serve as the resident's representative.

Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the residents prior to treatment with psychotropic (medications that affect brain activities associated with mental processed and behavior) medications for two of six sampled residents (Residents 77 and 86) by failing to: 1. Obtain informed consent from Resident 77, for the use Chlorpromazine (an antipsychotic medication [a medication that effects the mind, emotion, and behavior]). 2. Ensure Resident 86's informed consent for Risperidone (an antipsychotic medication), and Seroquel (an antipsychotic medication) was renewed every six months. The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications could have prevented Residents 77 from exercising the right to decline treatment with psychotropic medications. This increased the risk that Residents 86 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 77's Minimum Data Set (MDS - a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 77 cognition (process of thinking) was moderately impaired. The MDS indicated Resident 77 required moderate assistance (helper does less than half the effort) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 77 received antipsychotic medication. During a review of Resident 77's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated on 3/26/2025, Resident 77's attending physician prescribed Chlorpromazine 25 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount) via gastrostomy ([G-tube]-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems)every six hours as needed for HICCUPS (involuntary spasms of the diaphragm [muscle that separates the chest from the abdomen]). During a review of Resident 77's available informed consent documentation and clinical record, the informed consent documentation and clinical record did not indicate there was documentation Resident 77 received education regarding the risks and benefits of Chlorpromazine prior to initiation on 3/26/2025. During an interview on 6/5/2025 at 3:10 p.m., with the Director of Nursing (DON), the DON stated the facility failed to obtain informed consent related to Resident 77's Chlorpromazine. The DON stated even though this medication was being used to treat HICCUPS for Resident 77, it was still a psychotropic medication which affects the brain and needed informed consent prior to initiation. The DON stated there was a risk that Resident 77 would not be able to exercise their right to opt out of the treatment with Chlorpromazine if the informed consent was not done. The DON stated this increased the risk that Resident 77 could have experienced adverse effects related to the treatment with Chlorpromazine. b. During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia and metabolic encephalopathy (brain dysfunction). During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86's cognition was intact. The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes activity) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 86 received antipsychotic medications. During a review of Resident 68's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated to give: 1. Risperidone 0.25 mg, one tablet by mouth, one time a day for schizophrenia as manifested by (m/b) verbal aggression and angry outbursts. 2. Seroquel 50 mg, one tablet by mouth, at bedtime for schizophrenia as m/b auditory (hearing) hallucination (sensory experiences that a person perceives as real, but are not actually present in the environment). During a concurrent interview and record review on 6/4/2025 at 9:50 a.m., with Registered Nurse (RN) 2, Resident 86's Psychotherapeutic Drugs Informed Consent Form, dated 10/27/2024, was reviewed. The Psychotherapeutic Drugs Informed Consent Form indicated consent was obtained for Risperidone 0.25 mg and Seroquel 50 mg for schizophrenia. RN 2 stated Resident 86's psychotherapeutic drugs informed consent form for Risperidone and Seroquel were outdated. RN 2 stated current regulation required the psychotherapeutic drugs informed consent to be renewed every six months. RN 2 stated Resident 86's psychotherapeutic drugs informed consent should have been renewed for Risperidone and Seroquel on 4/2025. RN 2 it was important to ensure informed consents were renewed every six months so the resident would be aware of the medication's continued use, risks, or benefits. During a review of the Health and Human Services Agency California Department of Public Health All Facilities Letter (AFL), dated 2/28/2024, the AFL indicated the following: 1. All facilities were to obtain a resident's written informed consent for treatment using psychotherapeutic drugs, and consent renewal every six months. 2. Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative along with, the signature of the health care professional declaring the required material information has been provided. 3. The signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures. During a review of the facility's policy and procedure (P&P) titled Informed Consent, revised 1/1/2012, the P&P indicated the facility would ensure a resident's informed consent would be obtained for the use of psychotherapeutic drugs.

Based on observation, interview, and record review, the facility failed to ensure the call light was kept within reach for two of 25 sampled residents (Resident 23 and Resident 34). This deficient practice removed Resident 23's and Resident 34's ability to exercise their right to request assistance from staff and created the potential for accidents and/or delays in care. Findings: a. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted on [DATE] and most recently readmitted on [DATE]. Resident 23's admitting diagnoses included generalized muscle weakness, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (when blood flow to the brain is interrupted, leading to a lack of oxygen and nutrients to brain tissue) affecting left non-dominant side, symptoms and signs involving the musculoskeletal system, and dementia (progressive state of decline in mental abilities). During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 23 had severe cognitive impairments (a decline in mental processes like memory, attention, language, and reasoning). The MDS indicated Resident 23 had upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hips, knees, ankles, feet) impairments on one side of the body. The MDS indicated Resident 23 was dependent on staff for getting dressed and putting on/taking off footwear. The MDS indicated Resident 23 required partial assistance from staff for movement while in bed. During an observation on 6/2/2025 at 10:35 a.m., at Resident 23's bedside, Resident 23's call light was observed on the ground, behind the head of his bed, tangled in the bed frame. During an observation on 6/2/2025 at 12:41 p.m., at Resident 23's bedside, Resident 23's call light was observed on the ground, behind the head of his bed, tangled in the bed frame. During a concurrent interview and record review, on 6/4/2025 at 10:46 a.m., with Registered Nurse (RN) 1, the facility's policy and procedure (P&P) titled Communication - Call System, revised 10/2022, was reviewed. The P&P indicated all residents were to be provided with a call system to enable them to alert nursing staff. RN 1 stated this was for the safety of the resident, and to allow the resident to call for help if needed. RN 1 stated an out of reach call light created the potential for delayed provision of care. During an interview on 6/5/2025 at 11:07 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNAs did room rounds (visual check-ins on the residents) every hour or more frequently. CNA 1 stated the purpose of room rounds was to ensure the residents' needs were met, and to ensure their environment was safe and equipped to meet their needs. CNA 1 stated call light placement was part of the room rounds. CNA 1 stated if a call light was observed out of reach, the CNAs should have placed it within reach of the resident. b. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnosis which included hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), and diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34's cognition was severely impaired. The MDS indicated Resident 34 was totally dependent (helper does all the effort) on staff for 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 34's care plan titled Resident at high risk for falls and injuries ., initiated 6/17/2021, the care plan indicated the facility would ensure the call light was within reach for the resident to use to request assistance. During an observation on 6/2/2025 at 10:05 a.m., in Resident 34's room, observed Resident 34 lying in bed. Resident 43's call light was observed on the floor behind the resident's bed. Resident 34's call light was not within reach. During a concurrent observation and interview on 6/2/2025 at 1:40 p.m., with Certified Nursing Assistant (CNA) 3, in Resident 34's room, Resident 34 was observed lying in bed in a semi-Fowler's position (lying on the back with head and upper body raised). CNA 3 stated the call light was observed on the floor behind the resident's bed, not within reach. CNA 3 stated Resident 34's call light should have been attached to the resident's bed and within reach. CNA 3 stated it was important the resident was able to reach and use the call light when needed and for an emergency. During an interview on 6/5/2025 at 9:15 a.m., with Registered Nurse (RN) 1, RN 1 stated the call light should be placed within resident reach and near the resident's bedside. RN 1 stated the call light was important for resident's to be able to communicate with the staff. RN 1 stated the facility's licensed staff were responsible for checking the residents' call light and placing it within resident reach at the bedside. RN 1 stated if the call light not within the resident's reach, the residents would not be able to use the call light and would not be able to call for help and assistance when needed. RN 1 stated the call light not within reach was a resident safety issue and placed residents at risk for falls and injury. During a review of the facility's policy and procedure (P&P) titled Communication-Call System, revised 10/24/2022, the P&P indicated the facility would provide a call system to enable residents to alert the nursing staff from their beds. The P&P indicated the call cords would be placed within the resident's reach in the resident's room.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, a resident assessment tool) for three of 25 sampled residents (Residents 72, 76, and 83) accurately reflected the care and services they received. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for Residents 72, 76, and 83 to not receive the interventions needed monitor the effectiveness of the care received. Findings: 1. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 76's admitting diagnoses included dementia (a progressive state of decline in mental abilities) and epilepsy (a condition causing recurring seizures [sudden, uncontrolled electrical disturbances in the brain causing uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76 had severe cognitive impairments (ability to think and reason). The MDS indicated Resident 76 was dependent on staff for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS did not indicate Resident 76 received oxygen therapy while a resident. During an interview on 6/4/2025 at 9:18 a.m., with Minimum Data Set Nurse (MDSN) 1, MDSN 1 stated it was important to ensure the MDS was coded correctly because it guided the resident's individualized plan of care. During a concurrent interview and record review, on 6/4/2025 at 9:22 a.m., with MDSN 1, Resident 76's MDS dated [DATE] was reviewed. MDSN 1 stated the MDS did not indicate Resident 76 received oxygen therapy while a resident. During a concurrent interview and record review, on 6/4/2025 at 9:23 a.m., with MDSN 1, Resident 76's physician order, dated 4/19/2025 was reviewed. MDSN 1 stated the order indicated Resident 76 had orders for oxygen therapy. During a concurrent interview and record review, on 6/4/2025 at 9:25 a.m., with MDSN 1, Resident 76's vital sign (measurement of the body's most basic functions) flowsheet for oxygen saturation (level of oxygen in the blood), dated 5/2025, MDSN 1 stated the flowsheet indicated Resident 76 was receiving oxygen therapy. MDSN 1 stated Resident 76's MDS dated [DATE] was not accurate. MDSN 1 stated it was important for Resident 76's MDS to accurately reflect her use of oxygen therapy because there were special precautions required when a resident was on oxygen therapy.2. During a review of Resident 72's admission Record (Face Sheet), the Face Sheet indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72's cognition was intact. The MDS indicated Resident 72 required setup or clean-up assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. During a review of Resident 72's History and Physical (H&P), dated 3/10/2025, the H&P indicated Resident 72 had the capacity to understand and make decisions. During an interview on 6/4/2025 at 9:49 a.m., with MDSN 1, MDSN 1 stated the purpose of the MDS was to assess each resident to create an individualized plan of care to manage the resident's diagnoses or problems. MDSN 1 stated the MDS had to be accurate to ensure the resident received the best care possible. MDSN 1 stated a resident's medical diagnoses were included into the MDS upon admission to the facility based on their hospital paperwork and interview with the resident. During a concurrent interview and record review on 6/4/2025 at 9:53 a.m., with MDSN 2, Resident 72's MDS, dated [DATE], was reviewed. MDSN 2 stated Resident 72's MDS indicated he had Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) as a diagnosis. MDSN 2 stated Resident 72's MDS was inaccurate because Resident 72 was not medically diagnosed with Alzheimer's Disease and did not have any issues with his mental abilities. MDSN 2 stated due to Resident 72's inaccurate MDS, Resident 72 was at risk for unnecessary treatment and prescribed medications to treat Alzheimer's Disease. 3. During a review of Resident 83's admission Record, the admission Record indicated was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included malignant neoplasm (cancer) of liver (organ in the body), schizophrenia. During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83's cognition was severely impaired. The MDS indicated Resident 83 was totally dependent (helper does all the effort) on staff for ADLs. The MDS indicated Resident 83 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 6/3/2025 at 10:43 a.m., in Resident 83's room, was observed Resident 83 did not have any natural teeth. Resident 83 stated, I do not have any real teeth left, and I do not have dentures either. I just eat soft food. During a concurrent interview and record review on 6/5/2025 at 7:40 a.m., with MDSN 1, Resident 83's MDS, dated [DATE], was reviewed. MDSN 1 stated she was aware that the resident did not have any natural teeth. MDSN 1 stated Resident 83's MDS oral/dental assessment was coded incorrectly and did not reflect the resident's actual oral and/or dental status. MDSN 1 stated because Resident 83 did not have natural teeth, the MDS should have been coded correctly. MDSN 1 stated inaccuracy of the MDS assessment had the potential to result in not meeting the resident's care needs and services. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument (RAI) Process, revised 5/2025, the P&P indicated each MDS section was to be completed and all information within the MDS assessment was to reflect the resident's status at the time of the Assessment Reference Date.

Based on observation, interview, and record review, the facility failed to develop a care plan for five of 25 sampled residents (Resident 94, 101, 121, 83 and 77) by failing to: 1. Develop a care plan to address Resident 94's use of valproic acid (an anticonvulsant medication, a medication used to prevent or treat seizures and can be used to treat behavioral disorders). 2. Develop a care plan for Resident 101's wearable external heart defibrillator (a device that provides an electric shock to the heart to allow it to treat a potentially fatal abnormal heart rhythm). 3. Develop a care plan for the refusal for Restorative Nurse Aid services (nursing interventions that promote a person's ability to adapt and adjust to living as independently and safely as possible) for Resident 121, a resident diagnosed with an extremely painful bone disorder that severely affected his mobility. 4. Develop a care plan for Resident 83's missing natural teeth. 5. Develop a care plan to address Resident 77's use of chlorpromazine (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]). These deficient practices had the potential to negatively affect Residents 94, 101, 121, 83, and 77's physical, mental, and psychosocial well-being and had the potential to delay the delivery of necessary care and services. Findings: 1. During a review of Resident 94's admission Record (Face Sheet), the Face Sheet indicated Resident 94 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 94's Minimum Data Set ([MDS], a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 94's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 94 required supervision with toileting, dressing, and personal hygiene. During a review of Resident 94's History and Physical (H&P), dated 1/6/2025, the H&P indicated Resident 94 had the capacity to understand and make decisions. During a review of Resident 94's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated to give valproic acid 5 milliliters (ml, unit of measurement) by mouth, once time a day for schizoaffective disorder as manifested by verbal angry outburst. During an interview on 6/4/2025 at 9:58 a.m., with Minimum Data Set Nurse (MDSN) 1, MDSN 1 stated care plans were developed to dictate the individualized plan of care for each resident. MDSN 1 stated care plans should be developed for residents who received medications to treat behaviors. MDSN 1 stated the manifested behavior, and the medication had to be care planned. During a concurrent interview and record review on 6/4/2025 at 10 a.m. with MDSN 1, Resident 94's Care Plan titled, Risk for aggression, dated 3/24/2022, was reviewed. MDSN 1 stated the Care Plan indicated Resident 94 had schizoaffective disorder manifested by verbal angry outbursts. MDSN 1 stated the Care Plan did not address Resident 94's use of valproic acid to treat his behaviors. MDSN 1 stated the purpose of addressing Resident 94's use of valproic acid was to provide guidance on how to properly monitor, assess, and treat for any potential side effects of the medication. MDSN 1 stated without a care plan, the staff may not know how to properly care for Resident 94. During an interview on 6/4/2025 at 2:20 p.m., with the Director of Nursing (DON), the DON stated care plans were used as a communication tool between the staff to dictate the care each resident received in the facility. The DON stated Resident 94 should have had a care plan that addressed his use of valproic acid due to the potential side effects that could occur. The DON stated the care plan would indicate the staff's interventions to monitor for potential side effects and for the efficacy of the medication to treat Resident 94's behaviors. The DON stated these interventions would then allow the psychiatrist to determine if any changes to the medication was required. The DON stated without a care plan for Resident 94's use of valproic acid, the staff may not be informed of the necessary care Resident 94 had to receive. 2. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included coronary angioplasty (procedure to open narrowed or blocked coronary arteries, which supply blood to the heart), tachycardia (fast heart rate), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and anxiety (an overwhelming feeling of uneasiness). During a review of Resident 101's MDS, dated [DATE], the MDS indicated Resident 101's cognitive skills for daily decision making were intact. The MDS indicated Resident 101 required partial moderate assistance (helper does less than half of the effort) for bathing, toileting, lower body dressing, putting on footwear, and bed mobility. The MDS indicated Resident 101 had an active diagnosis of a stroke (when blood supply to part of the brain is interrupted). During a review of Resident 101's Order Summary Report, dated 6/3/2025, there were no orders for Resident 101 to physically wear an external defibrillator (a device that provides an electric shock to the heart to allow it to treat a potentially fatal abnormal heart rhythm) vest, no specified parameters that outlined how long the vest should be worn, and there were no orders to monitor, check the functionality of, and assess the cardiac device. During observations made on 6/2/2025 at 10:00 a.m.,11:56 a.m., and 6/3/2025 at 1:42 p.m., in Resident 101's room, Resident 101 was observed wearing a gray external defibrillator vest. During a concurrent interview and record review on 6/4/2025 11:49 a.m. with Registered Nurse (RN) 1, Resident 101's care plan titled, Cardiac Distress, dated 5/2/2025, and all of Resident 101's active care plans, dated 5/2025, were reviewed. The care plan did not indicate interventions specific to the care and monitoring of Resident 101's wearable defibrillator. There were no other care plans that outlined specific interventions for the care of Resident 101's defibrillator. RN 1 stated it was very important to know the functionality, brand of the device, and how often a cardiologist (a physician that specializes in treating conditions of the heart) appointment should be scheduled for the maintenance of Resident 101's defibrillator to ensure proper care was rendered. RN 1 stated the lack of a care plan for Resident 101's defibrillator placed Resident 101 at risk for an adverse cardiac-related emergency. During an interview on 6/4/2025 at 12:10 p.m. with the DON, the DON stated care plans were important to ensure a proper plan of care was in place for a resident. The DON stated proper nursing interventions for the care of Residents 101's defibrillator were to know how to operate the defibrillator and to ensure that the defibrillator operated correctly. The DON stated a care plan specific to the care of Resident 101's defibrillator was necessary to ensure proper nursing interventions were communicated and implemented. 3. During a review of Resident 121's admission Record, the admission Record indicated Resident 121 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included disorder of bone, diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and muscle weakness. During a review of Resident 121's MDS, dated [DATE], the MDS indicated Resident 121's cognitive skills were intact. The MDS indicated Resident 121 was entirely dependent on staff for toileting, bathing, upper and lower body dressing, and performing personal hygiene. During a review of Resident 121's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated Resident 121 was ordered for the restorative nurse aid (RNA) to perform ambulation (walking) every day three times a week using the front wheeled walker to maintain current levels of mobility. During a review of Resident 121's RNA Progress Note, dated 5/30/2025, the Progress Note indicated Resident 121 refused all (three) RNA sessions that week. During a concurrent observation and interview on 6/2/2025 at 10:10 a.m., in Resident 121's room, Resident 121 was in his bed, positioned on his right side. Resident 121 stated he had bone issues that caused him pain all over his body, predominantly in his hip and arms. Resident 121 stated this affected his overall mobility and limited his ability to participate in physical activities. During a concurrent interview and record review on 6/4/2025 at 11:20 a.m. with RN 2, Resident 121's care plans, dated 5/2025 to 6/2025, were reviewed. There were no care plans for Resident 121's refusals for RNA therapy. RN 2 stated it was important for a refusal care plan to be developed and implemented for Resident 121 to ensure proper interventions were in place to prevent physical decline and to ensure reasons for Resident 121's refusals, like pain, were addressed. RN 2 stated nursing interventions for RNA refusals typically included notifying the physician, identifying the reason why the resident refused the RNA session, and implementing care plan interventions to prevent any functional decline. During an interview on 6/4/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON stated care plans were important to ensure a proper plan of care was in place for a resident. The DON stated Resident 121 should have had an At High Risk for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Decline Secondary to RNA Therapy Refusals care plan after Resident 121 had persistent episodes of refusals. The DON stated the lack of a care plan that addressed the risk of ADL decline secondary to RNA therapy refusals placed Resident 121 at risk for ADL decline due to a lack of communicated interventions amongst the departments involved in his care. 4. During a review of Resident 83's admission Record, the admission Record indicated was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included malignant neoplasm (cancer) of the liver (organ in the body), schizophrenia (a mental illness that is characterized by disturbances in thought), and muscle weakness (loss of muscle strength). During a review of Resident 83's MDS, dated [DATE], the MDs indicated Resident 83's cognition was severely impaired. The MDS indicated Resident 83 was totally dependent (helper does all the effort) on staff for ADLs. The MDs indicated Resident 83 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 6/3/2025 at 10:43 a.m., in Resident 83's room, observed Resident 83 without any natural teeth. Resident 83 stated, I do not have any real teeth left, and I do not have dentures either. I just eat soft food. During a concurrent interview and record review on 6/3/2025 at 3:20 p.m., with MDSN 1, Resident 83's care plans, dated 2024 through 2025, were reviewed. MDSN 1 stated she was aware that the resident did not have any natural teeth. MDSN 1 stated there was no care plan addressing the resident's edentulous (absence of the natural teeth) status. MDSN 1 stated a care plan should have been initiated upon resident's admission to the facility to address oral care needs. MDSN 1 stated care planning serves as a communication tool among facility staff to ensure consistent and effective care. MDSN 1 stated without a care plan in place, staff would not be able to provide care that meets the resident's individualized needs. During an interview on 6/5/2025 at 9:15 a.m., with the DON, the DON stated developing a care plan based on a resident's oral/dental status it was essential to ensure the resident received the appropriate care. The DON stated that without a comprehensive care plan to guide staff in managing the resident's oral care, the resident would be at increased risk for discomfort and decreased quality of life. The DON stated it was important to develop a care plan with individualized interventions to help support or maintain each resident's overall health. 5. During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia, encephalopathy (disease that affects the brain), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77 cognition was moderately impaired. The MDS indicated Resident 7 required moderate assistance from staff for ADLs. The MDS indicated Resident 77 received antipsychotic (a medication that affects the mind, emotions, and behavior) medication. During a review of Resident 77's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated on 3/26/2025, Resident 77's attending physician prescribed Chlorpromazine 25 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount) via gastrostomy ([G-tube]- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) one tablet every six hours as needed for HICCUPS (involuntary spasms of the diaphragm [muscle that separates the chest from the abdomen]). During a concurrent interview and record review on 6/3/2025 at 3:21 p.m., with RN 1, Resident 77's care plans, dated 3/2025 through 6/2025, were reviewed. RN 1 stated there was no care plan addressing the resident's use of Chlorpromazine. RN 1 stated it was important to include Chlorpromazine medication in Resident 77's care plan to ensure appropriate monitoring for potential side effects such sedation (sleepiness), extrapyramidal symptoms (tremors), and guide overall resident care. RN 1 stated without a person-centered care plan addressing this medication the facility would not be able to monitor Resident 77's response to treatment, prevent avoidable complications, and provide quality care. During a review of the facility's policy and procedure (P&P) titled, Care Planning, revised 12/10/2009, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT, a group of different disciplines working together towards a common goal for a resident) shall develop a comprehensive care plan for each resident. During a review of the facility's P&P, titled, Care and Services, dated 5/1/2018, the P&P indicated the facility staff were to ensure residents were provided with the necessary care and services to maintain the highest level of practicable functioning in an environment that enhances quality of life in the scope of a long term care facility.

Based on interview and record review, the facility failed to revise one of five sampled resident's (Resident 5) care plan and interventions after Resident 5 had an unwitnessed fall on 11/24/2025. This deficient practice had the potential to result in Resident 5 sustaining a major injury after another fall. Findings: During a review of Resident 5's admission Record (Face Sheet), the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5's Minimum Data Set ([MDS], a resident assessment tool), dated 5/25/2025, the MDS indicated Resident 5's cognitive skills (ability to think and reason) for daily decision making was moderately impaired. The MDS indicated Resident 5 had impairment on one side of her upper extremities (limbs of the upper body such as shoulder, elbow, wrist, and hand). The MDS indicated Resident 5 was dependent on staff's assistance with toileting, bathing, and personal hygiene. During a review of Resident 5's History and Physical (H&P), dated 11/26/2024, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Fall Risk Evaluation, dated 11/24/2024, the Fall Risk Evaluation indicated Resident 5 was a high risk for falls. During a review of Resident 5's Situation, Background, Assessment, Recommendation (SBAR, communication tool used by healthcare workers when there is a change of condition among the residents) form, dated 11/24/2024, the SBAR indicated Resident 5 was found on her left side, lying on the floor on the left side of the bed. The SBAR indicated Resident 5 stated she was trying to go to the other side. During an interview on 6/4/2025 at 10:03 a.m., with Minimum Data Set Nurse (MDSN) 1, MDSN 1 stated after a fall, a short-term care plan was developed to address the current situation and acute interventions for 72 hours, however, the long-term care plan had to be revised to address the ongoing interventions to help prevent further falls and/or injuries from a fall. During a concurrent interview and record review on 6/4/2025 at 10:03 a.m., with MDSN 1, Resident 5's Care Plan titled, High Risk for Falls, dated 9/10/2024, was reviewed. MDSN 1 stated Resident 5's care plan was not revised after her fall on 11/24/2025. MDSN 1 stated an Interdisciplinary Team ([IDT], a coordinated group of experts from several different fields) meeting was conducted after Resident 5's fall where the IDT consulted other departments to determine additional interventions to address Resident 5's fall and risk for falls. MDSN 1 stated new interventions were put into place to help prevent Resident 5 from falling again and those interventions should have been added to Resident 5's care plan. During an interview on 6/4/2025 at 10:17 a.m., with the Quality Assurance (QA) Nurse, the QA Nurse stated the IDT would meet after a resident fall incident to determine the root cause and develop additional interventions to prevent further falls. The QA Nurse stated additional interventions had to be included into the resident's care plan to communicate to the rest of the staff. During a concurrent interview and record review on 6/4/2025 at 11:20 a.m., with the QA Nurse, Resident 5's Post Fall Assessment and Investigation, dated 11/24/2025, was reviewed. The QA Nurse stated the social services, rehab, nursing, and activities department made up the IDT who conducted Resident 5's Post Fall Assessment and Investigation. The QA Nurse stated the IDT recommended bed rails (short rails on one or both sides of the bed) for safe bed mobility. The QA Nurse stated Resident 5's use of bed rails should have been included into a revised care plan. During an interview on 6/4/2025 at 2:26 p.m., with the Director of Nursing (DON), the DON stated once the IDT recommended new interventions after Resident 5's fall, Resident 5's care plan should have been revised. The DON stated revising the care plan was important to communicate to the staff of the interventions to properly care for Resident 5. The DON stated revising the care plan was essential to reevaluate whether Resident 5's goals were met in relation to the interventions set forth in the care plan. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention and Management, revised 2018, the P&P indicated, The IDT will initiate, review, and update resident fall risks and Plan of Care at the following intervals: Admission, Quarterly, Annually, upon Significant Change of Condition Identification, and post fall.

Based on interview and record review, the facility failed to provide a safe transfer to a medical appointment for one resident of three sampled residents (Resident 1) by failing to: 1. Ensure a transportation vehicle was parked in a designated parking space to transport Resident 1 to a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) appointment. The medical transportation van was double parked (parked beside a row of vehicles already parked parallel to the curb) in the middle of a street. 2. Ensure staff was in-serviced on safe resident transportation to medical appointments. 3. Follow its policy and procedure (P&P) titled Accidents and Incidents, which indicated the facility will comply with current rules and regulations to prevent accidents. 4. Follow its P&P titled and Safety Committee-Composition and Duties, which indicated the facility will develop a reporting system for staff to identify potential safety risks, hazardous areas, and unsafe work practices. As a result, Resident 1 ' s medical transportation van was hit by a speeding vehicle while strapped in his wheelchair in the back of the medical transportation van. Resident 1 was pinned to the floor inside the van by the moving car. Resident 1 sustained life threatening injuries and was transported to the general acute care hospital (GACH) where he died on [DATE]. On [DATE] at 3:58 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) due to the facility ' s failure of not having a designated area to pick up and drop off residents, in-servicing staff on safe transportation to medical appointments, complying with rules and regulations to prevent accidents, and not identifying a potential safety risk, hazardous areas, and an unsafe work practice. On [DATE] at 2:27 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After verification of the IJRP implementation through observation, interview, and record review, the IJ was removed onsite on [DATE] at 2:58 p.m., in the presence of Registered Nurse (RN) Supervisor 1. The IJPR included the following immediate actions: 1. On [DATE] and on [DATE], Social Services Staff sent a written notice to all outside transportation providers via fax and e-mail to inform them of the accident that occurred on [DATE] and to remind transportation companies that provide service to this facility to never double-park or park in the flow of traffic lanes while loading and unloading residents and staff in front of the facility and that they are required to comply with all applicable traffic laws and best practices to ensure the safety and well-being for all parties. 2. The ADM checked to ensure that signs were posted to designate a space for loading and unloading residents from transportation vehicles, located in the parking lot closest to the entrance to the facility on [DATE]. 3. On [DATE], the Director of Staff Development (DSD) in-serviced licensed nurses, Certified Nursing Assistants (CNAs), and front Lobby staff to ask drivers upon entry to the facility as to where they are parked to ensure that residents are transferred onto vehicles that are parked safely and not double-parked in the flow of traffic. 4. All staff in the facility, beginning 5:00 p.m. on [DATE] were in-serviced by the DSD/ RN Supervisor/ ADM regarding transportation safety with emphasis upon: a. The incident / accident that occurred on [DATE]. b. Importance of informing transportation services to use only designated parking space when transferring residents to/ from the facility. c. Ensure there will be no double parking in front of the facility while loading and unloading residents. d. Ensure the transportation vehicle must park at the marked loading area at all times. e. Ensure Residents are transported / escorted to and from the facility in a safe manner. f. The importance of reporting any safety hazards or unsafe work practices having potential for possible harm or danger to Residents [i.e. double-parked transportation vehicles] to the RN Supervisor and/or ADM to ensure timely corrective action. g. Instruct staff to not park in areas designated for transportation services. 5. The RN Supervisor will report any unwanted findings to the facility ADM during daily stand-up meetings to ensure timely corrective action and implementation into the Safety Committee for systemic review and additional corrective action. 6. The Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) nurse and facility ADM will develop a Performance Improvement Plan, with completion on [DATE] and report the findings to the QAPI committee on a monthly basis for 3 months to monitor and ensure the effectiveness of the corrective action and systemic changes. Findings: During a review of Resident 1 ' s Admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included end stage renal disease ([ESRD] irreversible kidney failure) and dependence on renal (relating to the kidneys) dialysis. During a review of Resident 1 ' s History and Physical (H&P) dated [DATE], the H&P indicated Resident 1 did not have capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 1 required set up assistance (helper sets up or clean up) for eating and supervision (helper provides verbal cues and/or touching) for dressing, toileting hygiene, and oral hygiene. During a review of Resident 1 ' s Order Summary Report dated [DATE], the order summary report indicated Resident 1 had an order for ESRD treatment on Tuesdays, Thursdays, and Saturdays. During a review of Resident 1 ' s Nursing Progress Note dated [DATE] at 8:27 a.m., the Nursing Progress Note indicated on [DATE] at 6:50 a.m., RN Supervisor 1 witnessed Resident 1 lying on his abdomen inside the transportation vehicle. The Nursing Progress Note indicated Resident 1 was bleeding from the right frontal head area and was transferred to a GACH for further evaluation/treatment. During a review of Resident 1 ' s Nursing Progress Note dated [DATE] at 1:23 p.m., the Nursing Progress Note indicated a licensed nurse received a report from the GACH on [DATE] at 12:30 p.m., that Resident 1 was in critical condition due to extensive injuries as a result of the incident. During a review of Resident 1 ' s Los Angeles Fire Department (LAFD) Report, dated [DATE] at 6:58 a.m., the LAFD report indicated Resident 1 was alert and oriented times one (person knows who they are but not where they are, what time it is, or what is happening to them). The LAFD report indicated Resident 1 had bilateral (both sides) femur (thigh bone) fractures (broken bone), scrapes and abrasions at various locations of the body. The LAFD report indicated Resident 1 was placed on a stretcher (flat structure covered with cloth which is used to carry someone who is sick or injured) and transferred to a GACH. During a review of Resident 1 ' s Emergency Department (ED) Triage Notes dated [DATE] at 7:43 a.m., the ED Triage Notes indicated Resident 1 was brought in by an ambulance with mild cognitive impairment. The ED Triage Notes indicated Resident 1 was rearended by another vehicle and extricated (process of removing injured or potentially injured people from their vehicles) by Emergency Medical Services (EMS) with lower extremities deformity. The ED Triage Notes indicated Resident 1 had a brief loss of pulses and received one round of cardiopulmonary resuscitation ([CPR] combines rescue breathing (mouth-to-mouth) and chest compressions to temporarily pump enough blood to the brain). The ED Triage Notes indicated on [DATE] at 10:38 a.m. Resident 1 was intubated (a tube inserted through a person's mouth or nose, then down into the airway/windpipe) due to respiratory failure (serious condition that occurs when the lungs can't get enough oxygen into the blood). During a review of Resident 1 ' s GACH History and Physical (H&P) Report dated [DATE] at 9:59 a.m., the H&P indicated Resident 1 sustained 8 left rib fractures (broken bones), 5 right rib fractures, pulmonary contusion (a lung injury that occurs when blunt force trauma to the chest causes bleeding and swelling in the lungs) of the right lung, paraspinal hematoma (collection of blood in the soft tissues around the spine), pubic rami (pelvis) fractures, transverse fracture of through the sacrum (large triangular bone that forms the base of the spine and the back wall of the pelvis - transverse fracture occurs when the bone of the sacrum breaks across its width, running perpendicular to the length of the bone, often resulting from high-impact trauma like falls from a significant height or severe motor vehicle accidents), bilateral fibula (outer and usually smaller of the two bones between the knee and ankle) fractures, left and right tibial (large bone in the lower leg) fractures, bilateral right femoral (thigh bone) fractures, and multiple fractures to the spine. The H&P indicated Resident 1 required 3 units of whole red blood. During a review of Resident 1 ' s Inpatient Progress Notes dated [DATE] at 3:55 p.m., the Progress Notes indicated on [DATE] at 3:47 p.m. Resident 1 was in asystole (no pulse), and unresponsive to painful or verbal stimulation. The Progress Notes indicated Resident 1 did not have any heart and lung sounds and was pronounced dead on [DATE] at 3:51 p.m. The Progress Notes indicated Resident 1 ' s cause of death was multisystem shock (reduced perfusion [flow of bodily fluids] of vital tissue) due to polytrauma (multiple injuries to different parts of the body or organ systems). During a review of Resident 1 ' s Death Record dated [DATE] at 4:28 p.m., the Death Record indicated Resident 1 ' s cause of death was multisystem shock due to polytrauma. During an interview on [DATE] at 10:48 a.m. with CNA 1, CNA 1 stated on [DATE] at 6:55 a.m., she observed the transportation vehicle double parked in front of the facility. CNA 1 stated Transportation Driver (TD) 1 wheeled Resident 1 over the sidewalk through two parked cars to get to the van. CNA 1 stated she did not instruct the transportation driver to move the van before transferring Resident 1 into the van because she was never in-serviced on transportation safety. CNA 1 stated while TD 1 was at the back of the van with Resident 1, she (CNA 1) observed TD 1 use a mechanical lift to transfer Resident 1 into the van. CNA 1 states she walked around to the passenger side to enter the van from the front, and suddenly heard a loud crash, turned around and saw that a car had crashed into the back of the transportation vehicle. CNA 1 stated TD 1 was pinned under the van while Resident 1 was inside the van. During a concurrent observation and interview on [DATE] at 11:17 a.m., with the Social Services Director (SSD), in front of the facility ' s main entrance, the SSD pointed to the street where Resident 1 ' s accident occurred on [DATE]. The SSD stated the transportation driver doubled parked because there was no street parking at the time. The SSD stated the facility did not have a system in place to for staff to identify potential safety risks, and unsafe work practices. During an interview on [DATE] at 11:54 p.m. with CNA 2, CNA 2 stated transportation vehicles parked on the street when picking up residents all the time. CNA 2 stated the facility did not provide training on transportation safety to staff and staff were not aware not to hand residents to transportation vehicles, when not parked in designated areas. During an interview on [DATE] at 12:21 p.m. with CNA 3, CNA 3 stated when residents were being picked up for medical appointments, she wheeled the residents outside to look for the transportation vehicles . CNA 3 stated the transportation vehicles either parked in the green zone (30-minute parking), red zone (no parking), or regular street parking when loading and unloading residents. CNA 3 stated transportation vehicles did not park in any of the three (3) employee parking lots to pick up or drop off residents. CNA 3 stated the facility did not have a designated resident loading area. CNA 3 stated she witnessed transportation vehicles double park in the street when picking up residents when street parking was not available. CNA 3 stated she had not been trained on safety transportation of residents. During an interview on [DATE] at 12:41 p.m. with CNA 4, CNA 4 stated all transportation drivers should not park on the street when picking up residents but would always double park on the street because all the street parking was taken. CNA 4 stated the facility had not provided any training on transportation safety. During an interview on [DATE] at 1:22 p.m., with the DSD, the DSD stated she had not provided training on escorting residents to appointments and resident safety. The DSD stated she had not provided training on what to look out for during the transportation of a resident into a transportation vehicle. The DSD stated it was important to keep residents safe during transportation. The DSD stated she should have identified potential safety risks regarding resident transportation and in-serviced staff. The DSD stated CNAs must standby as residents were transferred into the transportation vehicle and must enter the vehicle after the resident was safely inside. During an interview on [DATE] at 2:30 p.m., with the transportation company ' s Transportation Service Manager (TSA), the TSA stated his drivers previously informed him all parking spots in front of the facility were always taken by the facility staff. The TSA stated his drivers double parked because the facility did not have a safe designated area to pick up and drop off residents. The TSA stated the facility staff never told his drivers not to double park or to park in the staff parking lot to pick up or drop off residents. During an interview on [DATE] at 1:10 p.m. with RN Supervisor 1, RN Supervisor 1 stated on [DATE] at 6:50 a.m., he heard loud screams and went outside. RN Supervisor 1 stated he observed the back of the transportation van was hit by another vehicle. RN Supervisor 1 stated he observed Resident 1 lying on his abdomen inside the van bleeding from the front of his head. RN Supervisor 1 stated transportation vehicles did not have a designated area to pick up or drop off residents because facility staff took all the street parking. RN Supervisor 1 stated he had never been told not to park in the street to keep open parking spaces for transportation vehicles. RN Supervisor 1 stated transportation vehicles always doubled parked to pick up or drop off residents. RN Supervisor 1 stated it was important not to allow transportation vehicles to double park to prevent accidents. RN Supervisor 1 stated CNA 1 should have said something to the transportation driver about not parking on the street. During an interview on [DATE] at 2:34 p.m., with the ADM, the ADM stated transportation vehicles could park anywhere on the street and in the facility, parking lots to pick up and drop off residents. The ADM stated the best practice was for CNAs to inform transportation drivers to move when they were double park. During an interview on [DATE] at 3:47 p.m., with the ADM, the ADM stated it was not safe to transfer a resident while the transportation vehicle was parked in the middle of the street. The ADM stated CNA 1 should have informed the RN Supervisor the driver was double parked to prevent accidents. During a review of the facility ' s P&P titled Accidents and Incidents undated, the P&P indicated the facility would comply with current rules and regulations to prevent accidents. During a review of the facility ' s P&P titled Safety Committee-Composition and Duties dated [DATE], the P&P indicated the facility would develop a reporting system for staff to identify potential safety risks, hazardous areas, and unsafe work practices.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Communication Barriers, which indicated the facility will provide effective interpretation or arrange for a qualified interpreter to meet the needs of residents who had a hearing, visual, or speech disability, for one of one sampled resident (Resident 107). The facility failed to: 1. Provide Resident 107 with communication aides to enable Resident 107 communicate her needs to staff. 2. Ensure staff used communication tools such as a writing board or American Sign Language (ASL) when communicating with Resident 107. 3. Assess Resident 107's behaviors of agitation, frustration, and desire to leave the facility. 4. Assess the cause of Resident 107's poor oral intake starting on 6/8/2024. 5. Revise Resident 107's care plan titled The resident has a communication problem related to expressive aphasia (a condition where a person may understand speech, but they have difficulty speaking fluently themselves), hearing deficit (deaf), which indicated staff would use a communication board to communicate with Resident 107, when Resident 107 was assessed as unable to use a communication board for effective communication. These deficient practices resulted in Resident 107's attempt to elope (to leave unnoticed and unsupervised) from the facility, and display signs of frustration, agitation (irritability, easily annoyed) and restlessness due to her inability to effectively communicate with facility staff. These deficient practices also led to Resident 107 experiencing a nine-pound ([lb.] a unit of measurement) weight loss from 4/12/2024 to 6/7/2024, and a transfer to general acute care hospital (GACH) 2 on 6/12/2024 due to abdominal pain. Findings: A review of Resident 107's History and Physical (H&P) from a general acute care hospital (GACH) 1, dated 4/8/2024, indicated Resident 107 had a history of deafness, visual impairment/blindness, and dementia (loss of memory, language, problem-solving and other thinking abilities). The H&P further indicated history collection was limited due to Resident 107's hearing and visual deficits. A review of Resident 107's Admission Record indicated Resident 107 was admitted to the facility on [DATE]. Resident 107's admitting diagnoses included dementia, deaf nonspeaking, history of falling, and generalized muscle weakness. The Admission Record also indicated Family Member (FM) 1 was Resident 107's responsible party and decision maker. A review of Resident 107's H&P, dated 4/17/2023, indicated Resident 107 did not have the capacity to understand and make decisions. A review of Resident 107's Minimum Data Set (MDS, a standardized care-planning and care-screening tool), dated 4/19/2024, indicated Resident 107 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 107 had highly impaired hearing, did not speak, and had moderately impaired vision requiring the use of corrective lenses. The MDS indicated Resident 107 was unable to respond when asked how often she needed to have someone help her read instructions or written material. The MDS indicated Resident 107 exhibited rejection of care necessary to achieve goals for health and well-being for one to three days over a period of seven days. The MDS indicated Resident 107 required partial to moderate assistance from staff for hygiene after toileting, dressing her upper body, personal hygiene activities, mobility while in bed, and transitioning between surfaces (bed to chair, getting on and off the toilet). The MDS indicated Resident 107 required verbal cues and/or touching/steadying assistance from staff when eating, brushing her teeth, dressing her lower body, putting on/taking off her shoes, and walking. A review of Resident 107's Progress Note, dated 4/12/2024 at 10:59 p.m., indicated Resident 107 had an episode of aggressive behavior due to frustration from inability to communicate her needs. A review of Resident 107's Admission Summary, dated 4/13/2024, indicated Resident 107 was admitted from GACH 1, was deaf and used American Sign Language (ASL, a language expressed by movements of the hands and face) to communicate. The Admission Summary indicated due to frustration from being unable to talk, Resident 107 spat water at the nursing staff who were attempting to assess her. A review of Resident 107's Progress Note, dated 4/14/2024 at 8:20 a.m., indicated Resident 107 was agitated, and displayed restlessness, walked up and down the hallway, and communicated that no one could understand her. The progress note did not indicate any attempts to assess Resident 107's preferred method of communication, or staff attempts to communicate with the resident in her preferred method of communication. The progress note indicated Resident 107's admission weight was 104 lbs. A review of Resident 107's Progress Note, dated 4/14/2024 at 9:59 p.m., indicated Resident 107 was observed with episodes of restlessness, wandering, and continuously trying to leave the facility. The progress notes further indicated Resident 107 was exhibiting increased frustration evidenced by her facial expressions. The progress note indicated Resident 107 was redirected to her room and placed under direct supervision. The progress note did not indicate any attempts to assess Resident 107's preferred method of communication, or staff's attempts to communicate with her in her preferred method of communication. A review of Resident 107's Progress Note, dated 4/15/2024 at 12:29 p.m., indicated FM 1 notified facility staff that the effective way to communicate with Resident 107 was through ASL. A review of Resident 107's Progress Note, dated 4/15/2024 9:29 p.m., indicated Resident 107 was agitated, restless, and communicating through hand gestures and no one could understand her. The progress note did not indicate any staff interventions to address Resident 107's agitation, restlessness, or any attempts to communicate with Resident 107 in her preferred method of communication, to meet her needs. A review of Resident 107's Dietary Progress Note, dated 4/17/2024 at 10:45 a.m., indicated Resident 107 was unable to answer questions verbally, and was asked by the Dietary Supervisor (DS) about her food and beverage preferences by writing with a pen and paper. The notes indicated Resident 107 responded by nodding her head. The progress note indicated Resident 107 requested to have coffee and the facility would honor her preferences. The progress note did not indicate that an ASL interpreter or other communication devices/methods were used to verify the accuracy of the interview. The progress note did not indicate Resident 107's responsible party, (FM 1), was contacted for additional information related to Resident 107's dietary restrictions or preferences. A review of Resident 107's Progress Note, dated 4/17/2024 at 4:06 p.m., indicated Resident 107 wrote on pen and paper, indicating she wanted to go home. A review of Resident 107's Change in Condition Evaluation (COC), dated 4/18/2024 at 9:23 p.m., indicated Resident 107 was non-verbal and communicated in sign language. The COC indicated Resident 107 attempted to leave the facility. The COC indicated Resident 107 had episodes of restlessness and agitation. The COC indicated attempts to redirect the resident were less effective due to a communication barrier between Resident 107 and the staff. The COC indicated Resident 107 refused to go back to her room and continued to try to communicate in sign language and gestures. The COC did not indicate that attempts were made to communicate with Resident 107 in her preferred method of communication, or address Resident 107's restlessness and attempts to leave the facility. A review of Resident 107's Progress Note, dated 6/6/2024 at 4:10 a.m., indicated on 5/15/2024, Resident 107's weight was 100 pounds (lbs). A review of Resident 107's Progress Note, dated 6/8/2024 at 12:23 p.m., indicated staff attempted to contact FM 1 to notify her of Resident 107's weight change, inadequate eating patterns, and Resident 107's behavior of pointing to her flank (the side of the body between the ribs and the hip). The progress note indicated Resident 107 had no complaints of pain or discomfort. The progress note did not indicate if a formal assessment was conducted, or an interpreter was used to assess Resident 107. A review of Resident 107's COC, dated 6/8/2024 at 4:59 p.m., indicated Resident 107 had weight loss, and on 6/7/2024 Resident 107's weight was 95 lbs. The COC indicated Resident 107 exhibited signs of inadequate food intake and was not eating or drinking at all. The COC indicated abdominal/gastrointestinal (relating to the stomach and the intestines) and pain status evaluations were not clinically applicable to the change being reported. The COC further indicated Resident 107 was unable to speak. The COC did not indicate that staff used an interpreter to perform any of the assessments. A review of Resident 107's Progress Note, dated 6/8/2024 at 5:23 p.m., indicated FM 1 returned the facility's call from 12:23 p.m. and was notified of Resident 107's weight loss and that Resident 107 had been pointing to her stomach. The progress note indicated FM 1 informed staff that Resident 107 had chronic problems with gastrointestinal discomfort and hyperacidity. The progress note indicated FM 1 informed staff that Resident 107 was not supposed to have acidic beverages, including coffee. A review of Resident 107's Progress Note, dated 6/11/2024 at 8:30 p.m., indicated Resident 107 had a weight loss of nine (9) lbs. since admission on 4/12/2024. The progress notes f indicated Certified Nursing Assistant (CNA) staff reported Resident 107 ate less of her meals and sometimes pointed to her stomach. The progress note did not indicate that any further assessment was conducted to assess the cause of the decreased intake or why Resident 107 was pointing to her stomach. The progress notes indicated Resident 107's primary physician (MD) was notified, and the MD gave an order for Resident 1 to be transferred to a GACH. A review of Resident 107's Progress Note, dated 6/12/2024 at 3:15 p.m., indicated Resident 107 displayed facial grimacing, and pointed her hands to her stomach, back and shoulder. The progress note indicated FM 1 was contacted to assist with interpreting Resident 107's gestures. The progress note indicated Resident 107's covering MD ordered for Resident 107 to be transferred to a GACH for further evaluation. The progress note did not indicate that a formal assessment was conducted using interpreter services. A review of Resident 107's COC, dated 6/12/2024 at 3:35 p.m., indicated Resident 107 had abdominal pain that started on 6/11/2024. The COC indicated 500 milligrams (mg, a unit of measurement) of Tylenol was administered for the abdominal pain. A review of Resident 107's Progress Note, dated 6/12/2024 at 4:18 p.m., indicated Resident 107 complained of severe abdominal pain since the evening of 6/11/2024. The progress note indicated Resident 107's primary MD was on vacation and staff received orders from the facility's Medical Director (MD 2) to transfer Resident 107 to a GACH. A review of Resident 107's Progress Note, dated 6/12/2024 at 4:18 p.m., indicated Resident 107 was observed eating dinner and she was a poor eater. The progress note indicated staff encouraged Resident 107 to eat by pointing to the food. The progress note indicated Resident 107 ate 50% of her meal. The progress note did not indicate staff used an interpreter or alternative communication method to assess the cause of Resident 107's poor intake, or to encourage Resident 107 to eat. A review of Resident 107's Progress Note, dated 6/12/2024 at 10:10 p.m., indicated Resident 107 was transferred to GACH 2 due to intractable pain to her right lower abdomen and right shoulder. During an observation on 6/10/2024 at 10:10 a.m., in the doorway of Resident 107's room, Resident 107 was observed sitting up at the right edge of her bed. Resident 107 did not respond to vocalized questions. Upon entering the room, Resident 107 vocalized unintelligible sounds, and pointed to her ears and eyes. No communication board, writing pad, or any other communication devices were observed readily available at Resident 107's bedside. During an observation on 6/10/2024 at 10:13 a.m., in Resident 107's room, a Licensed Vocational Nurse (LVN) 1 entered Resident 107's room holding a blood pressure machine. LVN 1 approached Resident 107, pointed at her (LVN 1's) own arm, and told Resident 107 that she was to check the resident's blood pressure. LVN 1 showed Resident 107 the machine. LVN 1 did not use any communication device to communicate with or explain the care to be provided to Resident 107. LVN 1 then directed Resident 107 to the bed using hand gestures and checked Resident 107's blood pressure. During a concurrent observation and interview, on 6/10/2024 at 10:14 a.m., with LVN 1, in Resident 107's room, LVN 1 was observed providing care to Resident 107. LVN 1 stated staff used hand gestures or wrote with pen and paper to communicate with Resident 107. LVN 1 told Resident 107 she was going to go through Resident 107's belongings, then proceeded to go through Resident 107's bedside dresser. Resident 107 frowned while LVN 1 went through her belongings. LVN 1 did not use any communication board, pen, paper, or any other communication device to explain her actions to Resident 107. LVN 1 exited the room and did not communicate further with Resident 107. During an observation on 6/10/2024 at 10:18 a.m., in Resident 107's room, Resident 107 was observed pacing at her bedside and pointing at her eyes and ears. During an observation on 6/11/2024 at 9:04 a.m., in Resident 107's room, Resident 107 was observed sitting upright in bed, staring at the wall across from her bed. There were no communication boards, writing pads, or other communication devices readily observed at her bedside. During an interview on 6/11/2024 at 9:16 a.m., with the Director of Staff Development (DSD), outside of Resident 107's room, the DSD stated there were no staff trained or certified in ASL. The DSD stated Resident 107 was one of the facility's first residents with severe hearing impairment. When asked how Resident 107 communicated or expressed her needs, the DSD stated Resident 107 made gestures with her hands and arms. When asked how staff communicated with Resident 107, or explained the care provided, the DSD stated staff also used hand gestures. The DSD stated hand gestures were not a reliable method of communication. The DSD stated Resident 107 also had visual impairments. The DSD stated the Social Services Assistant (SSA) attempted to set up interpreter services for Resident 107 but was unsure of the outcome. During a concurrent observation and interview on 6/11/2024 at 9:20 a.m., at Resident 107's bedside, with the DSD, the DSD was observed going through Resident 107's bedside dresser. The DSD removed a printed communication board from the drawer. When the DSD was asked to demonstrate how the communication board was used to communicate with Resident 107, the DSD stated Resident 107 did not use the communication board. The DSD stated FM 1 previously informed the facility that Resident 107 used ASL. Resident 107 was observed attempting to communicate through hand gestures with the DSD. The DSD was observed attempting to understand what Resident 107 was trying to communicate by verbally asking Resident 107 what she needed, in an attempt to illicit a response from Resident 107. The DSD did not use a written communication method or communication device to communicate with Resident 107. Resident 107 rolled her eyes and continued to make hand gestures, then proceeded to grab the DSD's arm and guided the DSD out of the room to the nurse's station. At the nurse's station, Resident 107 gestured to her stomach and the DSD stated Resident 107 was hungry. The DSD then redirected Resident 107 back to her room. The DSD did not communicate any plan of action to Resident 107 related to Resident 107's alleged hunger. During an interview on 6/11/2024 at 9:23 a.m., in Resident 107's room, with the DSD, the DSD stated staff were trying the best they could with the tools they had available. The DSD stated it was not safe for Resident 107 to rely on communicating with staff through unofficial hand gestures when her preferred method of communication was ASL. During an interview on 6/13/2024 at 10:01 a.m., with CNA 1, CNA 1 stated she was not aware of the Telecommunications Relay Service (TRS- a service that allows persons who are deaf, hard of hearing, deafblind, or with speech disabilities to communicate by telephone in a way that is equivalent to telephone services used by persons without such disabilities), text telephones (TTY- a device that enables individuals who are deaf, hard of hearing or who have a speech impairment to make and receive telephone calls), or Telecommunications Devices for the Deaf (TDD-special telecommunications equipment used by people who cannot use a regular telephone due to hearing loss or speech impairment). CNA 1 stated she had not received training on how to use the devices and was not aware if the devices were available for the residents. During an interview on 6/13/2024 at 11:41 a.m., with the MDS Nurse (MDSN), the MDSN stated she was responsible for the admission process and ensuring the services required of the resident were readily available prior to admitting the resident to the facility. The MDSN stated staff were aware of Resident 107's hearing impairment and aware the facility did not have interpreter services available, even before the resident was admitted to the facility. The MDSN stated the facility planned to rely on Resident 107's FM 1 as an interpreter. The MDSN stated interpreter services should have been available prior to accepting Resident 107 to the facility, and Resident 107 should not have been admitted without the necessary services available. During a concurrent observation and interview, on 6/12/2024 at 11:59 a.m., with CNA 2, in Resident 107's room, a binder was observed on Resident 107's bedside table. The ASL alphabet and associated hand gesture to communicate the specific letters, were printed on a piece of paper on the front of the binder. CNA 2 stated the tool was intended to be used to communicate with Resident 107. CNA 2 stated she did not know how to use the tool and did not know ASL. During the interview, Resident 107 was observed pointing to the ASL hand gestures and gesturing with her own hands. CNA 2 stated she could not understand what Resident 107 was trying to communicate. When asked if Resident 107 wore glasses, CNA 2 stated she was not sure. CNA 2 told Resident 107 that she was going to check the resident's bedside dresser for glasses. CNA 2 did not use the printed ASL graphic, a written communication method, or any other communication device to explain to Resident 107 what she was doing. CNA 2 went through Resident 107's belongings and stated Resident 107 did not have any glasses. After going through the bedside dresser, CNA 2 continued to communicate verbally to Resident 107. CNA 2 stated staff were supposed to explain all care and services provided, and it was not sufficient to use unofficial hand gestures to communicate with Resident 107. During an interview on 6/12/2024 at 12:12 p.m., with FM 1, FM 1 stated she was Resident 107's responsible party. FM 1 stated the facility contacted her through video calls whenever they need to and twice a month, if that. FM 1 stated Resident 107's preferred communication method was ASL, and stated the facility informed her they were using a relay service to communicate with Resident 107 during daily provision of care. FM 1 stated Resident 107 could not read small text and wore glasses. FM 1 stated Resident 107's vision was very bad. FM 1 stated Resident 107 had the physical capability to write but could not write or spell well. FM 1 stated she recommended the use of a TRS to the facility as a method for communicating with Resident 107. FM 1 stated that during her video calls with Resident 107, Resident 107 used ASL to express to FM 1 that facility staff did not understand what she was saying to them when she tried to explain her needs. FM 1 stated she could tell Resident 107 was frustrated based on her facial expressions. FM 1 stated Resident 1 asked her multiple times if she could go home. FM 1 stated Resident 107 appeared to be in distress during the conversations and FM 1 felt bad. During an interview and record review, on 6/12/2024 at 12:35 p.m., with the MDSN, Resident 107's MDS dated [DATE], and care plan titled The resident has a communication problem related to expressive aphasia, and hearing deficit, dated 4/13/2024 and revised 5/23/2024, were reviewed. The MDSN stated she conducted the MDS assessment dated [DATE]. The MDSN stated the assessment indicated Resident 107 was sometimes understood, sometimes understood others, and had moderate visual impairment. When asked how the assessment was conducted, the MDSN stated she wrote questions on a piece of paper and asked Resident 107 to provide her responses in writing. The MDSN stated she did not verify Resident 107 if could read or understand the written questions to provide an accurate response. The MDSN stated Resident 107's degree of visual impairment was moderate and determined using her own judgment and not through a formal assessment. The MDSN stated, It was kind of hard to assess her vision. The MDSN stated the purpose of the MDS was to indicate the level of care and services required for the resident. The MDSN stated the MDS assessment also guided the care plan and should be as accurate as possible. The MDSN stated Resident 107's care plan included utilization of a communication board (a sheet of symbols, pictures, or photos that someone can point to, to communicate with those around them) and a writing tablet as needed. The MDSN stated she could not explain why the care plan had not been revised when it became apparent that the intervention was not effective. The MDSN stated there was no documentation in the record to indicate what had been done to address the communication challenges with Resident 107 when the communication board and writing tablet were determined to be ineffective. The MDSN stated not only was it frustrating for Resident 107 to be unable to express herself or understand others but it was also a safety concern. During an interview on 6/12/2024 at 1:29 p.m., with the DSS and the Social Services Assistant (SSA), the SSA stated on 6/6/2024, she attempted to use a phone application for interpretation which allowed Resident 107 to video chat with a live interpreter, for the first time. The SSA stated the phone application was not currently available for staff's use. The SSA stated the facility had a portable computer tablet to use but she had to look for its charger. The DSS stated video calls with FM 1 were the most effective method to communicate with Resident 107. The DSS stated an inability to communicate could cause Resident 107 to experience anxiety and frustration. During a concurrent interview and record review, on 6/13/2024 at 12:12 p.m., with the DON, Resident 107's Admission Record, and nursing progress notes dated 4/12/2024 to 6/13/2024, the medical record titled Change in Condition Evaluation (COC), dated 4/18/2024, the facility's P&P titled Communication Barriers, dated 4/5/2023, the P&P titled Translation or Interpretation Services, dated 6/1/2021, and Resident 107's GACH 1 H&P, dated 4/8/2024, were reviewed. The DON stated the progress notes indicated staff were aware of Resident 107's preference to communicate using ASL, and Resident 107 displayed signs of frustration, agitation, and restlessness due to her inability to communicate with the staff. The DON stated the COC, dated 4/18/2024, indicated Resident 107 attempted to the leave the facility and that attempts to redirect Resident 107 were less effective due to communication barriers. The DON stated staff should have been able to communicate with Resident 107. The DON stated she was aware since Resident 107's admission to the facility, that staff had difficulty communicating with the resident. The DON stated it was reasonable that Resident 107 wanted to elope due to an inability to communicate or understand others. The DON stated clear communication was important for staff to identify and address Resident 107's needs. The DON stated it was a safety concern if Resident 107 could not communicate her needs with the staff. The DON also stated lack of clear communication could lead to inaccurate assessments of Resident 107's clinical condition, and negatively impact the plan of care. The DON stated Resident 107's psychosocial well-being could also be negatively affected, and Resident 107 could suffer anxiety and frustration. The DON stated the facility's P&P, dated 4/5/2023, indicated interpreter services should have been available to Resident 107. The DON stated the facility did not provide interpreter services and did not have access to any interpreter services. The DON stated she assumed Resident 107 could communicate by writing but she did not verify with GACH 1. The DON stated the facility's P&P dated 6/1/2021 indicated staff should not rely on family members for translation services. A review of the facility's policy and procedure (P&P) titled RAI Process - MDS Assessments, Processing and Documentation, dated 1/1/2012, indicated the purpose of the policy was to provide residents assessment that accurately depict and identify resident-specific issues and objectives. The P&P indicated the MDS was a part of the Resident Assessment Instrument (RAI) and indicated the RAI included an accurate reflection of the resident's status. A review of the facility's policy and procedure (P&P) titled Behavior - Management, dated 1/1/2012, indicated staff will perform an appropriate assessment of the resident's behavioral symptoms and implemented appropriate interventions. The P&P indicated when a resident displayed new behavioral symptoms, staff would implement non-pharmacologic interventions to alleviate possible causative factors and use effective verbal and non-verbal communication techniques to manage the behavior problems, prior to initiating psychotropic medications. The P&P indicated possible interventions included addressing psychosocial stressors and medical conditions. A review of the facility's P&P titled Admission of Patients, undated, indicated the facility was supposed to accept and retain only those patients for whom the facility can provide adequate care. A review of the facility's policy and procedure titled Care Planning, dated 5/1/2018, indicated it was the facility policy to ensure that a comprehensive, person-centered care plan was developed for each resident based on their individually assessed needs, and changes made to the care plan on an ongoing basis as needed. The P&P indicated the care plans should describe the services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A review of the facility's P&P titled Translation or Interpretation Services, dated 6/1/2021, indicated the purpose of the P&P was to ensure residents who have hearing deficiencies have the same access to Facility services as other residents. The P&P indicated family members and friends were not to be relied upon to provide interpretation services for the resident. A review of the facility's P&P titled Communication Barriers, dated 4/5/2023, indicated the facility was responsible for providing effective interpretation or arranging for a qualified interpreter when needed. The P&P indicated if an interpreter was needed the facility was responsible for maintaining a list of qualified interpreters and coordinating services with the qualified interpreter. The P&P indicated the facility was supposed to provide language assistance and auxiliary aids, as appropriate, to residents who had a hearing, visual, or speech disability. The P&P indicated that upon hire and at least annually, facility staff were supposed to be trained to provide access to interpreter services by referring residents to social services. A review of the facility's P&P titled Resident Rights - Accommodation of Needs, dated 5/1/2023, indicated it was the facility's policy to ensure that the facility provided an environment and services that met the resident's individual needs. The P&P further indicated facility staff were supposed to interact with the resident in a way that accommodated the physical or sensory limitations of the residents, promoted communication, and maintained the resident's dignity.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was supervised while walking. Resident 1 was allowed to walk independently after being assessed by the physical therapist (PT, professionals who educate patients about exercises for muscle strength, coordination, and balance) as requiring moderate assistance (staff does half the work for the resident) while walking. This deficient practice resulted in an avoidable fall. Resident 1 fell at the front lobby and sustained a bump on the back side of her head, a right hip fracture (broken bone) that required admission and surgical intervention at the general acute care hospital (GACH) for six days. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included muscles weakness, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), epilepsy (seizures- sudden electrical activity in the brain), cerebral infarction (disrupted blood flow to the brain, heart failure, and difficulty walking. A review of Resident 1 ' s Minimum Data Set ([MDS]), a standardized assessment and care planning tool), dated 2/10/24 indicated Resident 1 had severe cognitive impairment (ability to reason, understand, remember, judge, and learn). The MDS indicated Resident 1 required supervision or touching assistance (staff provides touching and/or steadying assistance) when walking 50 feet ([ft.] unit of measurement) and 150 ft. A review of Resident 1 ' s care plan, dated 4/8/24, indicated Resident 1 was at high risk for falls and injuries related to generalized weakness, psychotropic medications (any drug that affects brain activities associated with mental processes and behavior), having lack of awareness, poor judgement of safety, and gait (manner of walking) instability. Staff ' s interventions included to check the environment that increased risk of falls such as wet spots on the floor and broken handrails, educate resident to change position slowly from sitting to standing, educate resident to use call light to ask for assistance, and referral to rehabilitation services (healthcare services to improve skills for daily living). A review of Resident 1 ' s Fall Risk Evaluation, dated 4/8/24 indicated Resident 1 was at risk for falls and had a balance problem while standing and walking, had decreased muscular coordination and required the use of assistive devices (a device to help someone perform a task). A review of Resident 1 ' s PT Evaluation and Plan of Treatment, dated 4/9/24, indicated Resident 1 was referred to PT for a decline in functional capacity (capability for an individual to perform tasks necessary or desirable in their life), functional ambulation (ability to walk), and functional mobility. The PT evaluation indicated precautions (measures taken in advanced to prevent something dangerous) and contraindications (anything that serves as a reason not to provide a procedure or treatment) for Resident 1 included being a fall risk. The PT evaluation indicated Resident 1 had a significant decline in function and generalized weakness due to deconditioning (a decline in physical function because of inactivity), unsteady gait (a person ' s manner of walking) and has poor endurance in functional mobility. A review of Resident 1 ' s Situation Background Appearance Review (SBAR) Communication Form, dated 4/14/24, indicated Resident 1 fell on [DATE] at approximately 11:15 AM. The SBAR indicated Resident 1 had a head injury with a bump on the back side of her head. The SBAR indicated Resident 1 complained of right leg pain. A review of Resident 1 ' s GACH History and Physical (H&P) Final Report dated 4/14/24, indicated Resident 1 was being evaluated for right leg pain and headache after a fall on 4/14/24. The H&P indicated a right hip x-ray (a medical test that takes pictures of bones in the body) showed mildly displaced (movement from its usual position) intertrochanteric (area on the femur [thigh bone] where the hip and thigh meet) fractured on the right femur. During a concurrent interview and record review on 4/30/24 at 2:36 PM with the PT Assistant (PTA), Resident 1 ' s PT Treatment Encounter Notes dated 4/9/24- 4/14/24 were reviewed. The PTA stated Resident 1 was referred to PT due to a need in performing activities of daily living ([ADL]-tasks related to personal care), decreased coordination, reduced balance, decrease in strength and a high risk for falls. The PTA stated Resident 1 was last evaluated on the morning of 4/14/24 before the fall occurred. The PTA stated Resident 1 ' s functional status indicated that Resident 1 ' s gait on level surfaces required moderate assistance, the distance on level surfaces was 50 ft., and an assistive device used was handheld assistance which means they would hold their hand to guide the resident while walking. The PTA stated moderate assistance was defined as the resident performing 50 percent (%) of the activity or task and the staff did the other 50% which could include verbal and tactile cues (physical touch to guide or remind completion of a task or activity), setup of equipment such as siderails and wheelchairs, holding onto the residents gait belt (device put on a person with mobility issues to help them move around), or resident holding or using assistive devices such as the staff members hand or a handrail. The PT Treatment Encounter Notes from 4/10/24 to 4/14/24 indicated Resident 1 ' s gait on level surfaces required moderate assistance going 50 ft on level surfaces with assistive device being handheld assist. The PTA stated that her method of communication to the nursing staff was done verbally, and it was assumed the information would be endorsed to the nurses on the next shift. The PTA stated the PTA ' s did not have access to document in the system the nurses used. During a concurrent interview and record review on 4/30/24 at 9:51 AM with the Registered PT (RPT), Resident 1 ' s PT Discharge Summary was reviewed. The RPT stated she has worked with Resident 1, and the resident was sometimes non-compliant with safety measures and could be impulsive (doing something without thought). The RPT stated Resident 1 did not like using a walker and preferred to walk on her own. During an interview on 4/29/24 at 12:50 PM with the Security Guard (SG), the SG stated she saw Resident 1 fall in the front lobby on 4/14/24 around 11:00 AM. The SG stated she was sitting at her desk and saw Resident 1 walking out the door from the patio across from the front lobby when Resident 1 turned, fell , and hit the ground. The SG stated Resident 1 was walking by herself without a walker. The SG stated she noticed Resident 1 had blood on her head that looked like an abrasion (a rub or wearing off of the skin). The SG stated she has often saw Resident 1 walking by herself. During an interview on 4/29/24 at 1:00 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the charge nurse on the day the resident fell , 4/14/24but did not witness the fall. LVN 1 stated she was alerted of the fall by Activities Assistant (AA) 1. LVN 1 stated the resident was wearing non-skid socks and the resident was alert with no change in her level of consciousness (state of being awake). LVN 1 stated Resident 1 often walked on her own without the use of assistive devices and could be impulsive. LVN 1 stated staff had to remind Resident 1 to slow down when walking or hold onto the handrails. During an interview on 4/29/24 at 1:50 PM with LVN 2 and Certified Nurse Assistant (CNA) 1, LVN 2 and CNA 1 both stated they were familiar with Resident 1, and often walked around the facility by herself, and did not use any assistive devices when doing so. CNA 1 stated the staff did not walk with Resident 1 but would check up on to make sure she was okay. CNA 1 stated staff did not need to help her when getting up off the bed or chair and going to the restroom. LVN 2 stated he was not aware that Resident 1 required more assistance or supervision while walking. During a concurrent observation and interview on 4/30/24 at 11:20 AM with Resident 1, in Resident 1 ' s room, Resident 1 was observed lying on her bed with a dressing noted on her right hip. Resident 1 stated she had surgery for a broken bone after she fell . Resident 1 stated she finished smoking in the patio and was walking back to her room when she felt dizzy. Resident 1 stated she could not catch herself and fell to the ground. Resident 1 stated she was working with physical therapy to be able to walk again. During an interview on 4/30/24 at 3:20 PM with the Director of Rehabilitation (DOR), the DOR stated the bulk of the rehabilitation department ' s documentation was done in their own system that did not cross over to the system the nursing staff used and could not see their assessment and notes. The DOR stated if there was something important that needed to be discussed regarding a resident, they would have a verbal conversation with the nursing staff. The DOR stated Resident 1 could be impulsive and needed some verbal or visual cues from staff to remind her to walk slower. During a concurrent interview and record review, on 5/1/24 at 11:14 AM with LVN 1, Resident 1 ' s PT Treatment Encounter Notes dated 4/9/24- 4/14/24 was reviewed. LVN 1 stated based on the notes from the rehabilitation department, Resident 1 was not as independent as she thinks when ambulating and required more assistance and supervision from staff. LVN 1 stated she was not made aware of this assessment from PT and was not aware of any special instructions for Resident 1. LVN 1 stated if she knew the resident required more assistance and supervision, there would have been more interventions in place to keep the resident safe while walking and the resident might have avoided the fall. During a concurrent interview and record review on 5/1/24 at 12:39 PM with RPT, Resident 1 ' s PT Discharge Summary was reviewed. RPT stated one of Resident 1 ' s long-term goals were to ambulate on level surfaces for 150 ft. using no assistive devices but with contact guard assist (CGA) which means the staff was standing by to provide reminders and nudges as necessary. RPT stated on the day Resident 1 fell , she did not meet this goal of having CGA and ambulating 150 ft. with no assistive devices and Resident 1 still required moderate assistance from staff. During an interview on 5/1/24 at 2:30 PM with RN 1, RN 1 stated Resident 1 had a history of seizures, was a high fall risk and needed redirection at times. During an interview on 5/1/24 at 3:05 PM with the Director of Nursing (DON), the DON stated Resident 1 walked independently with a short stride, was a high fall risk, had a history of seizures, and was impulsive. The DON stated Resident 1 could ambulate independently and did not require staff to be by her side constantly to supervise her. The DON stated if there were concerns or precautions to take regarding a resident but was not communicated or followed up on, the resident might get hurt. A review of the facility policy and procedure (P&P) titled, Fall Prevention and Management, revised 2018, indicated the facility will have a fall prevention and management program that provides an environment free from hazards over which the facility has control. A review of the facility P&P titled, Resident Rights- Quality of Life, dated 5/1/2023, indicated facility staff provide care and services that ensure the resident ' s abilities in activities of daily living do not diminish while in the care of the facility, except when unavoidable as evidenced by clinical condition.

Based on observation, interview, and record review, the facility failed to maintain an infection preventions and control program to prevent the spread of the coronavirus disease ([COVID19 is a disease caused by virus called [CONDITION(S)]-CoV-2}) an illness caused by a virus that can easily spread from person to person) by failing to: 1. Perform N95 respirator (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air] and prevent infections) fit testing (a method of ensuring the mask properly fits the face of the wearer to protect from inhaling infectious particles) for twenty-seven (27) new employees. 2. Ensure seven (7) certified nurse assistants (CNA 4, 5, 6, 8, 9,10, and 11) wore properly fitted N95 masks while providing direct resident care in yellow zone (an area housing covid 19 suspected, symptomatic or exposed residents). 3. Ensure 2 of 10 CNAs (CNA 1 and 2) were accurately screened for signs and symptoms(s/s) of COVID19 before entering the facility and before providing care to 31 residents. These deficient practices placed all 103 inhouse residents, 72 residents in the green zone (an area in which the residents have not come into contact with COVID 19) and 31 residents in the yellow zone, staff, and the community at risk for the transmission and spread of COVID-19. On 12/30/2021 at 4:10 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified due to facility failure to perform N95 fit testing for twenty-seven (27) new employees, ensure seven (7) CNAs (CNA 4, 5, 6, 8, 9, 10, and 11) wore properly fitted N95 masks and screen CNA 1 and 2 for signs and symptoms of Covid-19 prior to entering the facility and providing direct care to residents while exhibiting symptoms of COVID-19. The IJ was called in the presence of the director of nursing (DON) and the infection preventionist (IP). On 12/31/2021 at 5:12 p.m., the Administrator (Admin) submitted an acceptable Plan of Action ([POA] a plan with interventions to correct the deficient practices). The IJ was lifted on 1/1/2022 at 3:40 p.m., after verifying and confirming onsite the POA was implemented per observations, interviews, and record reviews. The acceptable POA included the following immediate corrections: 1) The 31 residents identified potentially affected by this deficient practice remained in the yellow zone and were monitored every four hours for signs and symptoms of Covid-19. The director of staff development (DSD) and IP contacted all 27 new employees for the N95 fit testing procedure. On 12/31/2021 all 6 CNAs were fit tested for N95. On 12/29/2021, CNA 1 was re-screened for signs and symptoms of Covid-19; CNA 1 disclosed she had signs and symptoms of Covid-19, so she was counseled to disclose and report signs and symptoms of Covid-19 before taking care of residents and was taken off duty due to positive Covid-19 test results. 2) The Director of Staff Development, IP and Designee will do fit testing of N95 mask for 27 staff on from 12/31/2021 to 1/7/2022. On 12/30/2021 and 12/31/2021, DSD, IP and registered nurse (RN) supervisors verified all CNAs in the yellow zone donned the correct properly fit tested N95 mask on and used all required personal protective equipment ([PPE] equipment used to prevent transmission of disease) while on duty in the yellow zone. On 12/30/2021 and 12/31/2021, DSD and IP checked the screening check point of staff for signs and symptoms of Covid-19 before taking care of residents. 3) On 12/30/2021 and 12/31/2021 IP, DSD, and Designee educated staff on the regulation that all staff must be N95 fit tested prior to use, as needed (per change of mask, change or physical condition), and yearly thereafter; and utilization of the required PPE and properly fit tested N95 when working in the yellow and red zones. On 12/30/2021 and 12/31/2021 IP, DSD, and DON in-serviced staff on importance of the screening process for signs and symptoms of Covid-19 before taking care residents. Staff education conducted by the DON, IP, and DSD will be continued from 1/1/2022 to 1/5/2022. 4) Measures implemented to monitor the continued effectiveness of the corrective action: i. IP will audit and submit results of fit testing of N95 to Quality Assurance and Performance Improvement Committee ([QAPI] key m members that discuss processes in the facility that focuses on improving the quality of care) monthly for 3 months. ii. IP will submit the results of the audits of staff proper donning PPE and proper N95 usage to QAPI monthly for 3 months. iii. DON or designee will submit the audits of the completion of signs and symptoms of Covid-19 screening process to QAPI Committee monthly for 3 months. The QAPI Committee will review the deficient practices and plan of corrections to ensure system effectiveness. Any additional recommendations to be given at that time. Findings: During a review of the facility's census, dated December 30, 2022, the census indicated the facility had 103 in-house residents that included 31 residents were housed in the yellow zone and 72 residents were housed in the green zone. A. During an interview 12/30/2021 at 3:45 p.m. with DON, DON stated thirty-one (31) residents were transferred from the green zone to yellow zone, because five (5) staff members (Administrator, CNA 1, 2, and 3, and physical therapy aide [PTA]) were identified to have COVID-19. The CNAs and PTA were direct care staff spending more than 15 minutes and less than 6 feet in contact with the residents. During a concurrent record review and interview with IP on 12/30/2021 at 4:12 p.m., IP reviewed the facility's Employee List of New Hires from January 2021 (printed 12/30/2021), the list indicated none of the new hired staff were fit tested for N95 including the newly hired direct care staff (CAN 1 and 2) who came into close contact with residents providing activities of daily living (ADL's- showering, feeding, grooming). IP stated the last fir testing was conducted on 11/3/2020, fit testing was not done this year, 2021, but will do fit testing early next year 2022. IP stated CNA 3 tested positive and worked the 7 am to 3 pm shift on 12/29/2021 with symptoms and was not fit tested for N95.When asked if CNA 3 provided direct patient care to residents? IP answered yes, that is why the facility have 31 residents that are exposed to Covid-19 and some residents with symptoms. IP stated when in the yellow zone and/ or red zone (group of residents with Covid-19) direct care nurses are required to wear N95 masks, gloves, isolation gown and eye protection. IP stated it is important for N95 respirators to be fit tested because the N95 must not have a leak, it the N95 have a leak, particles from the coronavirus can leak through to the wearer. During an interview on 12/30/2021 at 4:40 p.m., with CNA 12, CNA 12 stated she works both yellow zone and green zone. CNA 12 stated that she wears N95 respirator on top of surgical mask for double protection because she is high risk due to medical conditions. When asked when she got fit tested was there surgical mask on the bottom of the N95 respirator, CNA 12 answered she does not remember. CNA 12 stated she gives direct care to resident standing less than 6 feet of distance and CNA 12 stated she stayed for more than 15 minutes inside the room. CNA 12 stated it's been a while since she was fit tested and could not remember the date. During an observation on 12/30/2021 at 5:26 p.m., in the yellow zone, licensed vocational nurse (LVN) 2 was observed wearing a non-fit tested N95 with eye protection while conducting medication pass, checking vital signs, and LVN 2 was within 6 feet of residents. During an interview on 12/30/2021 at 5:30 with LVN 2, LVN 2 stated he was in close contact with residents, and was wearing a non-fit tested N95 respirator, gowns, gloves, and eye protection. LVN 2 stated that N95 is important to prevent getting and spreading the virus. B. During an interview on 12/30/2021 at 6:05 p.m. with DON, DON stated fit testing for 27 new hires have not been completed to date and will be conducted on 1/7/2022. During a review of the Facility New Hired List for the year 2021, indicated 27 staff members were hired including the following: a. On 11/8/2021, the facility hired CNA 4 no fit testing record provided. b. On 12/21/2021, the facility hired CNA 5 no fit testing record provided. c. On 11/1/2021, the facility hired CNA 6 no fit testing record provided. d. On 3/12/2021, the facility hired CNA 8 no fit testing record provided. e. On 9/16/2021, the facility hired CNA 9 no fit testing record provided. f. On 4/20/2021, the facility hired CNA 10 no fit testing record provided. g. On 2/17/2021, the facility hired CNA 11 no fit testing record provided. During a review of the Nursing Assignments for the month of December 29-30, 2021, indicated the following staff assignments were included: a. 12/29/2021 a.m. shift, CNA 4 assigned to cross in between rooms of yellow and green zone, CNA 5 was a sitter for yellow zone room. b. 12/29/2021 3:00 p.m. to 11:00 p.m. (PM shift), CNA 9 assigned to cross in between rooms of yellow and green zone. c. 12/29/2021 11:00 p.m. to 7:00 a.m. (Noc shift), CNA 10 and CNA 11 assigned to work in the yellow zone. d. 12/30/2021 a.m. shift, CNA 4 assigned to cross in between rooms of yellow and green zone rooms and CNA 6 worked in yellow zone room. e. 12/30/2021 p.m. shift, CNA 8 assigned to cross in between rooms of yellow zone and green zone. During an interview on 12/30/2021 at 6:15p.m., with DON, DON stated the facility had 31 residents in yellow zone and 72 residents in the green zone. The DON stated when staff provided resident care and come into close contact with residents (within 6 feet) staff must wear full PPE, which includes eye protection, an N95 respirator (mask), a gown, and gloves. The DON stated staff must be fit tested for the N95 prior to its use with residents who were potentially exposed to Covid-19. DON stated that fit testing of the N95 respirator mask must be retested whenever employee has a change in physical condition that could affect the fit of the employee's N95 respirator such as large weight gain or loss, facial surgery, major dental work, or any facial changes could affect the N95 respirator to properly seal to your face. During a concurrent interview and record review on 12/30/2021 at 6:30 p.m. with the IP of the facility's policy titled, N95 Fit Testing was reviewed. IP stated the policy indicated staff fit testing for N95 was supposed to continue for newly hired staff. Not fit testing the staff increased the risk of Covid-19 transmission within the facility. The administrator bought the Fit Testing kits and was waiting for the solution to arrive. CNAs and licensed nurses who come into close contact with residents must wear an approved N95 respirator before taking care of the yellow zone or red zone residents. New hire staff should have been fit tested . IP stated that the facility policy indicated: 1. Employees will have a proper respirator PPE to protect his/her health. 2. Employees will have fitted N95 respirator mask; and 3. The employees will use the N95 properly and correctly. During a record review of the facility's N95 Fit Testing policy (undated), the policy indicated the purpose of N95 respirator mask is to ensure that employee will have proper respiratory PPE to protect his/her health, to ensure employees will have proper fitted N95 respirator face mask and to ensure the employee use the N95 properly and correctly. N95 must be tight-fitting and form a tight seal with the face and neck to work properly. A respirator can't protect employee if it doesn't fit the face correctly. C. During a concurrent interview and record review on 12/30/2021 at 6:38 p.m., with IP regarding CNA 1 and CNA 2's Covid-19 screening logs for the month of December, the screening logs were reviewed. IP stated that the screening log indicated CNA 1 and CNA 2 both reported having no muscle/ body ache, headache, sore throat, congestion, runny nose, diarrhea, nausea, and no vomiting as verified with an initial by the screener. Both CNA 1 and CNA 2 should not have entered the facility and should not have provided direct care to residents while exhibiting symptoms of COVID-19. IP stated CNA 1 reported no symptoms during working hours on 12/29/2021 but after informing CNA 1 that she tested positive of COVID-19 after the end of her shift, CNA 1 informed IP she had symptoms before starting her shift. IP stated no one verifies the log for accuracy before staff entered the building. IP stated CNA 2 wrote no symptoms on 12/25/2021, 12/26/2021, 12/27/2021, and 12/28/2021 but after relaying laboratory result of CNA 2 that she tested positive for COVID-19, CNA 2 told IP she had body aches, was sneezing and had a runny nose while working in the facility on 12/25/2021. During a review of the undated Line Listing, indicated CNA 1 symptoms started 12/27/2021 and CNA 2 symptoms started 12/25/2021. During an interview on 12/30/2021 at 3:45 p.m. with the screener (Staff S), Staff S stated that she was the one who initials and checks if staff missed anything in the form, but staff do self-screening, and the screener does not verify the employee's symptoms. During an interview with the DON on 12/30/2021 at 6:40 p.m., DON stated CNA 1 and CNA 2 should have accurately answered the questionnaire and accuracy should have been verified by the screener. DON stated someone should have been auditing and checking randomly on CNAs who give residents direct care. If they have symptoms during working hours, the staff should be sent home right away and to isolate instead of risking vulnerable resident to get the virus. During a record review of the facility's Mitigation Plan (MP), dated 8/27/2021, the MP indicated every individual including all staff entering the facility would be screened for COVID-19 symptoms including temperature checks. Facility staff with symptoms or signs of COVID-19 must be tested and will be restricted from work pending the results of COVID-19 testing.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) known to have aggressive behavior towards the staff and residents was closely monitored to prevent physical altercation. This deficient practice resulted in Resident 2 flipping Resident 1 off the wheelchair on to the floor on purpose. Findings: a. A review of Resident 1's Face sheet (Admission Record) indicated the facility admitted Resident 1 on 6/21/14, and readmitted the resident on 12/4/17, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's undated history and physical (H&P), indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's care plan on altercation with another resident dated 9/6/18, indicated Resident 1 was a victim of an altercation with another resident. Interventions included monitor Resident 1 for signs of fear, withdrawn behavior and isolation, observe for change in activity, encourage the resident to verbalize concerns and assess Resident 1 for pain, redness, bruising and swelling and notify the physician. A review of Resident 1's Licensed Nurse Progress Notes dated 9/7/18 timed 12:30 a.m., indicated Resident 1 was propelling himself towards his room when Resident 2 flipped Resident 1 from the wheelchair onto the floor. The same licensed nurse progress notes indicated Resident 1 did not sustain any injury and denied pain. A review of Resident 1's Licensed Nurse Progress Notes dated 9/8/18 timed 3:00 p.m. to 11:00 p.m., indicated Resident 1 was on monitoring after another resident pushed down Resident 1. A review of Resident 1's Minimum Data Set (MDS, assessment and care screening tool) dated 9/10/18, indicated Resident 1 was able to understand and be understood by others. The same MDS indicated, Resident 1 required one-person physical assist with bed mobility, transferring from a bed and chair to a standing position, dressing, eating, toilet use and personal hygiene. The same MDS indicated Resident 1 did not walk and used a wheelchair for movement. A review of an Abuse Investigation Reporting Form dated 9/11/18, indicated on 9/6/18 at 11:33 p.m., Resident 1 was wheeling himself towards his room and Resident 2 flipped Resident 1 off the wheelchair (w/c) on to the floor on purpose. The same abuse investigation reporting form, indicated Resident 2 could have avoided this by going around and instead Resident 2 stated Resident 1 deserved it. The same abuse investigation reporting form indicated a licensed vocational nurse (LVN) and two certified nurse assistants (CNAs), assisted Resident 1 back to the w/c. The same abuse investigation reporting form, indicated Resident 1 stated he was going to his room when Resident 2 grabbed the w/c and flipped me out of the w/c. b. A review of Resident 2's Face sheet, indicated the facility admitted Resident 2 on 1/7/16, and readmitted the resident on 4/2/18, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's H&P dated 4/3/18, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 2's care plan dated 4/2/18 indicated Resident 2 was at risk for aggression with other residents due to [CONDITION(S)], [CONDITION(S)] and use of elbow to bump female staff. Interventions included staff be on the alert for signs and changes in Resident 2's behavior by observing for presence of yelling, anger, restlessness, repetitive pacing and talking to self. Interventions further included to redirect Resident 2 away from the group when having outburst of behavior of signs of anger, administer medications for behavior management and notify the physician of any outburst or increase in behavior. A review of Resident 2's Psycho-Social Assessment Form dated 4/6/18, indicated Resident 2 was verbally aggressive and cursing with the and could harm others. and had a tendency of standing too close to other residents which provoked negative reaction. A review of Resident 2's care plan dated 4/6/18, indicated Resident 2 was at risk for altercation towards staff and other residents' secondary to behavior of walking around with hands on hips and elbows without regard to other residents and staff and behavior of standing close to other residents. The goals included Resident 2 will not have altercation as a result of the resident's behaviors. Interventions included to encourage Resident 2 to respect other residents' personal space, redirect the resident to a positive activity, and offer food or snacks and psychology follow up. A review of Resident 2's care plan dated 4/6/18, indicated Resident 2 had alteration in behavior related to [CONDITION(S)] and [CONDITION(S)] manifested by verbal threatening, cursing, and screaming at others and behavior of invading personal space. The staff's interventions included to separate Resident 2 from others when the resident had signs of verbal or physical aggression, approach firmly in a non-judgmental manner, discuss and listen to options, preferences, likes and dislikes, always redirect Resident 2, and alter the resident's environment during periods of behavior problems. A review of Resident 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS dated [DATE] indicated the Resident 2 had verbal behavioral symptoms directed towards others including threatening, screaming, and cursing at others that occurred four to six days but less than daily. The same MDS indicated, Resident 2 did not require assistance with bed mobility, surface transfer from bed and to chair, to stand, dress, eat, toilet use, and personal hygiene. The same MDS indicated Resident 2did not have range of motion limitation to both upper and lower extremities and did not use assistive devices for mobility. A review of Resident 2's Psychologist's Progress Note dated 8/8/18 indicated Resident 2's mood was mildly depressed and irritable. This note indicated Resident 2 had unrealistic demanding of staff and demonstrated inappropriate behaviors at times. A review of Resident 2's Monthly [CONDITION(S)] Drug Management dated 8/1/2018 to 8/31/2018 indicated Resident 2 had 6 behavioral episodes. A review Resident 2's Nurse's Notes dated 9/6/18 timed 11:35 p.m., indicated Resident 2 stated Resident 1 was going towards his room, when Resident 2 suddenly appeared and was noted to touch Resident 1's w/c. Resident 2 then flipped Resident 1 off the w/c, took the w/c and put it over Resident 1 and stated he was in [MEDICATION(S)] and he deserved it. Resident 2 was transferred to another room in another station and placed on every 30 minutes monitoring. A review of Resident 2's Administrative Information Record dated 9/7/18, indicated Resident 2 was transferred to an acute care hospital (GACH) for psychiatric evaluation secondary to physical aggression. During an interview on 9/18/18 at 2:10 p.m., Resident 1 stated that on 9/6/18, Resident 2 grabbed his w/c and threw Resident 1 right on the ground. Resident 1 state that earlier that day, Resident 1 had a verbal altercation with Resident 2 in the patio and thought it was over. Resident 1 also stated that an activities assistant was at the patio when the verbal altercation happened. Resident 1 stated he felt pain to his back after the incident and was fearful living in the facility with Resident 2. During an interview on 9/18/18 at 2:23 p.m., LVN 1 stated Resident 2 was aggressive towards staff and other residents and was difficult to redirect. During an interview on 9/18/18 at 2:50 p.m., the Activities Assistant 1 (AA 1) stated Resident 2 had increasing become verbally aggressive towards staff and residents. During an interview on and concurrent Resident 2's care plan review on 9/18/18 at 2:54 p.m., Registered Nurse 1 (RN 1) stated on 4/2/18, Resident 2 bumped a female staff and had episodes of verbal aggression towards staff and other residents. RN 1 stated Resident 2 was not monitored when he physically abused Resident 1. RN 1 further stated Resident 2 was supposed to be monitored to prevent any form of abuse to other residents. During an interview on 9/18/18 at 3:46 p.m., the Director of Nursing (DON) stated Resident 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that on 9/6/18, Resident 2 flipped Resident 1 from a wheelchair to the floor, the staff did not closely monitor Resident 2. A review of the facility's undated Policy on Patient Abuse and Mistreatment indicated the facility would uphold residents' rights to be free from verbal, sexual, physical and mental abuse. The policy further indicated the facility would establish a system to prevent abuse and those practices that led to abuse, and that residents would not be subjected to abuse by anyone, including facility staff. A review of the facility's undated policy and procedure titled Nursing Administration Resident Rights Abuse, Resident to Resident, indicated if the physician and the facility feel that a resident will be a danger to other residents and or self, the facility will seek proper placement at another facility.

Based on observation, interview and record review, the facility failed to adhere to its policy to ensure residents rights were not violated regarding personal privacy and confidential medical records, as in Protected Health Information ((PHI) any information in a medical record that can be used to identify an individual), were secure and not breached for three of six sampled residents (Residents 1, 2, and 3). The facility's staff (Certified Nursing Assistant 1 (CNA1)) posted resident's personal and PHI on social media. This deficient practice resulted in Residents 1, 2 and 3 rights being violated after the facility's staff exposed the resident's PHI and facial pictures on social media without the residents' or the resident's responsible parties' consent or knowledge. This failure had the potential to result in a security breach for Residents 1, 2 and 3, which could lead to identity theft and fraudulent activity, as well as placed the other residents who resided in the facility at risk. On 2/11/2020 at 2 p.m., during an interview and record review with the Administrator (ADM) and the Director of Nursing (DON), an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's inability to ensure resident's PHI and personal information was protected. The facility's ADM, DON and the Director of Staff Development (DSD) were notified of the immediacy and seriousness of the residents' health and safety being threatened. On 2/13/2020 at 2 p.m., the ADM submitted an unacceptable plan of action (POA), which did not remedy the facility's noncompliance. On 2/14/2020 at 2 p.m., the DON and ADM provided a revised acceptable POA that included the following actions: 1. The immediate termination of Certified Nursing Assistants (CNAs) 1 and 2. 2. The Administrator, DSD, Registered Nurse (RN) Supervisors would immediately educate the facility's staff to enhance the education of every staff member on every shift, especially the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shift. The in-services focus was as follow: a. Residents' Rights and protecting the rights of the residents and the residents' ability to exercise those rights. b. The Health Insurance Portability and Accountability Act ((HIPPA) a law designed to supply privacy standards to protect patients' medical records) and Privacy Protection/Breach Policy and Procedure/Notification c. In-services provided on Abuse Prevention, Investigation, and Mandated Reporting. d. The prohibition of cell phones usage during resident care (phone should not be visible while providing care). e. The staff to make rounds (checking on the residents) every two (2) hours on every shift. f. The prohibition of posting workplace information on Social Media. 3.The RN Supervisors and Charge Nurses will remind and reinforce the staff members on every shift about Resident's Rights, HIPAA and the Privacy Protection/Breach of Protective Medical Information of Residents, Abuse Protocol, Mandated Reporting, cell phone usage protocol during working hours and the prohibition of posting workplace information on social media. 4. The staff who are not on duty or are taking a leave of absence cannot work with residents without completion of the required in-services. 5. The facility's administration, the RN Supervisors and Charge Nurses will remind and reinforce to staff members that all residents must be treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. 6.The ADM and DSD will randomly interview the staff daily about these practices and report the findings in the daily meetings. On 2/14/2020 at 2:30 p.m., while onsite, the Team verified and confirmed through interview and records reviews that the POA was implemented, the IJ was removed and the ADM and DON were notified. Findings: a.On 2/11/2020 at 11 a.m., during a concurrent observation of a social media posted picture (10/26/19) and an interview the DSD identified and confirmed the CNAs involved were CNAs 1 and 2 in the posted picture. The photo showed CNAs 1 and 2 looking over their shoulders and sticking out their tongues in a seductive manner, while providing care to a resident in bed. The DSD identified the resident as (Resident 2). The DSD stated CNA 2 knew to report CNA 1's behavior because it was part of the abuse training, she had provided to all the facility's staff members. A review of Resident 2's admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS), an assessment and care screening tool), dated 12/7/19 indicated Resident 2 required extensive assistance with one-person physical assist to do activities of daily living (ADLs), such as personal hygiene, toilet use, and dressing. The MDS indicated the resident sometimes understands others and makes himself understood. On 2/11/2020 at 11:05 a.m., during an interview and review of the facility's workplace agreements, the DSD stated CNA 1 was not to take part in any social media postings while working in the facility. The DSD stated it was part of the training and education that was provided to the certified nursing assistants. The DSD acknowledged she trained CNAs 1 and 2 about abuse prevention and reporting and CNAs 1 and 2 signed an agreement about protecting the resident's privacy and PHI information. The DSD stated facility does not condone (accept or allow) the sharing of resident's pictures, video posts, or resident's PHI information on social media. The DSD stated CNA 1 signed the in-service, dated 7/29/19 regarding sharing pictures on social media without a residents' consent. The DSD presented the facility's Confidential Agreement indicating as a workplace member the staff had access to such confidential information and it was CNA 1's responsibility to protect Residents 1, 2 and 3's sensitive and personal data. The DSD stated CNA 1 also signed the in-service on 7/22/19 indicating she understood, and she would not use or show any resident's PHI information as part of the facility's HIPAA Privacy Compliance Statement (Health Insurance Portability and Accountability Act of 1996) Privacy Policies. On 2/11/2020 at 11:15 a.m., during a concurrent observation and interview the DON and Administrator identified another picture posted by CNA 1. In this photo, Resident 1's electronic health information was on a computer screen with Resident 1's name, allergies [REDACTED]. CNA 1 indicated on the photo, Three (3) more hours, I am off. b. A review of Resident 1's admission record Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. discomfort in breathing). A review of Resident 1's MDS, dated [DATE] indicated Resident 1 usually had the ability to understand others and was usually understood. According to the MDS, Resident 1 required extensive assistance with activities of daily living (ADLs), such as personal hygiene, toilet use, and dressing. c. A review of Resident 3's Admission Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE] indicated Resident 3 required limited assistance with ADLs, such as personal hygiene, toilet use, and dressing. The MDS indicated Resident 3 usually had the ability to understand and be understood by others. On 2/11/2020 at 11:30 a.m., during an interview, the DON stated CNA 1 should not have taken pictures or videos while working in the facility. The DON stated, Posting photos and videos on social media is against the facility's policy. On 2/11/2020 at 3:30 p.m., during an interview, the ADM stated, We were not aware that residents' pictures and video posts were shared on social media without prior authorization. The ADM stated they will be terminated, CNAs 1 and 2 immediately. On 2/11/2020 at 3:35 p.m., during an interview, CNA 2 stated she was aware of the way CNA 1 talked to Resident 3 but did not report CNA 1's rude remarks. CNA 2 stated she received training about protecting the resident's privacy and personal information but did not report CNA1 because I did not want CNA1 to get in trouble. On 2/11/2020 at 3:50 p.m., during an interview, CNA 1 stated she did post the picture of Resident 1's PHI on social media and live streamed videos. CNA 1 admitted to posting a picture of herself and CNA 2 while changing Resident 2's diaper on social media. CNA1 stated she should not have posed pictures on social media while providing care to Resident 2 because it was a violation of privacy rights of Resident 2. On 2/11/2020 at 5:35 p.m., during an interview, the DSD stated CNA1 admitted to recording live stream videos and posting on social media. The DSD stated the Administrator will report the CNAs to the respected boards after completing the investigation. On 2/11/2020 5:45 p.m., Licensed Vocational Nurse 2 (LVN 2) stated he did not know CNA1 had posted photos on live social media, because it was not acceptable and against the facility's policy. On 2/12/2020 at 11:30 a.m., during a concurrent observation of the social media posting and interview, the DON, DSD, and the ADM identified CNA 1 as the one who posted a live streamed video on social media of her being rude to Resident 3. A review of facility's undated investigation of the incident titled, Summary of Findings, indicated CNA 1 confirmed to have acted inappropriately by taking a selfie photo with a co-worker in a resident's room with the resident in the background; using harsh, unprofessional language in resident care areas and exposing a resident's name from an electronic medical record (EMR) screen within the facility and posting the photos on social media. The investigation listed the following as examples of inappropriate conduct: 1.The CNA (CNA 1) posted a photo on 10/26/19 while in a resident's room with her and a coworker's (CNA 2) tongue sticking out looking over their own shoulders. The resident's (Resident 2) face was captured in the photo). 2. The CNA (CNA1), while live streaming a video it captured a resident's EMR on the screen, which included the resident's face and name. 3.On 12/1/19 a CNA (CNA 1), who was at the facility's nursing station and posted a live stream on social media while speaking to a resident (Resident 2) not visible on the live stream in an inappropriate language. A review of both CNAs 1 and 2's employee files indicated they both were terminated on 2/11/2020. The termination document titled, Inappropriate Conduct-Breach of Resident's Privacy, indicated they participated in filming, inappropriate behavior, posing, photography and posting confidential resident information, which was in violation of basic, professional standards within a long-term care facility. The facility's investigation documented interviews indicated CNA 1 stated she never meant to put anyone in danger and realized her mistake after posting the pictures and video. CNA 2, who was in the picture that was posted on social media with a resident's picture stated felt ashamed. A review of an online article by HIPPA Compliance, titled A Commonsense Approach indicated more than 70% of hospital data breaches include sensitive demographic or financial information that could lead to identity theft due to exposure of sensitive demographic or financial information @https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 78/ A review of facility's undated Employee Handbook under Section for Social Media Guidelines indicated social media activities are not allowed at work or while on company time. When authorized, employees must consult with their supervisor, and receive approval for any posting, prior to posting and must abide by all company policies and applicable laws in such postings. A review of facility's policy and procedure (P/P), dated 11/2017 and titled, Policy indicated that the protection of all resident's data was the responsibility of the facility under the Privacy Act, and shall be protected from accidental or malicious destruction, disclosure or modification. The P/P also indicated the resident's computerized data base/electronic records shall be monitored by the facility to provide a comprehensive program of oversight, responsibility of designation, and protective measures to foster data integrity and security.

the one Based on observation, interview and record review, the facility failed to adhere to its policy to ensure residents rights were not violated and the residents were free from verbal and mental abuse; mistreatment and humiliation for one of six sampled residents (Resident 3) and other residents who resided in the facility. The facility's staff, a certified nursing assistant (CNA1) posted live stream videos on social media being verbally abusive towards residents and using profane language in the residents' earshot while working in the facility. This deficient practice resulted in Resident 2 and other residents in the facility rights being violated and being subjected to ongoing verbal abuse, as the management staff were aware of CNA 1's continued use profane language while providing care to the residents, which is abuse and had the potential to result in mental anguish. Findings: On 2/11/2020 at 11 a.m., during an interview and a concurrent observation of social media posting of a picture (10/26/19) and live-streamed videos with the facility's Director of Staff Development (DSD), she identified and confirmed the two certified nursing assistants (CNA) involved were CNAs 1 and 2. The video posted on social media, dated 11/20/19 showed CNA 1 in the facility's smoking patio in the presence and ear shot of residents using the following profanity in the presence of the residents and other staff over and over again on the video while it was live-streaming on social media B--ch, F--k, Sh-t, Fu-ker, N-gga, Motherf--ker, A-s. CNA1 was heard saying, I do not smoke crystal meth b--ch, I smoke weed. CNA 1 also stated while talking to another CNA about a resident, Sh-tty booty over again, that ni--a over there sat in some sh-t and he smells like sh-t now. A review of another live streamed posting, dated 1/16/2020 and timed at 10:57 p.m., while in the facility and in earshot of residents, CNA1 stated, I am ready for the rain, the rain is not going to f--k up my motherf--k--g suede shoes, I [***] did and do not have $80 more dollars, I am the brokest b---h that work here. During the video, CNA 1 captured a visual of her shoes covered in plastic and stated, I have to go out in the rain like this, so that her my shoes will not get f-ked up. The DSD stated CNA 2 was aware, as an abuse mandated reporter, she should have reported CNA 1's behavior because it was part of the abuse training that was provided to all the facility's staff members. The DSD stated CNA 1 was not to take part in any social media postings while working in the facility. The DSD stated it was part of the training and education that was provided to all certified nursing assistants. The DSD acknowledged she trained CNAs 1 and 2 about abuse prevention and reporting. The DSD stated facility does not condone (accept or allow) the sharing of resident's pictures, video posts, and abuse. On 2/11/2020 at 11:30 a.m., during a concurrent observation of the social media posting and interview, the Director of Nursing (DON), DSD, and Administrator (ADM) identified CNA 1 as who posted the videos on social media. On one video, CNA 1 was seen ridiculing Resident 3, while she ate a slice of pizza at the nursing station and Resident 3 asking for a slice of pizza. CNA 1 responded, You don't have no teeth, you can't have pizza, your dinner will be out in a minute, and CNA 2 was heard laughing at Resident 3 on the video, as CNA 1 teased Resident 3. The DON stated CNA 1 should not have taken pictures or videos while working in the facility. The DON stated, Posting photos and videos on social media it is against the facility's policy. On 2/11/2020 at 3:30 p.m., during an interview, the ADM stated, We were not aware that residents' pictures and video posts were shared on social media without prior authorization until now. We will terminated both CNAs 1 and 2 immediately. On 2/11/2020 at 3:35 p.m., during an interview, CNA 2 stated she was aware of the way CNA1 talked to Resident 3 was inappropriate but did not report CNA 1's remarks about making fun of the resident not having teeth when he asked for pizza. CNA 2 stated she received training about abuse but did not report CNA1. CNA2 stated, I did not want to get her in trouble. On 2/11/2020 at 3:50 p.m., during an interview, CNA 1 stated she posted a live streamed video of Resident 3 requesting for pizza while she was at the nursing station eating pizza. CNA 1 stated she should not have made the comment because it was verbal abuse. CNA 1 admitted her comment caused CNA 3 to laugh when she was making fun of Resident 3. A review of Resident 3's Admission Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE] indicated Resident 3 required limited assistance with ADLs, such as personal hygiene, toilet use, and dressing. The MDS indicated Resident 3 usually had the ability to understand and be understood by others. On 2/11/2020 at 5:35 p.m., during an interview, the DSD stated CNA1 admitted to recording live stream videos and posting on social media. The DSD stated the Administrator will report the CNAs to the respected boards after completing the investigation. On 2/11/2020 5:45 p.m., Licensed Vocational Nurse 2 (LVN 2) stated he has heard how CNA 1 talks in the facility and she (CNA1) would always curse and use profanity, in front of residents and nursing staff. LVN 2 stated he did not know she posted photos on live social media. LVN 2 stated CNA 1's behavior was not acceptable, but stated, We were all aware of it. A review of the facility's undated investigation of the abuse incident titled, Summary of Findings, indicated CNA 1 confirmed to have acted inappropriately by taking a in the background; using harsh, profane words while caring for residents and in the earshot of other residents. The facility's investigation included interviews with CNAs 1 and 2 which indicated the following: CNA1 stated she never meant to put anyone in danger, and she made a big mistake, when she posted pictures and videos while at work. CNA 2 stated she was in the picture and felt ashamed after viewing it. CNA 2 stated she had been a CNA for six years and has never been in trouble. A review of both CNAs 1 and 2's employee files indicated they both were terminated on 2/11/2020. A review of a termination document titled, Inappropriate Conduct-Breach of Resident's Privacy, indicated they participated in filming, inappropriate behavior, posing, photography and posting confidential resident information, which was in violation of basic, professional standards within a long-term care facility. A review of facility's undated Employee Handbook under Section for Social Media Guidelines indicated social media activities are not allowed at work or while on company time. When authorized, employees must consult with their supervisor, and receive approval for any posting, prior to posting and must abide by all company policies and applicable laws in such postings. A review of facility's policy and procedure (P/P), updated on 5/2019 and titled, Policy on Patient Abuse and Mistreatment, indicated the facility would uphold resident's rights to be free from mistreatment, neglect, verbal, sexual, physical and mental abuse. The P/P defined verbal abuse as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend or disability.

Based on record review, observation, and interview, the facility failed to ensure one of three (3) sampled residents was free from physical abuse (Resident A) as indicated in the facility's policy procedure. Resident A stated Licensed Vocational Nurse (LVN) 1 hit him on the right side of his chest with his knuckles. This deficient practice resulted in Resident A's complaint of pain on the right side of his chest. Three days later after the incident, on 4/29/19, Resident A complained of severe chest pain, and he required to be transferred to a general acute care hospital (GACH) for evaluation. Resident A was identified with ecchymosis (purplish discoloration on the skin as a result of trauma to the underlying blood vessel walls) on the right side of the chest. Findings: A review of Resident A's Face Sheet (Admission Record) indicated the facility admitted Resident A on 6/21/14 with the most recent re-admitted d 2/22/19. Resident A's [DIAGNOSES REDACTED]. with the ability to function)). A review of Resident A's Minimum Data Set (MDS- standardized assessment and care screening tool) dated 12/11/18, indicated Resident A's Brief Interview for Mental Status ((BIMS) mental assessment) score was 11 (intact thought process skills). According to the MDS assessment, Resident A had indicators of delusions (misconceptions or beliefs that are firmly held, contrary to reality) with verbal behavioral symptoms, such as threatening, screaming and cursing directed toward others. A review of Resident A's care plan, dated 3/4/19 for Resident A's potential to be verbally aggressive manifested by yelling, cursing, and screaming at staff during care included the following staff approaches: a. Assess the resident's understanding of the situation and allow time for the resident to express self and feelings towards the situation. b. Monitor for signs and changes in behavior by observing presence of yelling, anger, restlessness, repetitive talking to self. A review of Resident A's Order Summary Report dated 3/9/19, indicated to apply [MEDICATION NAME] Patch (Buprenorphine (An opioid narcotic skin patch) used for around-the-clock treatment of [REDACTED]. A review of an Interdisciplinary Team (IDT - a group of health professionals from different disciplines along with patient, working collaboratively as a team)/Care Plan Conference Summary note, dated 3/12/19, indicated a medication patch was ordered for pain management related to history of an old left [MEDICAL CONDITION] and with no significant change of condition. A review of a Nurse's Progress Note, dated 4/26/19 and timed at 2:15 p.m., indicated Resident A alleged that a charge nurse (Licensed Vocational Nurse 1 (LVN 1)) struck him on his chest area during the removal of his medication patch. The note indicated that Registered Nurse 1 (RN 1) assessed Resident A's chest area and there were no signs of injuries, such as redness, swelling nor complaint of pain on the chest area. A review of the facility's Abuse Investigation Reporting Form signed and dated on 5/31/19 by the Administrator indicated Resident A alleged on 4/26/19 at 12:30 p.m. that a charge nurse (LVN 1) struck him on his chest area during the removal of the patch. The form indicated LVN 1 was suspended pending completion of the facility's investigation. A review of the Nurse Note, on 4/29/19 at 5:40 p.m., indicated Resident A propelled his wheelchair to the nursing station and was coughing. Resident A placed his right hand on his chest complaining of chest pain and requesting pain medication. The resident stated his pain level was 10/10 on a pain scale of 1-10, 10 being the worse. A review of the Nurse's Note, dated 4/29/19 at 6 p.m., indicated Resident A's face turned red, while crying with his right hand placed on his right chest screaming in pain. The paramedics were called and Resident A was transferred to the GACH. A review of Resident A's Transfer Record, dated 4/29/19, indicated Resident A's skin was intact, and he was being transferred to the GACH for evaluation of chest pain. A review of the GACH's emergency room (ER) note, dated 4/29/19 and timed at 9:31 p.m., indicated Resident A reported that approximately three days prior, a nurse was changing his buprenorphine patch and they had an argument. Resident A reported he punched on the right side of the chest, resulting in a bruise (discolored spot on the skin). The resident has had no chest pain since then, but the pain worsen with coughing and respiration. A review of Resident A's GACH's History and Physical (H/P), dated 4/30/19, indicated Resident A presented to the emergency room for shortness of breath and chest pain. Resident A's chest pain was localized to the right side where there was a bruise after the resident was reportedly punched by a nurse (LVN1) at the skilled nursing facility (SNF) when the nurse was attempting to change his buprenorphine ([MEDICATION NAME]) patch. The chest pain was consistent and throbbing at the site of the bruising and the pain radiated to his back when he took deep breaths or when he coughed. There were no obvious rib fractures per review, only chest pain localized to site of the ecchymosis where Resident A reported he was punched three days prior. The ecchymosis area on the right chest measured 4 centimeters (cm) long. There was a buprenorphine patch on the left chest dated last changed 4/26/19. The [DIAGNOSES REDACTED]. A review of Resident A's admission record indicated the resident was readmitted from the GACH to the facility on [DATE]. On 5/10/19, at 2:35 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated she never had problem with Resident [NAME] CNA 1 stated the resident usually would get out of bed and go to activities room or the smoking patio. On 5/10/19, at 3 p.m., during an observation, Resident A was propelling his wheelchair to the smoking patio adjacent to the front lobby. During a concurrent interview on 5/10/19 at 3 p.m., Resident A stated he thought LVN 1 was doing something to him while changing the medication patch on his chest. Resident A stated he put his hands up and the nurse (LVN 1) hit him on the right side of his chest with his knuckles. Resident A further stated he had a bruise to his chest from being hit and it was painful. Resident A stated he went out to the hospital for breathing problems and chest pain. On 5/10/19 at 3:15 p.m., RN 1 stated during his assessment of Resident A on 4/26/19, there was no injury observed, only tape marks on the right chest area and there was no eyewitness. On 6/25/19, at 1:25 p.m., during an interview, LVN 1 stated there was a misunderstanding when he went to put the [MEDICATION NAME] on Resident [NAME] When he went to the resident to remove the patch, by the time he reached for the patch, Resident A raised his hands so he quickly snatched the patch off. LVN 1 further stated Resident A was mad and yelling because he was late changing the patch. LVN 1 denied hitting Resident A on the chest and stated Resident A's skin was clear and there was no redness. A review of LVN 1's employee file indicated there was a Personnel Action Report dated 5/29/18 (last year), alleging that LVN 1 struck another resident on the back. During an interview on 6/25/19 at 2:55 p.m., the Administrator stated the facility was unable to substantiate LVN 1's allegation on 5/29/18. A review of the facility's undated policy and procedure titled, Policy on Patient Abuse and Mistreatment, indicated the residents shall not be subjected to abuse by anyone, including staff members, other resident, consultants, or volunteers, staff of other agencies serving the individual family members or legal guardians, friends, or other individual. The policy indicated abuse is defined as the willful infliction of injury which resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being.

Based on observation, interview and record review the facility failed to follow its policy and a resident's plan of care to ensure adequate supervision was provided for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls, had multiple falls with injuries without close supervision provided and new interventions put in place to further falls prevent falls and injury. These deficient practices resulted in Resident 1 having five (5) falls within four (4) months and two (2) of the injuries requiring a transfer to a general acute care hospital (GACH) for evaluation, treatment and surgery for [REDACTED]. Findings: A review of an Admission Record indicated Resident 1, who was conserved (protecting someone who cannot properly provide their own mental, personal needs) and initially admitted to the facility on [DATE] and most recently re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk Evaluations dated 7/5/18, 7/10/18, 8/20/18, and 9/7/18 indicated the resident had a fall score greater than 20. According to the fall risk assessment, a total score of 10 or more represented a high risk. A review of Resident 1's Minimum Data Set ((MDS) a standardized assessment and care-screening tool), dated 8/20/18, indicated Resident 1's cognitive status (thought process) was not measured, the resident's gait was unsteady, yet able to stabilize without staff assistance but required supervision while ambulating in the facility. A review of Resident 1's Post Fall Assessment, indicated on 8/20/18 at 8 p.m., the resident was observed walking in the hallway of the facility when suddenly Resident 1 lost her balance and fell . A review of a plan of care dated 8/20/18 and titled, At Risk for Falls and Injuries, indicated Resident 1 was at risk related to lack of awareness, poor judgement and safety, gait (walking) and instability. The staff's interventions included to educate Resident 1 on using the call light system for assistance and refer the resident to rehabilitation services for a screening for gait and balance status. A review of an Interdisciplinary Team ((IDT) a meeting to develop care that meets the resident's needs and goals) record, dated 8/22/18, indicated Resident 1 started ambulating independently on 8/14/18, but refused to use a wheelchair and was at risk for repeated falls. A review of Resident 1's x-ray (a test that produces images of body structures) report dated 8/22/18, indicated there was no acute fracture to the left shoulder. A review of Resident 1's Post Fall Assessment, indicated on 9/7/18 at 6:30 p.m., the resident had an unsteady gait and mobility and was a high risk for falls, was walking towards the patio when Resident 1 suddenly fell . A review of a nurses' note, dated 10/28/18 and timed at 2:45 p.m., indicated Resident 1 was found on the floor in her room with left forehead swelling measuring 2.0 x 3.0 centimeters (cm). The note indicated Resident 1 stated she was walking to her bed, lost her balance and fell on the floor. A review of Resident 1's Post Fall Assessment indicated on 10/28/18 at 2:45 p.m., the resident was found on the floor next to her bed and sustained a 2 x 3 centimeter (cm) bump on the right side of the forehead. A review of the IDT report dated 10/29/18 indicated a hip saver (padded hip protector) was recommended for Resident 1 to use to prevent further injuries and lessen the impact during a fall. A review of a computerized tomography ((CT scan) detailed pictures of parts of the body and the structures) from the GACH records, dated 10/31/18, indicated Resident 1 sustained a 2.3 cm x 1.7 cm anterior left frontal hemorrhage (bleeding) and was admitted to the Neurosurgery (disorders or injuries to the brain, spinal cord or nerves in the hands or feet) unit. A review of Resident 1's plan of care dated 10/31/18 and titled Fall, the staff interventions indicated to provide frequent observation to learn Resident 1's habits and accommodate the resident's needs accordingly. A review of Resident 1's plan of care dated 10/31/18 and titled History of Falls, at risk for further falls secondary to an unsteady gait, indicated for the staff to assist the resident with activities of daily living ((ADLs)-routine activities that people do every day without needing assistance, such as: eating, bathing, dressing, toileting, transferring and walking). A review of Resident 1's Fall Risk Evaluation, dated 10/31/18, 11/2/18, 11/26/18 and 12/4/18, indicated the resident's fall score had increased greater than 20. According to the Fall Risk Evaluation, a total score of 10 or more represented a high risk. A review of the Physical Therapy (PT) note, dated 11/1/18, indicated Resident 1 had difficulty with an immediate standing balance and standing balance with a narrow base of surface ((BOS)- the area beneath an object or person that included every point of contact that the object or person makes with the supporting surface). The PT note further indicated Resident 1 had posture abnormalities, decreased velocity (speed), decreased stride (pace) and a decreased step length. A review of a Post Fall Assessment, indicated on 11/2/18 at 11:50 a.m., Resident 1 was observed by the staff attempting to pick up a cigarette from the patio floor when the resident lost her balance and fell on to the right side of her face. A review of a Post Fall Assessment, indicated on 12/3/18 at 8 p.m., Resident 1 was ambulatory and capable of transferring self in and out of the bed prior to fall, but refused to use a lap buddy (an inflatable cushion that snugs into the wheelchair frame), pad alarms and Resident 1's repeated falls were unavoidable. A review of a nurses' note, dated 12/4/18 and timed at 1:40 p.m., indicated Resident 1 stated that she fell the day before and was in pain, but did not indicate a location of pain. A review of the nurses' note, dated 12/4/18 and timed at 3 p.m., indicated a late entry note for 12/3/18 at 8 p.m., that Resident 1 was found sitting on the side of her bed on the floor. A review of a physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. A review of the x-ray reports, dated 12/4/18 and 12/5/18, indicated Resident 1 had a fracture (a break in the bone) of the left femur. A review of the GACH's history and physical (H/P) indicated Resident 1 was admitted to the GACH on 12/6/18, with a [DIAGNOSES REDACTED]. Resident 1 was hospitalized for [REDACTED]. During a concurrent observation and interview on 12/17/18 at 9:20 a.m., Resident 1 was lying in bed with a foam wedge placed between her legs. Certified Nursing Assistant 1 (CNA 1) stated Resident 1 required a sitter secondary to a hip replacement and her frequent movements. On 12/17/18 at 2:25 p.m., during an interview, the Registered Nurse Supervisor (RNS) was asked about the methods in place to prevent Resident 1 from having recurrent falls. The RNS stated Resident 1 had a chair alarm, bed alarm and a wheelchair pad alarm, but Resident 1 would become combative which prevented the staff from putting the pad alarms in place. RNS stated Resident 1 was being visually monitored by the staff, however, the RNS stated there was no documented evidence of the staffs visual monitoring. The RNS stated after Resident 1 sustained a cranial hematoma, as a result of a fall, the fall preventative methods in place was hip saver pads, but Resident 1 refused to wear them and the pads were found in the trash. The RNS stated Resident 1 had poor safety awareness, was only oriented to self, yet, was constantly reminded of safety precautions. The RNS was asked how did Resident 1 comprehend information or instructions on safety prevention if the resident was only oriented to self, the RNS stated she could not think of any other measures to prevent falls for Resident 1. RNS further stated 1:1 monitoring could have been used for Resident 1 to prevent further falls. On 12/17/18 at 3:40 p.m., during an interview, CNA 2, who was Resident 1's primary care giver, stated she was not aware of Resident 1's multiple falls. CNA 2 also stated that pertinent information regarding the residents were not being communicated by the Licensed Vocational Nurses (LVNs) which was an ongoing practice in the facility. A review of the facility's policy, dated for (YEAR) and titled, Fall Program indicated the Department Managers would perform routine observation rounds during resident care through Room Rounds to identify if safety precautions measures are put in place for resident's safety and report results to the Administrator for review. A review of the facility's revised policy, dated for (YEAR) and titled, Fall Prevention and Management, indicated high risk patients will be placed and identified in the Fall Program based on risk factors, following a Post Fall, Licensed Nurse and IDT will determine the root cause if possible and contributing factors of the fall for appropriate intervention as necessary, the IDT will determine what kind of supervision and safety devices will be placed to utilized and minimize reoccurrence and complications associated with falls.

Based on interview and record review, the facility failed to implement and follow its policy for Assessment and Management for one of three sampled residents (Resident 1). Resident 1, who had a significant weight loss with decreased protein levels and the Interdisciplinary Team ((IDT) a team of professionals that meet for quality care improvement) Weight Loss Committee failed to address the resident's weight loss, as per policy. These deficient practices resulted in Resident 1 losing 26 pounds (lbs.) from 10/10/17 to 2/14/18, more than 23 percent (%) of body weight with decreased levels of protein, which put the resident at risk for further medical conditions, which include development of a pressure ulcer. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE] and with several re-admitted s (10/9/17, 11/21/17, 12/24/17, and 1/10/18), but last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. The re-admission record, dated 11/21/17, indicated Resident 1 had a [DIAGNOSES REDACTED]. A review of an online article titled, NPUAP Pressure Injury Stages, by The National Pressure Ulcer Advisory Panel - NPUAP, dated 8/28/12, indicated the importance of maintaining nutrition, especially protein levels in the prevention of pressure ulcers development. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ A review of the dehydration (excessive loss of body water) Risk Assessment indicated a score of eight or more equals a high risk for dehydration. Resident 1's dehydration risk assessments indicated the following: 10/9/17-------7 11/21/17-----15 12/24/17-----15 1/10/18------15 1/17/18------15 2/14/18------12 A review of Resident 1's weekly weights indicated the following: 10/10/17-152 pounds (lbs.) 10/24/17-153 lbs. 11/28/17- blank 12/6/17-139 lbs. (13 lb. weight loss) 12/12/17- 136 lbs. (3 lb. weight loss) 12/24/17- 127 lbs. (9 lb. weight loss) 1/2/18- 129 lbs. 1/4/18- 139 lbs. 1/17/18-125 lbs. 2/7/18- 123 lbs. 2/14/18-126 lbs. 2/20/18-124 lbs. 3/2/18- 135 lbs. 3/6/18- 130 lbs. (22 lb. weight loss in five months) A review of the Registered Dietician's (RD) assessment, dated 10/21/17, the RD documented Resident 1 consumed 100, 80 and 70 % of his meals while receiving an oral diet, was underweight and the resident's ideal body weight was 168-178- 196 lbs. A review of the physicians' orders, dated 11/21/17, indicated to administer Diabetic source AC (a tube feeding formula) at 65 cubic centimeters (cc) per hour to Resident 1. A review of Resident 1's Enteral Feeding Assessments indicated the RD completed the assessments and recommendations for Resident 1 on the following days: 11/26/17, 12/30/17, 1/18/18, 2/1/18 and 2/15/18. A review of the physicians' orders, dated 11/28/17, 1/19/18 and 2/14/18, indicated for the staff to administer Proheal (a liquid protein) 30 cc twice a day to Resident 1. A review of Resident 1's [MEDICATION NAME] (most common protein found in the blood; used by the body for growth and tissue repair; a good marker for malnutrition in the physically impaired elderly (normal reference range (NRR) for [MEDICATION NAME] is 3.4 g/dL to 5.4 g/dL)) laboratory results from the facility and the general acute care hospital (GACH) indicated the following: 11/19/17-1.80 g/dL. 12/15/17- 2.7 g/dL. 12/16/17- 3.1 g/dL. 1/2/18- 2.9 g/dL 1/5/18- 2.5 g/dL. 1/24/18-2.7 g/dL. A review of Resident 1's plan of care titled At risk for weight changes and dehydration secondary to [DIAGNOSES REDACTED]. The staffs' interventions indicated to assess for tolerance to diet, assess for signs and symptoms of dehydration, monitor weight as ordered and RD referral and evaluation for nutritional management as necessary. A review of Resident 1's plan of care, dated 11/21/17, and titled, At Risk for Nausea, Vomiting Weight loss and Dehydration. The staffs' interventions indicated to monitor the resident's weight as ordered and report to the physician significant weight loss in 30 days, 90 days and 180 days. A review of Resident 1's plan of care, dated 12/24/17 and last updated on 2/14/18, titled, At risk for Dehydration and Weight Fluctuations due to [DIAGNOSES REDACTED]. The staffs' interventions indicated to monitor skin turgor (an indication for dehydration) for tenting, dry mouth, urine output, muscle cramps and change in mental status, monitor weight, RD consult and follow-up. A review of Resident 1's plan of care, dated 2/15/18, and titled Significant Weight Changes, indicated Resident 1 had a 23 % weight loss in 180 days. The staffs' interventions indicated for the Weight Variance Committee to monitor the resident's weights and [DEVICE] feeding at 75cc/hr and assess for the need of further nutritional support. During an interview on 3/14/18 at 4:12 p.m., Licensed Vocational Nurse 1 (LVN 1) stated the Certified Nursing Assistants (CNAs) and the Rehabilitation Nursing Assistants (RNAs) documents the residents' weekly weights in a weight log book. LVN 1 stated the Registered Nursing Supervisors (RNS), are responsible for reviewing the residents' weights. During an interview on 3/14/18 at 4:15 p.m., RNS 1 stated that she was part of the Weight Variance Committee. RNS 1 stated the RD and the Weight Variance Committee met every Thursday to discuss updates on resident's weight. RNS 1 stated laboratory results, meal intake and compliance to dietary recommendations are documented four times a week. RNS 1 further stated that she was the one to ensure the staff were conducting weekly weights and residents who were part of the weight variance meeting. During a telephone interview on 5/21/18 at 3:47 p.m., the RD stated there were no weekly weight variance meetings for Resident 1. During a telephone interview on 5/29/18 at 12:17 p.m., the Director of Nursing (DON) stated Resident 1 had a weekly weight variance IDT meeting in (MONTH) (YEAR). The DON was asked about Resident 1's IDT weight variance notes prior to (MONTH) (YEAR) and was Resident 1's significant weight loss identified prior to (MONTH) (YEAR), the DON could not answer and stated she had to review the resident's clinical records. During a telephone interview on 5/30/18 at 9:37 a.m., the DON stated a Weight Variance IDT meeting was conducted on 2/15/18 for Resident 1. The DON stated the weight variance committee conducted the resident's weight reviews every 30, 90, and 180 days and waited for that time period to determine if a resident had significant weight loss. The DON was asked when the weight variance committee determined Resident 1 had significant weight loss and had the weight variance committee reviewed the residents' significant weight loss outside the 30, 90, and 180 day, time period, the DON stated in (MONTH) (YEAR). The DON was asked had the Weight Variance Committee considered Resident 1's weight loss of 26 lbs. from (MONTH) (YEAR) to (MONTH) (YEAR) a significant weight loss, the DON stated, No, because the resident had a [DEVICE]. When the DON was asked the purpose of the weight variance committee the DON stated, For the committee to monitor the residents' weekly weights for one month, review the RD recommendations, and follow-up with the nursing staff. The DON was asked when the RD recommendations were not effective and Resident 1 continued to lose weight, what was implemented by the facility. The DON responded by stating, Resident 1 was sent out to the hospital due to weight loss. The DON further stated the physician was aware of Resident 1's weight loss. After extensive review of Resident 1's clinical records from 10/9/17 through 2/14/18, (four months) there were no IDT notes that indicated a Weight Loss Variance meeting/review was conducted for Resident 1. A review of the weekly weights record indicated Resident 1 lost a total of 26 lbs. from 10/10/17 to 2/14/18. A review of the facility's revised policy, dated 5/1/18, and titled, Assessment and Management of Resident Weights indicated residents with significant weight change will be reviewed by the Director of Nursing Services (DNS) or designated licensed nurse. Significant weight changes are 5 % in one month, 7.5 % in three months, and 10 % in 6 months. If a resident weight is less than or greater than 5 lbs. from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight. Residents with significant weight change will be weighed at least weekly and discussed at the Resident at Risk or other clinical meetings to determine possible causes of weight gain or loss including individual goals for care. The IDT care plan will be updated to reflect individual goals and approaches for managing the weight change.