Every finding on record at Long Beach Care Center, Inc

Based on interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was conserved (when a resident has a court appointed conservator who has legal authority to make certain decisions on the resident's behalf because the resident has been found unable to make those decisions independently), was allowed to return to the facility after he was arrested on 7/6/2026, taken to jail, released to self and subsequently admitted to a General Acute Care hospital on 7/7/2026. On 7/9/2026, Resident 1 was deemed medically and psychiatrically stable for discharge back to the facility but was refused admission. The facility failed to provide a written Notice of Proposed Transfer/Discharge to Resident 1, and/or his Conservator (a legal guardian appointed by the court to manage health or financial affairs of an individual). As a result, Resident 1, who was cleared by the GACH for return to the facility on 7/9/2026, continued to occupy a bed at the GACH unnecessarily. These deficient practice had the potential for non-continuity of care, confusion, permanent displacement and an undue burden on the GACH to find placement for Resident 1. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), suicidal ideations (thoughts of death without a clear plan or intent to actively end your own life), anxiety (a feeling of fear, dread, and uneasiness), psychoactive substance abuse (harmful use of chemicals that change how your brain works), homicidal ideations (thoughts or fantasies about harming or killing another person), and encephalopathy (any syndrome or condition that affects the structure or function of the brain). Resident 1 was conserved. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/30/2026, the MDS indicated Resident 1's cognitive (a residents thought process) skills were moderately impaired, and he had a serious mental illness. The MDS indicated Resident 1 had no functional limitations in range of motion ([ROM] the direction a joint can move to its full potential) and was able to independently complete is activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's History and Physical (H&P) dated 2/27/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Change of Condition (COC) dated 7/6/2026 and timed at 2 p.m., the COC indicated Resident 1 had an episode of verbally aggressive behavior, hit Registered Nurse Supervisor (RNS) 1 on her head, and pushed and hit Certified Nursing Assistant (CNA) 1 in his left eye. Police were called and Resident 1 was taken to jail. A review of Resident 1's Clinical Records indicated there was no documented evidence of a Notice of Transfer Discharge. During a review of a Facility letter to Resident 1's Conservator, dated 7/7/2026, the Facility Letter indicated on 7/7/2026, via telephone, at approximately 11:30 a.m., Resident 1's Conservator was informed by the Administrator (ADM) that the facility could not safely meet the needs of Resident 1 due to his violent, physical behavior against staff on 7/66/2026, as well as a resident in 1/2026. The Facility Letter indicated the Conservator was made aware Resident 1 would be discharged from the facility as his need could not be met. Continued review of this letter did not indicate the effective date of Resident 1's discharge, the location where Resident 1 would be discharged to, a statement of the resident's appeal rights, the name, address, email address (if available), the telephone number of the State Long-Term Ombudsman, and for residents with a mental disorder or serious mental illness, the mailing and email address (if available) and telephone number of the appropriate protection and advocacy agency. During a review of GACH's Social Service Progress Note, dated 7/15/2026 and timed at 4:13 p.m., the Social Sork Progress Note indicated the facility was unable to accommodate Resident 1. During a review of the GACH's Social Service Progress Note, dated 7/16/2026 and timed at 4:20 p.m., the Social Work Progress Notes indicated the facility told the Social Worker (SW) at the GACH, on 7/16/2026 at 2:10 p.m., that Resident 1 was not welcome at the facility after an incident with a staff member. During an interview on 7/11/2026 at 11:15 a.m., the Administrator (ADM) stated on 7/6/2026 Resident 1 hit RNS 1, who was transferred to a GACH via 911 for evaluation and treatment, and sometime in 1/2026 (exact date unknown), Resident 1 had an altercation with another Resident (Resident unknown). The Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) met (date unknown) and assessed Resident 1 as a risk to staff and other residents and decided not to readmit him to the facility. The ADM stated Resident 1's Conservator was not provided a written Notice of Transfer Discharge but he informed the Conservator verbally on 7/6/2026 that Resident 1 would not be readmitted to the facility. During an interview on 7/11/2026 at 1:37 p.m., the Director of Nurses (DON) stated on 7/6/2026 Resident 1 was taken from the facility by police for assaulting staff and destroying property and was released to self (7/6/2026), per Resident 1's Conservator. The DON stated the facility could not safely meet Resident 1's needs due to his unprovoked violent behavior and he was not going to be re-admitted to the facility. During an interview on 7/12/2026 at 10:55 a.m., Resident 1's Conservator stated on 7/6/2024 at 3:26 a.m., she received a call from the facility reporting Resident 1's behavior and telling her Resident 1 was taken into custody by police but the facility could not tell her exactly where Resident 1 was taken. The Conservator stated she called multiple police stations before locating Resident 1 and was told by the police department they were going to book Resident 1, issue him a ticket and release him. She asked if they could take Resident 1 back to the facility, but they said they were not able to do that. When the police department released Resident 1 from jail Resident 1 walked to a Family Member's (FM) house. The Conservator stated Resident 1 was pacing for 2-3 hours at the FM's house, so the FM called the Psychiatrist Emergency Team ([PET] a mobile crises response unit of license mental health clinicians that evaluates individuals experiencing severe mental health crises to determine the need for involuntary psychiatric hospitalization) to evaluate him and he was admitted to the GACH (7/7/2026). During a review of the facility's undated Policy and Procedure (P&P), titled Transfer and Discharge Policy the P&P indicated the facility will document the specific resident needs that cannot be met, facility attempts to meet the resident needs. For emergency transfers/discharges for medical or for immediate safety and welfare of a resident the facility will notify the resident and or resident representative an ambulance service and provider hospital, transportation and admission arrangements will be made.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse when Resident 2 punched Resident 1 with his fist. This deficient practice resulted in Resident 1 sustaining a 1.0-centimeter ([cm] unit of measurement) V-shaped avulsion (injury in which tissue is forcibly torn away or detached) to his right lower lip, an open area to his right inner lip, and abrasion to his right upper lip. Resident 1 required immediate first aid for 14 days and transfer to a General Acute Care Hospital (GACH) for evaluation. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses including metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body from an underlying illness), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing) and type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's the Minimum Data Set (MDS] a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired.During a review of Resident 1's Nursing Progress Notes, dated 3/10/2025, the Nursing Note indicated on 3/10/2026 at approximately 5 p.m., Registered Nurse (RN) 1 was summoned to the dining area by staff that Resident 1 was punched by another resident. The Nursing Progress Notes indicated Resident 1 stated, Resident 2 came to his room, knocked on his door, and when Resident 1 came out of his room, Resident 2 punched him. The Nursing Progress Notes indicated Resident 1 was observed with a moderate amount of bleeding to his right lower lip and sustained a laceration to his right lower lip, an open area on his right inner lip, and an abrasion to his right upper lip. The Nursing Progress Notes indicated an order was received for Resident 1 to be sent to the GACH for evaluation. During a review of Resident 1's GACH Emergency Department (ED) Note dated 3/10/2026, the ED Note indicated Resident 1 was brought in from a Skilled Nursing Facility (SNF) after a witnessed altercation, Resident 1 was punched in the mouth and has a laceration on the right lower lip. The ED Note further indicated Resident 1's right lower lip was noted with a 1.0 cm V-shaped avulsion which was cleansed and bacitracin (an antibiotic ointment used on the skin to help prevent minor infections in small cuts, scrapes, or wounds) ointment. During a review of Resident 1's Treatment Administration Record ([TAR] a daily documentation record used by licensed nurses to document medications and treatments given to a resident) dated 3/2026, the TAR indicated to cleanse Resident 1's right lower lip laceration and right upper lip abrasion with normal saline, pat dry, and apply bacitracin ointment for 14 days.During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 had diagnoses including metabolic encephalopathy, chronic obstructive pulmonary disease and DM type 2.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. During a review of Resident 2's Nursing Progress Notes, dated 3/10/2026, the Nursing Progress Notes indicated on 3/10/2026 at approximately 5:40 pm, Resident 2 was interviewed and stated he was startled by Resident 1 and he (Resident 2) admitted to hitting Resident 1. The Nursing Progress Notes indicated Resident 2 stated, he did not know why he hit Resident 1 and did not intend to hit him.During an observation on 3/19/2026, at 9:25 a.m., in Resident 1's room, Resident 1 was observed to have a scab (hard, crusty layer of dried blood and cells that forms over a cut, scrape, or wound) on the right side of his lower lip. During an interview on 3/19/2026 at 9:30 a.m., Resident 1 stated another resident punched him in the face, causing a cut on his lip. Resident 1 stated he was sent to the hospital to ensure he was okay after he was punched.During an interview on 3/19/2026 at 10:00 a.m., Certified Nurse Assistant (CNA) 1 stated on 3/10/2026 at approximately 5 p.m., she was in the dining room assisting residents with their meals. CNA 1 stated she observed Resident 1 waving his hands toward Resident 2 as Resident 2 entered the dining room. CNA 1 stated Resident 1 was about six feet away from Resident 2. CNA 1 stated she continued scanning the room and when she looked back toward the residents' direction, she saw Resident 2 punch Resident 1 in the face. She observed blood on Resident 1's lip immediately after the punch. CNA 1 stated staff separated the residents right away and supervised them.During an interview on 3/23/2025 at 3:30 p.m., the Director of Nursing (DON) stated residents have the right to be free from physical abuse. The DON stated that based on the facility's investigation, the facility substantiated that Resident 2 hit Resident 1; however, it was determined that Resident 2 acted impulsively after being startled and struck out at Resident 1. The DON stated the facility felt that Resident 2's actions were unintentional and the incident was not preventable.During a review of the facility's undated policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, the P&P indicated each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.residents must not be subject to abuse by anyone including, but not limited to facility staff, other residents.

Based on interview and record review, the facility failed to involve one of three sampled residents (Resident 3) in Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conferences. This deficient practice violated Resident 3's rights to be informed and the right to participate in resident's plan of care.Findings:During a review of Resident 3's admission Record, the admission record indicated the facility originally admitted Resident 3 on 11/1/2022 and recently readmitted Resident 3 on 1/4/2023 with diagnoses including anxiety disorder (mental health illness causing pervasive worry and fear affecting daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool), dated 11/21/2025, the MDS indicated Resident 3 understood others and was understood. The MDS indicated Resident 3's cognition (ability to think and reason) for daily decision making was intact. The MDS indicated that it was very important to Resident 3 to participate and be involved in discussions about her care. During a review of Resident 3's History and Physical (H&P), dated 1/30/2025, the H&P indicated Resident 3 was alert, oriented to person, place, time, situation, and had the capacity to understand and make medical decisions.During an interview on 2/6/2026 at 10 a.m., Resident 3 stated she was not always made aware when her IDT team care conferences were being held. Resident 3 started to cry and stated she would like to participate in the IDT Care Conferences about her care.During a concurrent interview and record review on 2/6/2026 at 11:20 a.m., with the Infection Prevention Nurse (IPN), Resident 3's Interdisciplinary Team Conference Records, were reviewed. The IPN confirmed IDT Care Conference, dated 8/6/2025 indicated Resident 3 wanted to reschedule because she was not feeling well. The IDT meeting was not rescheduled, and the next IDT meeting was on 11/5/2025, three months later. The IPN confirmed the IDT Care Conference on 11/5/2025 had no documented evidence of Resident 3's participation. The IPN stated if residents request the meeting to be rescheduled then it should have been rescheduled. The IPN stated residents need to be part of their IDT meetings.During an interview on 2/9/2026 at 1:26 p.m. with the Director of Nursing (DON), the DON stated residents, or representatives should always be part of the IDT Care Conferences to be able to be part of their own plan of care. During a review of the facility's policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, revised 2023, the P&P indicated the resident, resident's family and/or responsible party were encouraged to participate in the development of and revisions to the resident's care plan. The P&P indicated the IDT was responsible for developing individualized care plans for each resident.During a review of the facility's document titled, Resident Rights, undated, the document indicated the resident has the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.The right to be informed, in advance, of changes to the care plan.The right to see the care plan, including the right to sign after changes to the care plan.

Based on interview and record review, the facility failed to ensure one of one resident's (Resident 3)'s consultation reports were in Resident 3's medical records.This deficient practice had the potential to result in a delay in care and services and depict an inaccurate and incomplete record of care and services received by Resident 3.Findings:During a review of Resident 3's admission Record, the admission record indicated the facility originally admitted Resident 3 on 11/1/2022 and recently readmitted Resident 3 on 1/4/2023 with diagnoses including anxiety disorder (mental health illness causing pervasive worry and fear affecting daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool), dated 11/21/2025, the MDS indicated Resident 3 understood others and was understood. The MDS indicated Resident 3's cognition (ability to think and reason) for daily decision making was intact. During an interview on 2/6/2026 at 10 a.m., Resident 3 stated she went to several consultation appointments in 2025 and Physician 1 informed Resident 3 that Resident 3's consultation notes were not in her (Resident 3) medical records. During a concurrent interview and record review on 2/6/2026 at 11:29 a.m., with the Medical Records Director (MRD), Resident 3's records were reviewed. The MRD confirmed that not all Resident 3's consultations for 2025 were in the medical records and it should have been placed in the chart or uploaded. The MRD stated it should be in the medical records so the physicians and staff could refer to it, and have a clearer picture of Resident 3's health. The MRD stated the missing records were Orthopedic (a medical specialty focused on diagnosing, treating, and preventing musculoskeletal system injuries and diseases, including bones, joints, ligaments, tendons, and muscles) and Neurologist (medical doctors specializing in diagnosing, treating, and managing disorders affecting the nervous system [body's command center]) consultations.During an interview on 2/9/2026 at 1:26 p.m., with the Director of Nursing (DON), the DON stated Resident 3 consultant's notes should be in Resident 3's medical records. During a review of the facility's policy and procedure (P&P) titled, Accuracy of Medical Records, undated, the P&P indicated the facility will ensure that all medical records are complete, accurate and updated to reflect care and services provided to each resident.

Based on interviews and record reviews, the facility failed ensure one of two Residents (Resident 1) was not able to throw a pitcher of water and a container of urine on Resident 2, after Resident 1 kicked Resident 2 out of the bed and onto the floor.This deficient practice resulted in Resident 1 drenching Resident 2 in water and urine, after he had kicked Resident 2 out of the bed onto the floor. Resident 2 also sustained a left maxillofacial (jaws and the face) contusion (bruise).Findings:During a review of Resident 1's admission Record, the admission record indicated the facility originally admitted Resident 1 on 3/1/2025 with diagnoses including encephalopathy (broad term for any disease, damage, or malfunction of the brain), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (mental health condition characterized by pervasive worry and fear).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 12/30/2025, the MDS indicated Resident 1 had severe cognitive (thought process) impairment and needed set-up assistance with eating, oral hygiene, and personal hygiene.During a review of Resident 2's admission Record, the admission record indicated the facility originally admitted Resident 2 on 9/24/2025 with diagnoses including encephalopathy, heart failure (heart cannot pump enough blood to the body), dementia (a progressive state of decline in mental abilities), schizoaffective disorder, mood disorder (mental health conditions involving long-term, extreme disturbances in emotional state, such as intense sadness or high energy elevated periods of emotional highs), and anxiety disorder.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 needed supervision when eating, partial assistance (helper does less than half the effort to complete the task) with oral hygiene, substantial assistance (helper does more than half the effort to complete the task) with personal hygiene, showering, and toileting hygiene.During a review of Certified Nurse Assistant (CNA) 1's signed statement, undated, the statement indicated that Resident 1 was standing at on the left side of Resident 2's bed while Resident 2 was lying on the bed. CNA 1's statement indicated Resident 1 kicked Resident 2 on the left side of his body and Resident 2 rolled and fell off the right side of the bed. CNA 1's statement indicated CNA 1 attempted to intervene and Resident 1 pushed CNA 1 and then CNA 1 called for help. CNA 1's statement indicated Resident 1 reached for and threw the water pitcher with water. The water pitcher and the water landed on Resident 2's face. Resident 1 then grabbed and threw the urinal (a portable container designed for resident to urinate into when they cannot easily access a toilet), and the urinal filled with urine landed on Resident 2's chest.During a review of Resident 2's Progress Notes titled, Nursing Note, dated 1/26/2026 at 2:15 p.m., the Nursing Notes indicated Resident 2 was hit by another resident (Resident 1). The Nursing Note indicated Resident 2 presented with slight swelling on left temporal (side of the head) area and redness on left shin (front of the leg below the knee), right knee, and redness on the chest area. The Nursing Note indicated Resident 2 responded to name by saying yes or moaning. The Nursing Note indicated on 1/26/2026 at 4:55 p.m. an ambulance transported Resident 2 to a General Acute Care Hospital (GACH) for further evaluation. During a review of Resident 2's ED (Emergency Department) Notes, Final Report, dated 1/26/2026 at 10 p.m., the notes indicated Resident 2 was hit in the face and sustained left maxillofacial contusion on 1/26/2026 at 2:30 p.m.During an interview with Resident 1, on 2/6/2026 at 11:40 a.m., Resident 1 stated he (Resident 1) kicked Resident 2 because Resident 2 stunk; Resident 1 stated he (Resident 1) then threw a water pitcher and a container of urine at Resident 2. During an interview on 2/6/2026 at 12:20 p.m., with CNA 1, CNA 1 stated on 1/26/2026 at about 2:15 p.m., Resident 1 was standing on the left side of Resident 2's bed when Resident 1 kicked Resident 2 on the left side of Resident 2's body while Resident 2 was lying down in bed. Resident 1 kicked Resident 2 again on the left side of his body and then Resident 2 fell off the bed to the right side and landed on the floor mat. CNA 1 stated she (CNA 1) attempted to intervene but Resident 1 pushed CNA 1 away, and CNA 1 called for help. CNA 1 stated Resident 1 reached for and threw the water pitcher, and the water pitcher and water landed on Resident 2's face. Resident 1 also grabbed and threw the urinal, and the urinal and urine landed on Resident 2's chest. During an interview on 2/6/2026 at 12:43 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 2 was a victim of physical abuse when Resident 1 kicked him, threw a water pitcher with water and urine on Resident 2. LVN 2 stated, on 1/26/2026, she heard CNA 1 and CNA 2 calling for help and by the time LVN 2 was in the room Resident 2 was on all fours on the blue fall mattress. LVN 2 stated Resident 1 was pacing in the room very agitated saying, I beat him up. I beat him up. LVN 2 stated there were fluids (water and urine) on the floor and on Resident 2.During an interview on 12/9/2026 at 1:23 p.m., with the Director of Nursing (DON), the DON stated residents have the right to be free from abuse. The DON stated Resident 1 physically abused Resident 2. The DON stated facility staff should have physically separated Resident 2 from Resident 1 when Resident 1 first kicked Resident 2, while Resident 2 was lying in bed. The DON stated Resident 2 should not have been able to kick resident 2 again, throw a pitcher and the water it contained and then pour urine on Resident 1.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, undated, the P&P indicated residents have the right to be free from physical abuse. The P&P indicated the facility will make efforts to protect all residents after alleged abuse by responding to the needs of the resident and protect them from further incident. The P&P indicated the facility will consider utilization of the following tips for prevention of abuse of residents by training staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents.

Based on interview and record review the facility failed to implement its facility policy to ensure the environment was free from accident hazards when one of two sampled residents' (Resident 3) bathroom floor was wet on 10/19/2025. The deficient practice resulted in Resident 3 slipping and falling onto the wet bathroom floor causing her to land on her right arm and shoulder. The slip and fall accident resulted in Resident 3's frequent complaint of right shoulder pain for a period of approximately 4 months and the accidental fall became a precipitating factor of the right shoulder full thickness tear of the supraspinatus tendon with retraction of the tendon (complete, through-and-through detachment of the tendon [connective tissue]from the shoulder bone that pulls back [retracts] from its attachment site) and fluid in the subacromial (space beneath the bony projection top of shoulder) and subdeltoid (space beneath the shoulder muscle) bursa (fluid-filled cushion) diagnosed on [DATE]. Findings: During a review of Resident 3's admission Record, the admission record indicated the facility originally admitted Resident 3 on 11/1/2022 and recently readmitted Resident 3 on 1/4/2023 with diagnoses including morbid obesity (severe and dangerous levels of obesity that significantly and negatively impacts health), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool), dated 8/6/2025, the MDS indicated Resident 3 understood others and was understood. The MDS indicated Resident 3's cognition (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 3 needed set-up assistance when eating, performing oral hygiene and Resident 3 needed supervision with toileting hygiene. Resident 3 can walk 10 feet, and the helper assists only prior to or following the activity.During a review of Resident 3's History and Physical (H&P), dated 1/30/2025, the H&P indicated Resident 3 was alert, oriented to person, place, time, situation, and had the capacity to understand and make medical decisions.During a review of Resident 3's fall risk assessment, dated 8/6/2025, the fall risk assessment indicated Resident 1 was at risk for falls.During a review of Resident 3's Care Plan Report, the report indicated a care plan titled, Potential for injury/falls, dated 5/4/2025, the goal indicated Resident 3's potential for injury and fall would be minimized daily. One of the care plan interventions indicated to maintain hazard free and safe environment.During a review of Resident 3's Progress Notes titled, Nursing Note, dated 10/19/2025 at 6:27 a.m., the Progress Notes indicated that Resident 3 was found on the floor of the bathroom. The Progress Notes indicated Resident stated, I lost my balance from the floor being wet. The note indicated Resident 3 stated, my arm hurts and complained of right shoulder pain with severity rated at an 8 out of 10 from the numerical pain scale ( 0 represents no pain, 1 to 3 indicating mild pain, 4 to 6 moderate pain, 7 to 10 severe pain). During a review of Resident 3's Progress Notes, titled Situation, Background, Assessment, Recommendation (SBAR) Summary for Providers, dated 10/23/2025 at 5:57 a.m., the Progress Notes indicated Resident 3 had a fading yellowish skin discoloration on her right upper arm and Resident 3 complained of severe right upper arm pain, 8 out of 10 from pain scale, because of the recent fall. During a review of Resident 3's Nursing Note, dated 10/23/2025 at 1:26 p.m., the Nursing Note indicated Physician 1 ordered Lidocaine ointment 5% (pain medication) twice a day for right shoulder pain management.During a review of Resident 3's Nursing Note, dated 10/26/2025 at 9:14 p.m., the Nursing Note indicated Resident 3 complained of right shoulder pain. During a review of Resident 3's Nursing Note, dated 11/3/2025 at 2 p.m., the Nursing Note indicated Resident 3 requested for an Magnetic Resonance Imaging ([MRI] diagnostic tool using strong magnets and radio waves to create detailed images of soft tissues, organs, and bones) of the right shoulder for the frequent right shoulder pain and Physician 1 ordered Orthopedic Surgeon (specialize in diagnosing, treating, and repairing bones, joints, muscles, tendons [connective tissue] using surgical and non-surgical methods) follow up for the MRI order.During a review of Resident 3's Orthopedic Consultation Notes, dated 11/12/2025 4:07 p.m., the notes indicated Resident 3 stated she was getting off the toilet, the floor was slippery, and Resident 3 fell landing on right shoulder and right knee. Resident 3 stated since the fall on 10/19/2025, she (Resident 3) has been having significant pain in the right shoulder and was unable to raise the arm. The Nursing Note indicated examination results revealed Resident 3 most likely had a rotator cuff (muscles that stabilize the shoulder joint) tear of the right shoulder and required an MRI. During a review of Resident 3's Nursing Note, dated 11/18/2025 at 3:24 p.m., the Nursing Note indicated Resident 3 was seen by Physician 2 for right shoulder spasticity (involuntary muscle contractions, stiffness, and abnormal posture) and continued right shoulder pain.During a review of Resident 3's SBAR Summary for Providers, dated 11/20/2025 at 5:37 p.m., the Note indicated Resident 3 claimed her shoulder popped when getting out of bed and was in pain.During a review of Resident 3's MRI of the right shoulder without contrast (special dye), performed on 12/9/2025 at 10:30 a.m., The MRI revealed Resident 3 had a full thickness tear of the tendons and fluid in the subacromial and subdeltoid bursa. During a review of Resident 3's Nursing Note, dated 1/23/2026 at 11:12 a.m., the note indicated Resident 3's surgery will be on 3/17/2026.During an interview on 2/6/2026 at 10 a.m., Resident 3 stated that on 10/19/2025, Sunday, at around 6 a.m., she (Resident 3) went to use the toilet, sat down, got up, pulled her pants up, then took a step forward, that's when she slipped and fell and landed on her right shoulder and right arm. Resident 3 stated she (Resident 3) then noticed her right arm hurt. Resident 3 stated she (Resident 3) called for help with no response so Resident 3 scooted to the bathroom door on her back, opened it with her left hand, called for help, and assistance came immediately.During an interview with the Housekeeping Supervisor (HKS) on 2/6/2026 at 4:35 p.m., the HKS stated floors should never be left wet. HKS stated the housekeepers clean the rooms assigned daily and housekeepers work from 8 a.m. to 4 p.m. The HKS stated outside those hours a Janitor was assigned to clean common areas and did not check resident rooms unless staff alerted them to go to a specific room. During a concurrent interview and record review on 2/9/2026 at 8:26 a.m., with Licensed Vocational Nurse (LVN)1, LVN 1 reviewed Resident 3's Nurses notes dated 10/19/2025 at 6:27 a.m., LVN 1 confirmed the notes she authored and stated that after 6 a.m. on 10/19/2025 she was alerted to go to Resident 3's room and Resident 3 was lying on the floor and complained of right shoulder and arm pain. LVN 1 stated that the floor Resident 3's bathroom floor was wet. LVN 1 was unable to quantify amount of water noted on the floor but stated it was not flooded. LVN 1 stated the paramedics were called and Resident 3 refused to go to the general acute care hospital (GACH). LVN 1 stated the floors shouldn't have been wet because of safety reasons; wet floors are hazardous and residents can slip and fall.During a concurrent interview and record review on 2/9/2026 at 1:26 p.m., with the Director of Nursing (DON), Resident 3's Fall Team Meeting Notes dated 10/19/2025 were reviewed. The notes indicated the fall appeared to be related to an environmental factor; wet floor surfaces were identified as a potential risk, especially for residents with balance limitations. The DON stated the team discussed the importance of keeping bathroom floors dry and addressing wet conditions promptly to reduce fall risk. During a review of the facility's policy and procedures (P&P) titled, Hazardous Areas, Devices, and Equipment, undated, the P&P indicated all hazardous areas in the facility will be identified and appropriately addressed to ensure resident safety and to mitigate hazards to the extent possible. A hazard is identified as anything in the that has the potential to cause injury. During a review of the facility's P&P titled, Falls and Falls Risk Managing, undated, the P&P indicated the staff will try to prevent resident falls with identified interventions.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was not subjected to abuse when Resident 1, who had aggressive behaviors and required one-to-one monitoring (a care approach where a dedicated staff member is assigned to closely observe and attend to the needs of a specific resident. This level of monitoring is crucial in managing residents with aggressive tendencies or other complex needs, ensuring that any potential incidents can be promptly addressed), was not assigned staff to monitor him. This deficient practice resulted in Resident 1 punching Resident 2 on the left side of his chest and had the potential for Resident 2's continued abuse and other residents to be assaulted by Resident 1.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 10/2/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required supervision or touch assistance (helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident complete activity) from facility staff to complete his activities of daily ([ADLs] activities such as bathing, dressing and toileting a person performs daily). Resident 1's MDS indicated Resident 1 exhibited physical behavior symptoms such as kicking, hitting and pushing towards others. During a review of Resident 1's Care Plan dated 12/4/2025, the Care Plan indicated Resident 1 had a potential for complications related to episodes of yelling/screaming, verbal aggression, and attempts to strike out at staff. Under this Care Plan a goal for Resident 1 was to minimize his behaviors daily. The Care Plan's interventions included one-to-one monitoring for Resident 1. During a review of Resident 1's Nursing Note dated 12/4/2025, the Nursing Note indicated Resident 1 required constant supervision. During a review of Resident 1's COC form dated 12/7/2025, the COC form indicated while on the smoking patio, Resident 1 put his hands on another resident's (Resident 2) left chest and activity staff immediately separated both residents. During a review of Resident 2's admission Records (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of schizophrenia. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact, and Resident 2 required supervision/touch assistance from facility staff to complete his ADLs. During a review of Resident 2's COC form dated 12/7/2025, the COC indicated while Resident 2 was on the smoking patio with the activities staff, another resident (Resident 1) put his hands on the left side of Resident 2's chest, and the activities staff immediately separated the residents. During an interview on 12/18/2025 at 9:16 a.m., Resident 2 stated he was on the smoking patio, just standing there when Resident 1 out of nowhere punched him (Resident 2) on the left side of his chest. During an interview on 12/18/2025 at 9:18 a.m. and a subsequent interview at 1:45 p.m., the Activities Assistant (AA) stated he was on the smoking patio monitoring the residents when he saw Resident 1 punch Resident 2 on the left side of his chest. The AA stated he was the only staff member present on the smoking patio when the incident occurred. During an interview on 12/18/2025 at 2 p.m., Licensed Vocational Nurse (LVN) 1 stated on 12/5/2025, he saw Resident 1 trying to leave through the front door. LVN 1 notified the Director of Nursing (DON), who placed Resident 1 on one-to-one monitoring due to his exit-seeking behavior. LVN 1 stated the AA was present on the smoking patio to provide smoking supplies and to monitor the residents who were smoking but the AA was not assigned as Resident 1's one-to-one monitor. During an interview on 12/18/2025 at 2:56 p.m., the DON stated Resident 1 needed one-to-one monitoring due to prior verbal aggression and exit-seeking behavior. The DON stated the assignment for the one-to-one monitoring for Resident 1 was missed. The DON stated, an assigned one-to-one staff would have been immediately beside Resident 1, potentially preventing the incident between Resident 1 and Resident 2 from occurring. During a review of the facility's undated Policy and Procedure (P/P) titled Abuse, Neglect and Exploitation the P/P indicated residents should not be subject to abuse by anyone including but not limited to facility staff, other residents .

Based on interview and record review, the facility failed to ensure the care plan for one of four sampled residents (Resident 1) whose interventions included one-to-one-monitoring (a care approach where a dedicated staff member is assigned to closely observe and attend to the needs of a specific resident. This level of monitoring is crucial in managing residents with aggressive tendencies or other complex needs, ensuring that any potential incidents can be promptly addressed) was implemented. This deficient practice resulted in Resident 1 not being provided one-to-one-monitoring, Resident 2 being left unsupervised and punching Resident 2 on the left side of his chest. This deficient practice had the potential for continued assault to Resident 2 as well as other residents who resided in the facility. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 10/2/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required supervision or touch assistance (helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident complete activity) from facility staff to complete his activities of daily ([ADLs] activities such as bathing, dressing and toileting a person performs daily). Resident 1's MDS indicated Resident 1 exhibited physical behavior symptoms such as kicking, hitting and pushing towards others. During a review of Resident 1's Care Plan dated 12/4/2025, the Care Plan indicated Resident 1 had a potential for complications related to episodes of yelling/screaming, verbal aggression, and attempts to strike out at staff. Under this Care Plan a goal for Resident 1 was to minimize his behaviors daily. The Care Plan's interventions included one-to-one monitoring for Resident 1. During a review of Resident 1's COC form dated 12/7/2025, the COC form indicated while on the smoking patio, Resident 1 put his hands on another resident's (Resident 2) left chest and activity staff immediately separated both residents. During an interview on 12/18/2025 at 9:16 a.m., Resident 2 stated he was on the smoking patio, just standing there when Resident 1 out of nowhere punched him (Resident 2) on the left side of his chest. During an interview on 12/18/2025 at 9:18 a.m. and a subsequent interview at 1:45 p.m., the Activities Assistant (AA) stated he was on the smoking patio monitoring the residents when he saw Resident 1 punch Resident 2 on the left side of his chest. The AA stated he was the only staff member present on the smoking patio when the incident occurred. During an interview on 12/18/2025 at 2 p.m., Licensed Vocational Nurse (LVN) 1 stated on 12/5/2025, he saw Resident 1 trying to leave through the front door. LVN 1 notified the Director of Nursing (DON), who placed Resident 1 on one-to-one monitoring due to his exit-seeking behavior. LVN 1 stated the AA was present on the smoking patio to provide smoking supplies and to monitor the residents who were smoking but the AA was not assigned as Resident 1's one-to-one monitor. LVN 1 stated one-to-one monitoring was on Resident 1's care plan and should have been followed, it was an intervention created after Resident 1 had a previous episode of yelling and being aggressive to staff. During an interview on 12/18/2025 at 2:56 p.m., the DON stated Resident 1 needed one-to-one monitoring due to prior verbal aggression and exit-seeking behavior. The DON stated the assignment for the one-to-one monitoring for Resident 1 was missed. The DON stated, an assigned one-to-one staff would have been immediately beside Resident 1, potentially preventing the incident between Resident 1 and Resident 2 from occurring. During a review of the facility's undated Policy and Procedure (P/P) titled Comprehensive Care Plans, the P/P indicated the facility will develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on interview and record review, the facility failed to report an allegation of sexual abuse to the California Department of Public Health (CDPH) for one of four sample residents (Resident 3) when Resident 3 was heard by facility staff accusing Resident 1 of raping her. This deficient practice resulted in CDPH being unaware of the allegation of sexual abuse and the inability to investigate the allegation timely. This deficient practice had the potential for information to be lost and/or forgotten and placed Resident 3 at risk for continued abuse. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy (brain dysfunction) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 9/21/2025, the MDS indicated Resident 3's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 3 required substantial/maximal assistance (helper does more than half the effort) to complete her ADLs. During an interview on 12/2/2025 at 2:48 p.m., Resident 7 stated he saw Resident 3 enter Resident 2's room, go straight to Resident 2 and said, you're the one you raped me . During a telephone interview on 12/3/2025 at 8:54 a.m., Certified Nursing Assistant (CNA) 1 stated she was taking out the linen and trash barrels near the kitchen area when she saw someone (Resident 3) rush into Resident 2's room, she then saw Resident 3 throw water from a pitcher onto the floor, then proceeded to hit Resident 2 with the water pitcher. CNA 1 stated Resident 3 was screaming and cursing at Resident 2 saying he gave me a shot, and he raped me. CNA 1 stated she provided a written report to Registered Nurse (RN 1), but she did not include Resident 3's accusation that Resident 2 raped her because she thought RN 1 would report it since she (RN 1) was nearby when Resident 3 made the allegation. During an interview on 12/3/2025 at 9:43 a.m., RN 1 stated she overheard CNA 1 talking about Resident 3's allegation that Resident 2 raped her and she (RN 1) reported that allegation to the Director of Nursing (DON). During an interview on 12/3/2025 at 1:45 p.m., the DON stated he was aware of Resident 3's allegation that Resident 2 raped her but stated he forgot to include the allegations when he reported the resident to resident incident on the same day between Resident 2 and Resident 3 to CDPH. During an interview on 12/3/2025 at 3:04 pm, the Administrator (ADM) stated he was not aware of the rape allegation made by Resident 3, had he known about the allegation, he would have reported it to CDPH. The ADM stated the allegation should have been reported to CDPH because facility staff were mandated reporters. During a review of the facility's undated Policy and Procedure (P/P) titled Abuse, Neglect and Exploitation the P/P indicated when abuse, neglect, or exploitation is suspected, the Licensed Nurse should contact the State Agency to report the alleged abuse.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 administered Heparin (a medication used to prevent the formation of blood clots [masses of blood that form when blood cells stick together]) as ordered by the physician for deep vein thrombosis ([DVT] a blood clot in a vein, usually in the leg) prophylaxis (treatment to prevent disease or infection from occurring or spreading) for one of four sampled residents (Resident 1). This deficient practice contributed to Resident 1 experiencing swelling and heaviness in her left lower extremity (leg), her subsequent transfer to a General Acute Care Hospital (GACH), where she was assessed and diagnosed with an extensive acute deep vein DVT of the left lower extremity.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of a displaced intertrochanteric fracture (a type of broken bone in the upper part of the thigh bone (femur) near the hip, where the bone pieces are out of place) of the right femur and fracture (broken bone) of right lower leg. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/5/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent (helper does all of the effort) on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 10/29/2025, the Physician's Order indicated Resident 1 was to receive Heparin Injection Solution 5000 units/milliliter ([ml] a unit of measurement), 1.0 ml injected subcutaneously (under the skin) every eight hours for DVT prophylaxis (treatment to prevent disease or infection from occurring or spreading). During a review of Resident 1's Change in Condition (COC) form dated 11/10/2025 and timed at 11:44 p.m., the COC form indicated Resident 1 reported to LVN 2 that her legs were swollen. The COC form indicated Resident 1's left lower extremity was observed to be swollen. The COC form indicated Resident 1's physician was made aware. During a review of Resident 1's Physician's Order dated 11/11/2025, the Physician's Order indicated an order for venous doppler (a medical ultrasound technique that uses high frequency sound waves to create images of the veins, primarily to check blood flow and detect any blockages or clots, commonly used to diagnose conditions such as DVTs) diagnostic test of Resident 1's left leg to rule out a DVT. During a review of Resident 1's Nursing Note dated 11/11/2025, the Nursing Note indicated the venous doppler diagnostic test could not be performed because a soft leg cast and leg brace were present on the resident's left leg. During a review of Resident 1's Physician's Order dated 11/11/2025, the Physician's Order indicated to transfer Resident 1 a GACH for further evaluation. The Nursing Note indicated Resident 1 was transferred to GACH via ambulance. During a review of the GACH's Emergency Department (ED) Encounter Note dated 11/11/2025, the ED Encounter Note indicated Resident 1 presented with bilateral (both) thigh swelling, worse on the left thigh, status post (indicates a patient has undergone a specific event or procedure in the past) multiple fractures after a car accident (date of care accident unknown). The ED Encounter Note indicated Resident 1 reported missing a dose of Heparin, had sudden swelling of her thigh, and her leg brace felt tighter. During a review of GACH's Ultrasound (a medical test that uses sound waves to create images of the inside of the body) of Resident 1's lower extremity dated 11/11/2025, the Ultrasound results indicated extensive acute (a condition that is severe and sudden in onset) DVTs of Resident 1's left lower extremity. During an interview on 12/1/2025 at 8:15 a.m., Resident 1 stated on 11/10/2025, her legs started to feel funny, as if they were swelling, she reported this to LVN 2 at the same time she reported to LVN 2 that LVN 1 did not give the afternoon dose (2 p.m.) of Heparin. Resident 1 stated she went to physical therapy at 12:30 p.m. and stayed there for about 45 minutes to one hour and returned to her room around 1:45 p.m. Resident 1 stated she waited for LVN 1 to give her the Heparin, but LVN 1 did not. Resident 1 stated after the change of shift, she informed LVN 2 she did not receive her afternoon dose of Heparin. LVN 2 confirmed that it had not been given by calling LVN 1. Resident 1 stated LVN 2 told her documentation he reviewed (the MAR) indicated LVN 1 had given her the afternoon dose (2 p.m.) of Heparin. Resident 1 stated when LVN 2 called LVN 1, LVN 1 told LVN 2 he had forgotten to administer Resident 1's dose of Heparin. During an interview on 12/1/2025 at 11:01 a.m., LVN 2 stated on 11/10/2025 around 4:45 p.m., Resident 1 reported to him that she did not receive her afternoon dose of Heparin. LVN 2 stated he reviewed Resident 1's MAR which indicated the dose of Heparin had been given by LVN 1 at 2 p.m LVN 2 stated he called LVN 1 to clarify the administration of Heparin and LVN 1 informed him that he (LVN 1) forgot to give the dose of Heparin to Resident 1. LVN 2 stated throughout the shift (3 p.m. - 11 p.m.), Resident 1 complained that her left leg was swollen. LVN 2 stated he assessed Resident 1 when the resident initially complained but around 9 p.m. LVN 2 stated the resident's left leg swelling was obvious and he reported it to Registered Nurse (RN 2) and Resident 1's physician. During a telephone interview on 12/1/2025 at 12:23 p.m., LVN 1 stated at approximately 2:45 p.m., he was finishing his charting and Resident 1 had not returned from physical therapy yet, which was why he did not give Resident 1 her dose of Heparin. LVN 1 stated he accidentally documented that he administered the dose of Heparin to Resident 1, and he should not have done that. LVN 1 stated he did not think one missed dose of Heparin could contribute to the development of a DVT because he believed Heparin stayed in the body long enough to prevent DVTs from forming. During an interview on 12/3/2025 at 11:14 a.m., Resident 1's physician stated Resident 1 probably already had a DVT, but the missed dose of Heparin could have contributed to the DVTs increase in size. Resident 1's physician stated he reviewed the doppler results and confirmed Resident 1 had an extensive clot which ran the length of Resident 1's entire left thigh. Resident 1's physician stated along with other contributing factors such as the leg brace fitting too tight and Resident 1's immobility, the missed dose of Heparin did not help Resident 1's condition. During an interview on 12/3/2025 at 1:45 p.m., the Director of Nursing (DON) stated LVN 1 forgot to administer Resident 1's afternoon dose of Heparin because Resident 1 was in physical therapy and it was close to change of shift. The DON stated LVN 1 should have notified the MD about the missed dose of Heparin, monitor Resident 1 for any COC, notify the pharmacist, the Registered Nurse Supervisor (RNS), and the DON. During a review of the facility's undated Policy and Procedure (P/P) titled Medication Administration, the P/P indicated medications are administered by licensed nurses. as ordered by the physician and in accordance with professional standards of practice. During a review of facility's Job Description for Charge Nurse - RN/LVN, the Job Description indicated one of the charge nurse's specific job functions included administering and documenting medication and treatments in compliance with facility policy and procedure.

Based on interview and record review, the facility failed to investigate one of four sampled residents' (Resident 3) allegation of sexual abuse when Resident 3 yelled and screamed at Resident 2 that he (Resident 2) raped her. This deficient practice resulted in the facility's inability to determine if the allegation had actually occurred and had the potential for other uninvestigated allegations of abuse to be uninvestigated. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy (brain dysfunction) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool) dated 9/21/2025, the MDS indicated Resident 3's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 3 required substantial/maximal assistance (helper does more than half the effort) to complete her ADLs. During a review of Resident 3's Nursing Notes dated 11/25/2025 and timed at 6:50 a.m., the Nursing Notes indicated facility staff responded to yelling and screaming and found Resident 3 in Resident 2's room. The Nursing Note indicated Resident 3 took a water pitcher and hit Resident 2 on the right side of his face. The Nursing Note indicated Resident 3 was very aggressive when facility staff assisted her back to her room and she continued to yell and scream in the hallway. The Nursing Notes indicated Resident 3 required one-to-one (the continuous supervision of a single resident by a dedicated staff member whose sole responsibility is to watch that resident) staff monitoring. During an interview on 12/2/2025 at 2:48 p.m., Resident 7 (Resident 2's roommate) stated he was in the hallway (11/25/2025) getting coffee when he saw Resident 3 enter Resident 2's room and go straight to Resident 2 saying you're the one and that he raped her (Resident 3). Resident 7 stated he saw Resident 3 swinging her fists and hit Resident 2. During a telephone interview on 12/3/2025 at 8:54 a.m., CNA 1 stated she was taking the linen and trash barrels near the kitchen area (11/25/2025) when she saw someone (Resident 3) rush into Resident 2's room. CNA 1 stated she saw Resident 3 throw water from a water pitcher onto the floor and proceeded to hit Resident 2 with the water pitcher. CNA 1 stated, Resident 3 was screaming and cursing at Resident 2 saying he gave me a shot, and he raped me. CNA 1 stated Resident 3 was very combative when she and CNA 2 removed her from Resident 2's room. During an interview on 12/3/2025 at 9:43 a.m., RN 1 stated she overheard CNA 1 talking about Resident 3's allegation that Resident 2 raped her and she (RN 1) reported that allegation to the Director of Nursing (DON). During an interview on 12/3/2025 at 1:45 p.m., the DON stated he was aware of Resident 3's allegation that Resident 2 raped her but stated he forgot to include the allegations when he reported the resident to resident incident on the same day between Resident 2 and Resident 3 to CDPH. The DON stated he interviewed Resident 2 and Resident 3 regarding Resident 3's allegation that she was raped by Resident 2, but he was told by 3 to get the Fuck out before, then she was transferred to a General Acute Care Hospital (GACH). The DON stated Resident 2 stated he did not know Resident 3. The DON stated Resident 2 could not get up without assistance, so he concluded the allegation was not true. The DON was not able to provide documentation to indicate he investigated Resident 3's allegation of rape against Resident 2. During a review of the facility's undated Policy and Procedure (P/P), titled Abuse, Neglect and Exploitation, the P/P indicated when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. The P/P indicated components of an investigation may include interviewing the involved residents, if possible, and to document all responses. The P/P indicated to document the entire investigation chronologically.

Based on interview and record review, the facility staff failed ensure a Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for one of four sampled residents (Resident 1) was not falsified, when Licensed Vocational Nurse (LVN) 1 documented he administered a dose of Heparin (a medication to prevent the formation of clots [masses of blood that form when blood cells stick together]) to Resident 1 on 11/10/2025 at 2 p.m., when he had not given it to her and then on 11/17/2025 documented another incorrect entry also indicating he had administered the Heparin dose to Resident 1. This deficient practice resulted in the inaccurate depiction of Resident 1's medication management and had the potential for non-continuity of care based on the inaccurate documentation. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of a displaced intertrochanteric fracture (a type of broken bone in the upper part of the thigh bone (femur) near the hip, where the bone pieces are out of place) of the right femur and fracture (broken bone) of right lower leg. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/5/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent (helper does all of the effort) on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 10/29/2025, the Physician's Order indicated Resident 1 was to receive Heparin Injection Solution 5000 units/milliliter ([ml] a unit of measurement), 1.0 ml injected subcutaneously (under the skin) every eight hours for DVT prophylaxis (treatment to prevent disease or infection from occurring or spreading). During a review of Resident 1's MAR dated 11/10/2025 and timed at 2 p.m., the MAR indicated a 9 signifying Resident 1 was not available because she was participating in therapy and Resident 1 preferred to receive her medication after completing her session. During a review of Resident 1's Medication Administration Audit Report ([MAAR] document of medication administration in the exact time the record was documented by staff), the MAAR indicated Resident 1's Heparin was administered on 11/10/2025 at 2:18 p.m., continued documentation indicated a change to the original time and date for 11/17/2025 at 10:20 a.m. During an interview on 12/1/2025 at 8:15 a.m., Resident 1 stated on 11/10/2025, her legs started to feel funny, as if they were swelling, she reported this to LVN 2 at the same time she reported to LVN 2 that LVN 1 did not give the afternoon dose (2 p.m.) of Heparin. Resident 1 stated she went to physical therapy at 12:30 p.m. and stayed there for about 45 minutes to one hour and returned to her room around 1:45 p.m. Resident 1 stated she waited for LVN 1 to give her the Heparin, but LVN 1 did not. Resident 1 stated after the change of shift, she informed LVN 2 she did not receive her afternoon dose of Heparin. LVN 2 confirmed that it had not been given by calling LVN 1. Resident 1 stated LVN 2 told her documentation he reviewed (the MAR) indicated LVN 1 had given her the afternoon dose (2 p.m.) of Heparin. Resident 1 stated when LVN 2 called LVN 1, LVN 1 told LVN 2 he had forgotten to administer Resident 1's dose of Heparin. During an interview on 12/1/2025 at 11:01 a.m., LVN 2 stated on 11/10/2025 around 4:45 p.m., Resident 1 reported to him that she did not receive her afternoon dose of Heparin. LVN 2 stated he reviewed Resident 1's MAR which indicated the dose of Heparin had been given by LVN 1 at 2 p.m LVN 2 stated he called LVN 1 to clarify the administration of Heparin and LVN 1 informed him that he (LVN 1) forgot to give the dose of Heparin to Resident 1. LVN 2 stated throughout the shift (3 p.m. - 11 p.m.), Resident 1 complained that her left leg was swollen. LVN 2 stated he assessed Resident 1 when the resident initially complained but around 9 p.m. LVN 2 stated the resident's left leg swelling was obvious and he reported it to Registered Nurse (RN 2) and Resident 1's physician. During a telephone interview on 12/1/2025 at 12:23 p.m., LVN 1 stated at approximately 2:45 p.m., he was finishing his charting and Resident 1 had not returned from physical therapy yet, which was why he did not give Resident 1 her dose of Heparin. LVN 1 stated he accidentally documented that he administered the dose of Heparin to Resident 1, and he should not have done that. LVN 1 stated he did not think one missed dose of Heparin could contribute to the development of a DVT because he believed Heparin stayed in the body long enough to prevent DVTs from forming. During a telephone interview on 12/1/2025 at 12:23 p.m., LVN 1 stated at approximately 2:45 p.m., he was finishing his charting and Resident 1 had not returned from physical therapy yet, which was why he did not give Resident 1 her dose of Heparin. LVN 1 stated he accidentally documented that he administered the dose of Heparin to Resident 1, and he should not have done that. LVN 1 stated he should not have documented that he gave Resident 1 her medication when he had not given it to her. LVN 1 stated when he returned to work on 12/17/2025, he edited Resident 1's medical records inaccurately. During an interview on 12/3/2025 at 1:45 p.m., the Director of Nursing (DON) stated he had spoken to LVN 1, who admitted he had forgotten to administer the 2 p.m., dose of Heparin on 11/10/2025 and that he had documented he had given the medication to Resident 1 when he had not given it to her. The DON stated LVN 1 was told to correct the documentation in Resident 1's record. The DON stated LVN 1 should have included late entry when the documentation was corrected. During a review of the facility's undated Policy and Procedure (P/P) titled Medication Administration the P/P indicated the MAR should be signed after the medication is administered.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was free from physical abuse when Resident 3 entered Resident 2's room and hit Resident 2 repeatedly with a plastic water pitcher and her fists. This deficient practice resulted in Resident 2 feeling afraid while using his arms in self-defense against Resident 3'a attack on him and sustaining a 1.0 centimeter ([cm]-unit of measurement) x 0.5 cm abrasion (a break in the skin when the skin rubs off) to the right side of his forehead, along with multiple areas of redness to Resident 2's right forehead and right forearm, requiring immediate first aid for seven days.Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance from an underlying illness). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 9/23/2025, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 2 was dependent on facility staff for bed mobility and ambulation was not attempted. During a review of Resident 2's Change of Condition (COC) form dated 11/25/2025 and timed at 6:50 a.m., the COC form indicated Resident 3 entered Resident 2's room, went directly to him, took a water pitcher (Resident 2's water pitcher) and struck Resident 2 on his face. The COC form indicated Resident 2 and 3 were immediately separated by removing Resident 3 from Resident 2's room. The COC form indicated Resident 2 sustained an abrasion to his right temporal (side of the forehead) area measuring 1 cm x 0.5 cm and multiple areas of redness to his right forearm. During a review of Resident 2's Skin Integrity Sheet dated 11/25/2025, the Skin Integrity Sheet indicated the following: 1. A right temporal abrasion measuring 1 cm x 0.5 cm draining blood and a pink wound bed 2. Multiple areas of redness to Resident 2's right forehead. 3. Multiple areas of redness to Resident 2's right forearm. During a review of Resident 2's Treatment Administration Record (TAR) date 11/25/2025 through 12/1/2025, the TAR indicated Resident 2's right forehead with multiple areas of redness was cleansed with normal saline (a sterile, saltwater solution used in medicine to clean wounds). dried, and bacitracin ointment applied for 14 days. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy (brain dysfunction) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was moderately impaired, and Resident 3 required substantial/maximal assistance (helper does more than half the effort) to complete her ADLs. During a review of Resident 3's Nursing Notes dated 11/25/2025 and timed at 6:50 a.m., the Nursing Notes indicated facility staff responded to yelling and screaming and found Resident 3 in Resident 2's room. The Nursing Note indicated Resident 3 took a water pitcher and hit Resident 2 on the right side of his face. The Nursing Note indicated Resident 3 was very aggressive when facility staff assisted her back to her room and she continued to yell and scream in the hallway. The Nursing Notes indicated Resident 3 required one-to-one (the continuous supervision of a single resident by a dedicated staff member whose sole responsibility is to watch that resident) staff monitoring. During an observation and interview on 12/2/2025 at 2:18 p.m., the right side of Resident 2's forehead revealed a small light area of a healed scar. Resident 2 stated on the morning of 11/25/2025, Resident 3 entered his room yelling at him he's the one then proceeded to throw a banana at him, then hit him with a plastic water pitcher. Resident 2 stated it happened so fast, he put his arms up to protect himself and even went under the blanket. Resident 2 stated he had never seen Resident 3 prior to her entering his room that morning, it shocked him, and he was scared because he didn't know what Resident 3 was going to do to him. Resident 2 stated he yelled for help, closed his eyes and he could feel repeated blows to his head for 10-15 seconds, then Certified Nursing Assistants (CNA 1 and CNA 2) came and removed Resident 3 from his room. During an interview on 12/2/2025 at 2:48 p.m., Resident 7 (Resident 2's roommate) stated he was in the hallway (11/25/2025) getting coffee when he saw Resident 3 enter Resident 2's room and go straight to Resident 2 saying you're the one and that he raped her (Resident 3). Resident 7 stated he saw Resident 3 swinging her fists and hit Resident 2. During a telephone interview on 12/3/2025 at 8:54 a.m., CNA 1 stated she was taking the linen and trash barrels near the kitchen area (11/25/2025) when she saw someone (Resident 3) rush into Resident 2's room. CNA 1 stated she saw Resident 3 throw water from a water pitcher onto the floor and proceeded to hit Resident 2 with the water pitcher. CNA 1 stated, Resident 3 was screaming and cursing at Resident 2 saying he gave me a shot, and he raped me. CNA 1 stated Resident 3 was very combative when she and CNA 2 removed her from Resident 2's room. During an interview on 12/3/2025 at 9:28 a.m., CNA 2 stated she was passing coffee to Resident 7 outside of Resident 2's room (11/25/2025) when she saw CNA 1 quickly enter Resident 2's room. CNA 2 stated she followed CNA 1 into Resident 2's room and saw Resident 3 grab a water pitcher and hit Resident 2 with it, while Resident 2 was covering himself. During an interview on 12/3/2025 at 1:45 p.m., the Director of Nursing (DON) stated Resident 2 reported to him that Resident 3 entered his room (11/25/2025) saying, he's the one and hit him (Resident 2) with a water pitcher. The DON stated Resident 2 did not know Resident 3 and he (Resident 2) did not know what prompted the incident. During a review of the facility's undated Policy and Procedure (P/P) titled, Abuse, Neglect and Exploitation the P/P indicated residents should not be subject to abuse by anyone including but not limited to facility staff, and other residents.

Based on interview and record review, the facility staff failed to ensure the physician for one of four sampled residents (Resident 1) was notified when Resident 1's dose of Heparin (medication to prevent the development of clots [masses of blood that form when blood cells stick together]) was missed and when Resident 1 was not transferred to a General Acute Care Hospital (GACH), per the physician's order. These deficient practices resulted in Resident 1's physician being unaware that Resident 1 did not receive a dose of Heparin, delayed evaluation, treatment and delayed transfer to the GACH. These deficient practices had the potential for development of and/or increase in the size of a deep vein thrombosis ([DVT] a blood clot in a vein, usually in the leg). Findings: a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of a displaced intertrochanteric fracture (a type of broken bone in the upper part of the thigh bone (femur) near the hip, where the bone pieces are out of place) of the right femur and fracture (broken bone) of the right lower leg. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/5/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent (helper does all of the effort) on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 10/29/2025, the Physician's Order indicated Resident 1 was to receive Heparin Injection Solution 5000 units/milliliter ([ml] a unit of measurement), one ml injected subcutaneously (under the skin) every eight hours for DVT prophylaxis (treatment to prevent disease or infection from occurring or spreading). During an interview on 12/1/2025 at 8:15 a.m., Resident 1 stated on 11/10/2025, her legs started to feel funny, as if they were swelling, she reported this to LVN 2 at the same time she reported to LVN 2 that LVN 1 did not give her, her afternoon dose of Heparin. Resident 1 stated she went to physical therapy at 12:30 p.m. and stayed there for about 45 minutes to one hour and returned to her room around 1:45 p.m. Resident 1 stated she waited for LVN 1 to give her the Heparin, but he did not. Resident 1 stated after change of shift, she informed LVN 2 she did not receive her afternoon dose of Heparin, which he (LVN 2) confirmed that it had not been given by calling LVN 1. Resident 1 stated when LVN 2 called LVN 1, LVN 1 told LVN 2 that he had forgotten to administer Resident 1's dose of Heparin. During an interview on 12/1/2025 at 11:01 a.m., LVN 2 stated on 11/10/2025 around 4:45 p.m., Resident 1 reported to him that she did not receive her afternoon dose of Heparin. LVN 2 stated he reviewed Resident 1's MAR which indicated the dose of Heparin had been given by LVN 1. LVN 2 stated he called LVN 1 to clarify the administration of Heparin and LVN 1 informed him that he (LVN 1) forgot to give the dose of Heparin to Resident 1. LVN 2 stated reflecting on the incident, he should have reported the missed dose of Heparin to Registered Nurse (RN 2) and Resident 1's physician. LVN 2 stated he did not report the missed dose of Heparin to RN 2 due to fear of being labeled a snitch. During a telephone interview on 12/1/2025 at 12:23 p.m., LVN 1 stated at approximately 2:45 p.m., he was finishing his charting and Resident 1 had not returned from physical therapy yet, which was why he did not give Resident 1 her dose of Heparin. LVN 1 stated he made a mistake, by not giving Resident 1 her dose of Heparin and not reporting the missed medication to Resident 1's physician. b. During an interview on 12/1/2025 at 1:24 p.m., Resident 1's Responsible Party (RP) stated she contacted Resident 1's physician on 11/11/2025 at 1:57 a.m., about her concerns regarding Resident 1's condition and the ultrasound doppler's (machine that uses sound waves to check how blood flows through the body) timelines. The RP stated Resident 1's physician agreed to send Resident 1 to the GACH prior taking conducting the doppler exam, however Resident 1 preferred to stay at the facility until the ultrasound doppler was completed. During a review of Resident 1's Physician's Order dated 11/11/2025, the Physician's Order indicated a Stat (immediate) venous doppler of Resident 1's left leg to rule out a DVT. During a review of facility's mobile phone text messages dated 11/11/2025 and timed at 2 a.m., the text message indicated Resident 1's physician sent a text message that indicated, Resident 1's RP requested to send Resident 1 to the GACH. During a review of Resident 1's Nursing Note dated 11/11/2025, the Nursing Note indicated the venous doppler could not be performed because a soft leg cast and leg brace were present. During a review of Resident 1's Physician Order dated 11/11/2025, the Physician Order indicated Resident 1 may transfer to the GACH for further evaluation. During an interview on 12/2/2025 at 3:09 p.m., LVN 3 stated he spoke to Resident 1 about the transfer to the GACH and Resident 1 told him she wanted to stay at the facility until the ultrasound doppler was completed. LVN 3 stated he did not call Resident 1's physician to inform him that Resident 1 would not be transferred to the GACH. LVN 3 stated he was waiting to see if the ultrasound doppler would be completed prior to the end of his shift and if not, he would endorse it to the next shift, who could call Resident 1's physician to obtain an order to transfer Resident 1 to the GACH. During a telephone interview on 12/3/2025 at 11:14 a.m., Resident 1's physician stated he was not informed that Resident 1 did not receive a dose of Heparin that was due to be given to her on 11/11/2025, until 11/16/2025, when the Director of Nursing (DON) informed him. Resident 1's physician stated he was not informed about Resident 1's decision not to transfer to the GACH on 11/11/2025, until the next morning (11/12/2025) when Resident 1 was transferred to the GACH after the ultrasound doppler was not completed at the facility on 11/11/2025. During an interview on 12/3/2025 at 1:45 p.m., the Director of Nursing (DON) stated LVN 1 forgot to administer Resident 1's afternoon dose of Heparin because Resident 1 was in physical therapy and it was close to change of shift. The DON stated LVN 1 should have notified Resident 1's physician about the missed dose of Heparin, monitor Resident 1 for any COC, notify the pharmacist, the Registered Nurse Supervisor (RNS), and the DON. The DON stated Resident 1's physician should have been informed when Resident 1 was not transferred to the GACH because additional interventions might have been ordered. During a review of the facility's Job Description for Charge Nurse - RN/LVN, the Job Description indicated a specific job function included observing, reporting and recording findings/changes in resident's condition to physician and nursing personnel. During a review of the facility's undated P/P titled Notification of Changes the P/P indicated the facility must consult with the resident's physician when there are circumstances that require a need to alter treatment. During a review of the facility's undated Policy and Procedure (P/P) titled Medication Error Policy the P/P indicated when a medication error is noticed the nurses contacts the provider as needed for direction and documents the communication. The P/P indicated the medication error should be reported within the facility by informing the charge nurse, RN supervisor, and DON according to the facility's communication process.

Based on interview and record review, the facility failed to update the facility assessment tool for 137 out of 137 residents when:1. The facility failed to include the Infection Prevention Nurse (IPN) as part of the required staff for daily facility operations; and2. The facility failed to assess the cultural and ethnic makeup of the facility's resident population.These deficient practices had the potential to result in delays of care and services and deter the facility to offer more culturally competent resident-centered care. Findings: During a concurrent interview and record review on 9/04/2025 at 8:43 a.m. with the Administrator, the Facility Assessment Tool, 7/10/2025, was reviewed. The Administrator confirmed missing that the Facility assessment Tool did not indicate that the IPN was part of the staff needed to function for the resident population every day and during emergencies. The Administrator stated the IPN needed to be included in the Facility Assessment Tool. The Administrator stated the tool was missing specific assessment on the different culture and ethnic backgrounds of the facility residents. The Administrator stated that it was important to assess the cultural backgrounds of the population to better cater to their needs. During a review of the facility's policy and procedure (P&P) titled, Facility Assessment Policy, undated, the P&P indicated that the facility conducts a comprehensive assessment that evaluates its resident population and resources. This assessment supports safe and effective care guides and staffing decisions and ensures compliance with applicable regulations.

Based on interview and record reviews, the facility failed to ensure three of six sampled residents' (Resident 7, 9 and 114) were free from unnecessary psychotropic medications (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, or feelings, or behavior) by:a. Failing to ensure nonpharmacological interventions (therapies and measures that do not involve taking medication like distraction, music therapy, and activities) were attempted prior to administering Ativan (medication for anxiety [mental health condition characterized by excessive fear and worry]) as needed for inability to relax for Resident 7.b. Failing to ensure Resident 9 was monitored for adverse effects for Mirtazapine (medication for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) use.c. Failing to indicate resident specific behaviors for Risperidone (medication used to treat various mental health conditions) use for Resident 114. These deficient practices had the potential to result in the violation of residents' right to be free from chemical restraints (refers to any drug used for discipline or that makes it more convenient for staff to care for a resident and not required to treat medical symptoms) and the potential for unwanted adverse side effects.Findings: a. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) with psychotic disturbance (a mental health condition characterized by a loss of contact with reality), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and generalized anxiety disorder (mental health condition characterized by excessive fear and worry). During a review of Resident 7's Minimum Data set ([MDS] a resident assessment tool), dated 7/28/2025, the MDS indicated Resident 7's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was severely impaired. The MDS indicated Resident 7 needed moderate assistance (helper does less than half the effort) with eating, oral hygiene, maximal assistance (helper does more than half the effort) with personal hygiene, and dependent (helper does all the effort) on staff with toileting hygiene and showering. During a review of Resident 7's Order Summary Report, as of 9/3/2025, the report indicated, starting on 8/24/2025, Ativan one milligram (mg - metric unit of measurement, used for medication dosage and/or amount), by mouth, every 6 hours as needed for inability to relax for 14 days. During a concurrent interview and record review on 9/3/2025 at 1:05 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 7's Medication Administration records for 9/2025 and Order summary were reviewed. LVN 1 confirmed and stated there was no documented evidence of nonpharmacological measures attempted prior to the use of Ativan for anxiety. During an interview on 9/5/2025 at 3:15 p.m., with the Director of Nursing (DON) the DON stated that nonpharmacological measures need to be attempted prior to administration of psychotropic medications. During a review of the facility's policy and procedure (P&P) titled, “Psychotropic Medication Management Policy”, undated, the P&P indicated that the interdisciplinary team would evaluate non-pharmacological interventions before or alongside medication use. b. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was readmitted to the facility on [DATE] with diagnosis including major depressive disorder. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 9 needed moderate assistance with oral hygiene, maximal assistance with toileting hygiene, showering, personal hygiene, and dependent (helper does all the effort) on staff with eating. During a review of Resident 9's Order Report, 7/20/2025, the order indicated, starting on 8/24/2025, Mirtazapine 15 mg, by mouth, at bedtime manifested by poor meal intake. During a concurrent interview and record review on 9/4/2025 at 10:30 a.m. with LVN 2, Resident 9's medical records were reviewed. LVN 2 confirmed Resident 9 was not monitored for adverse side effects associated with Mirtazapine use. LVN 2 stated monitoring for side effects was important to ensure the dose was appropriate. During an interview on 9/5/2025 at 3:15 p.m., with the DON, the DON stated that residents need to be monitored for adverse effects of medication use to make sure there were no complications. During a review of the facility's policy and procedure (P&P) titled, “Psychotropic Medication Management Policy”, undated, the P&P indicated that the staff would monitor residents for potential adverse effects. c. During a review of Resident 114's admission record, the admission record indicated Resident 114 was admitted to the facility on [DATE] with diagnoses post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), and dementia (a progressive state of decline in mental abilities). During a review of Resident 114's “History and Physical (H&P)”, dated 6/12/2025, the “H&P” indicated, Resident 114 has the fluctuating capacity to understand and make decisions. During a review of Resident 114's MDS, dated [DATE], the MDS indicated Resident 114 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for hygiene, bed mobility, transfer, dressing, bathing, and setup or clean-up assistance (Helper sets pup or cleans up) from one staff for eating. The MDS section E (Behavior) indicated, Resident 114 did not have hallucination (an experience involving the apparent perception of something not present) or delusions (having false or unrealistic beliefs). The MDS indicated, Resident 114 did not have physical and verbal behavioral symptoms directed toward others. During a review of Resident 114's “Order Summary Report (OSR)”, dated 9/4/2025, the OSR indicated togive one tablet Risperidone 0.5 milligram (mg) by mouth two times a day for behavioral disorder associated with dementia manifested by aggressive behavior was ordered 6/23/2025. The OSR indicated to monitor behavior disorder associated with dementia manifested by aggressive behavior and tally by episode every shift was ordered on 6/9/2025. During a review of Resident 114's “Care Plan (CP)”, revised on 6/23/2025, the CP Focus indicated, Resident 114 uses antipsychotic medication Risperidone for behavioral disorder associated with dementia manifested by aggressive behavior. The CP Goal indicated, Resident 114 will receive the lowest possible dosage of the prescribed psychotropic drug to ensure maximum functional ability. The CP Interventions indicated, to administer medication as prescribed and observe effectiveness of medication by monitoring targeted behaviors. During a concurrent interview and record review on 9/4/2025, at 3:08 p.m., with Registered Nurse (RN) 1, Resident 114's “Medication Administration Record (MAR)”, dated from 6/2025 to 9/4/2025 was reviewed. The MAR indicated to monitor behavior disorder associated with dementia manifested by aggressive behavior and tally by episode every shift for Risperidone use. The MAR indicated, there was no behavioral episodes and documented “0” episode of aggressive behavior. RN 1 stated, aggressive behaviors were not specific target behavior because it was too general, and it could be anything such as yelling, striking, and non-verbal. RN 1 stated, target behavior should be specific and measurable, so psychiatrist ( a medical practitioner specializing in the diagnosis and treatment of mental illness) could refer to and consider Gradual Dose Reduction (GDR- a systematic approach to stepwise tapering of medication dosage to assess if a lower dose can effectively manage symptoms, conditions, or risks, or if the medication can be discontinued entirely). RN 1 stated, the staff should monitor specific target behaviors, not general behavior. RN 1 stated, the facility should use less restrictive measures, if possible, to prevent resident suffering from adverse reaction due to unnecessary medication. During a telephone interview on 9/5/2025, 11:08 a.m., with the Psychiatric Nurse Practitioner (PNP) 1, the PNP 1 stated, Resident 114 was on Risperidone prior to admission from the General Acute Care Hospital (GACH). The PNP 1 stated, she did not discontinue the medication abruptly, and the nursing staff reported to her that Resident 114 was trying to strike the staff. The PNP 1 stated, aggressive behaviors are not specific and measurable target behavior. The PNP 1 stated, incorrect data of target behavior could affect the resident's care and treatment. The PNP 1 stated, she was not aware of staff documented no behavior and MDS assessment regarding no behavior. The PNP 1stated, Risperidone could be unnecessary medication, and it should be tapered down as soon as possible to avoid adverse reaction (an undesired or harmful effect of a drug) and chemical restraint (the use of medications to restrict a person's movement or freedom of action, or to control behavior, when the medication is not part of a standard treatment for their condition). During an interview on 9/5/2025, at 2:24 p.m., with the Director of Nursing (DON), the DON stated, target behavior should be specific and measurable to the resident's diagnoses. The DON stated, aggressive behaviors could be many things, and this should be clarified with PNP 1. The DON stated, monitoring specific target behavior was important, because GDR would be performed based on these data. The DON stated, inaccurate data would lead to delays on treatment, and the residents continuing to receive unnecessary medication. The DON stated, the resident might suffer from unnecessary side effects/adverse reactions. The DON stated, unnecessary medication could be used as chemical restraint as well. During a review of the facility's Policy and Procedure(P&P) titled, “Behavior Management Plan”, revised 2025, the P&P indicated, “Policy: Resident who exhibit behavioral concerns may require a behavior management plan to ensure they are receiving g appropriate services and interventions to meet their needs…Policy Explanation and Compliance Guidelines: 4. Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observation of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions.” During a review of the facility's Policy and Procedure(P&P) titled, “Psychotropic Medication Management Policy”, undated, the P&P indicated, “Policy: 2. Orders and Indications…Psychotropic medications will only be prescribed with a documented clinical indication. Orders must be specific, time-limited, and include target symptoms… 4. Monitoring and Review : Staff will monitor residents for effectiveness and potential adverse effects.”

Based on interview, and record review, the facility failed to Identify and to intervene in two of three sampled residents (Resident 114 and Resident 156)'s history of trauma (a strong emotional reaction to something upsetting or harmful that happened). and triggers (a sound, smell, place, or even a memory-that suddenly reminds someone of a scary or upsetting experience from the past. It can make them feel afraid, sad, or upset, even if they are safe now) which may cause re-traumatization as evidenced by:A. Failing to assess and identify the triggers of Resident 114's trauma related to a war he was in. B. Failed to do an assessment and identify the triggers of Resident 156's trauma related to family health status. This failure had the potential to result in Resident 114 and Resident 156 experience re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again).Findings: A. During a review of Resident 114's admission record, the admission record indicated Resident 114 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), and dementia (a progressive state of decline in mental abilities). During a review of Resident 114's History and Physical (H&P), dated 6/12/2025, the H&P indicated, Resident 114 had fluctuating capacity to understand and make decisions. During a review of Resident 114's Minimum Data Set (MDS-a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 114 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for hygiene, bed mobility, transfer, dressing, bathing, and setup or clean-up assistance (Helper sets pup or cleans up) from one staff for eating. During a concurrent interview and record review on 9/5/2025, at 12:11 p.m., with the Director of Social Services (DSS), Resident 114's “Social Service History and Initial Assessment”, dated 6/9/2025 was reviewed. The Social Service History and Initial Assessment indicated, Resident 114 stated he had trauma from the Vietnam War. The Social Service History and Initial Assessment indicated, there was no documentation regarding the triggers of trauma and how they affected Resident 114. The DSS stated, she could not get much information regarding trauma and its triggers from Resident 114 and his wife. The DSS stated, she should have contacted Resident 114's psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) and social service workers from the veterans' hospital to obtain information regarding his PTSD. The DSS stated, completing the trauma assessment was important, because the resident's care would be different according to the needs from the assessment. The DSS stated, she would refer the resident to proper services according to the trauma assessment to prevent re-traumatization. The DSS stated, Resident 114's care plan was not person centered because there was no proper assessment done for the trauma. During an interview on 9/5/2025, at 2:24 p.m., with the Director of Nursing (DON), the DON stated, when the resident who has PTSD as a part of diagnosis admitted to the facility, the DSS should assessed for its triggers, and past history to prevent re-traumatization. The DON stated, the care plan could not be resident centered, and resident focused if the trauma assessment was not done correctly. The DON stated, the facility has many residents who were veterans. The DON stated, staff should have assessed the residents' PTSD and made the plan of care according to the findings. The DON stated re-traumatization would harm Residents' psychosocial well-being. During a review of Resident 114's “Care Plan (CP)”, revised on 6/23/2025, the CP Focus indicated, Resident 114 had episodes of flashbacks/nightmares from PTSD. The CP goal indicated, Resident 114's episode of flashbacks/nightmares from Vietnam war will be minimized daily through next review date (9/10/2025). The CP Interventions indicated, staff should approach resident calmly, be aware of resident's whereabouts, and observe behavior. During a review of the facility's Policy and Procedure (P&P) titled, “Trauma Informed Care”, revised on 1/2025, the P&P indicated, “Policy: It is the policy of this facility to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice… Policy Explanation and Compliance Guidelines: 1. Each resident will be screened for a history of trauma upon admission…5. The facility will account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.” B. During a review of Resident 156's admission Record, the admission Record indicated Resident 156 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest, and anxiety (a mental health condition that cause fear, dread and other symptoms that are out of proportion to the situation). During a record review of Resident 156's MDS, dated [DATE], the MDS indicated Resident 156 had intact cognitive skills (thought process) for daily decision-making and needed assistance (helper sets up while resident completes the activities) with self-care abilities and mobility such eating, oral hygiene, dressing, and transfers. During a record review of Resident 156's H&P dated 1/30/2025, the H&P indicated Resident 156 had the capacity to understand and make decisions. During a record review of Resident 156's social service assessment dated [DATE], the social service assessment did not address Resident 156's diagnosis of PTSD, the triggers, and how the facility can help the resident with past traumas. There was no other assessment done after this initial assessment. During a concurrent interview and record review on 9/5/2025 at 12:03 p.m., with the Director of Social Services (DSS), the social service assessment dated [DATE] was reviewed. The DSS stated she does not see the question asked about any history of trauma nor if there were any triggers on the assessment that was done in 2022 when Resident 156 was first admitted to the facility. The DSS stated the importance of asking these questions during the admission process was for the overall psychosocial (relationship of social factors and individual thought and behavior) wellbeing of the residents and how the residents are doing emotionally and mentally. The DSS stated if the assessment (regarding PTSD and triggers) was done during the admission process, the staff would know and would plan Resident 156's care to avoid his triggers. During an interview on 9/5/2025 at 3:04 p.m., with the Director of Nursing (DON), the DON stated residents should be properly assessed for any trauma, so the facility staff are aware of what the triggers are. The DON stated the assessment should be done upon admission to the facility and when the facility staff are aware of what the triggers are, trauma informed care would be tailored to the resident from the assessment done. The DON stated if assessment was not done, facility staff would not know what the triggers are and could retrigger the trauma for the residents. During a review of the facility's policy and procedure (P&P) titled, “Trauma Informed Care”, revised 1/2025, the P&P indicated it is the policy of this facility to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice…. trauma is defined as an event, a series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening, that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being…. 1. Each resident will be screened for a history of trauma upon admission. 2. The facility social worker or designee will conduct the screening in a private setting. 3. If the screening indicates that the resident has a history of trauma and/or trauma-related symptoms, a physician's order will be obtained for the resident to be evaluated by a mental health professional who is experienced in working with those exposed to trauma. The mental health professional should be licensed to assess, diagnose, and treat the resident accordingly… . 5. The facility will account for residents' experiences, preferences, and cultural differences in eliminating or mitigate triggers that may cause re-traumatization of the resident. Potential causes of re-traumatization by staff may include, but are not limited to a. Being unaware of the resident's traumatic history, b. Failing to screen resident for trauma history prior to treatment planning, c. Challenging or discounting reports of traumatic events.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for two of seven sampled residents (Residents 5 and 16) with ROM concerns by failing to: Objectively measure Resident 5's ROM in both hands during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 6/27/2025.Provide ROM services to Resident 16 who was identified as having ROM limitations in both arms and both legs.These deficient practices had the potential for Residents 5 and 16 to experience a further decline in ROM resulting in contracture (loss of motion of a joint associated with stiffness and joint deformity) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting).Findings:1. During a review of Resident 5's admission Record, the admission Record indicated the facility initially admitted Resident 5 on 8/31/2018 and re-admitted Resident 5 on 6/26/2025 with diagnoses including chronic obstructive pulmonary disease (lung disease that causes obstruction of airflow and can limit normal breathing), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement).During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 8/1/2025, the MDS indicated Resident 5 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 required substantial/maximal assistance (helper does all the effort) for oral hygiene, bathing, dressing, personal hygiene, and rolling to both sides and was dependent (helper does all the effort) for transfers and toileting hygiene. The MDS indicated Resident 5 had functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a review of Resident 5's OT Evaluation, dated 6/27/2025, the OT Evaluation indicated Resident 5's ROM of the right hand, right thumb, right index finger, right middle finger, right ring finger, and right little finger were impaired. The OT evaluation indicated Resident 5's ROM of the left hand, left thumb, left index finger, left middle finger, left ring finger, and left little finger were impaired. During an observation of Resident 5's Restorative Nursing Aide program (RNA, nursing aide program that helps residents maintain their function and joint mobility) session on 9/4/2025 at 10:29 am, in Resident 5's room, Resident 5 was sitting in a wheelchair. Restorative Nursing Aide 1 (RNA 1) assisted Resident 5 with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 5's both arms and right leg and applied splints to Resident 5's right hand and right knee. Resident 5 moved both shoulders to less than shoulder height, could not fully extend both elbows, and had both hands closed in fists. RNA 1 stated Resident 5 was unable to straighten the fingers of both hands. Resident 5 grimaced when RNA 1 tried to straighten Resident 5's fingers to place a carrot splint (a device that opens the hand and positions the fingers away from the palm to protect the skin from moisture, pressure, and nail puncture) in Resident 5's hand.During a concurrent interview and record review on 9/4/2025 at 3:37 pm, Occupational Therapist 1 (OT 1) stated OTs used goniometers (instrument used for the precise measurement of angles) to measure joint mobility to objectively (unbiased, based on facts) determine a resident's baseline ROM and detect changes in joint ROM. OT 1 reviewed Resident 5's OT Evaluation, 6/27/2025, and confirmed Resident 5's ROM of both hands were limited. OT 1 confirmed he did not use a goniometer to measure the joints of both hands but should have because Resident 5 had ROM limitations. OT 1 stated Resident 5's baseline ROM of both hands was not determined because the ROM limitations were not measured with a goniometer. OT 1 stated lack of objective ROM measurements had the potential to negatively impact the staff's ability to detect changes such as improvements or declines in Resident 5's ROM. OT 1 stated it was important to provide objective measurements of a limited joint in the OT evaluation to ensure subtle changes of ROM could be detected which would in turn guided the treatments and services provided. During a concurrent interview and record review on 9/5/2025 at 12:25 pm, the Director of Rehabilitation (DOR) stated OT and Physical Therapists (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) used goniometers to objectively measure ROM. The DOR stated any limitations in joint ROM observed in an OT or PT evaluation should be measured with a goniometer and documented in the evaluation because it was an objective way of establishing a resident's ROM baseline and monitoring for changes in ROM. The DOR reviewed Resident 5's OT Evaluation, dated 6/27/2025, and stated Resident 5's ROM of both hands should have been measured with a goniometer since they were impaired but was not. The DOR stated Resident 5's baseline ROM of both hands was not determined due to lack of objective measurements in the OT evaluation which in turn affected staff's ability to monitor and detect any changes in ROM. 2. During a review of Resident 16's admission Record, the admission Record indicated the facility initially admitted Resident 16 on 7/12/2022 and re-admitted Resident 16 on 9/24/2024 with diagnoses including Alzheimer's disease (a type of disease that affects memory, thinking, and behavior), chronic kidney disease (gradual loss of kidney function), and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain).During a review of Resident 16's Order Summary Report, the Order Summary Report indicated a physician's order, dated 9/25/2024, indicating Resident 16 was placed on Hospice Services (care focused on comfort and quality of life of a person with a serious illness who is approaching the end of life).During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had severe cognitive impairment. The MDS indicated Resident 16 was dependent with eating, hygiene, bathing, dressing, and mobility (ability to move). The MDS indicated Resident 16 had functional limitations in ROM in both arms and both legs.During a review of Resident 16's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 7/3/2025, the JMA indicated Resident 16 had minimal ROM limitations (75 to 100% available ROM) in the left shoulder, both wrists, and both hands, moderate/severe ROM limitations (25 to 50% available ROM) in the right shoulder and both ankles, and severe ROM limitations (0 to 25% available ROM) in both hips and both knees. The JMA comments indicated Resident 16 was on hospice care and nursing was to integrate ROM exercises during care. During an observation and interview on 9/3/2025 at 9:35 am, in Resident 16's room, Resident 16 was lying in bed with his body hunched over to the left side of the bed and blankets covering his left arm and both legs. Resident 16 moved his right shoulder and elbow slightly when trying to move the blankets. Licensed Vocational Nurse 2 (LVN 2) entered the room and assisted Resident 16 with removing the blankets. Resident 16's both legs were rotated to the left side of the body with both hips and both knees bent and both toes pointing downwards. LVN 2 stated Resident 16 had limited ROM in both arms and both legs and needed assistance with ROM. LVN 2 stated Resident 16 moved both arms every now and then but rarely moved both legs on his own. LVN 2 tried but was unable to fully straighten Resident 16's both hips and knees. LVN 2 assisted Resident 16 to move both arms up to shoulder level and slowly straightened Resident 16's both elbows. LVN 2 stated Resident 16 benefitted from ROM exercises to both arms and both legs because Resident 16 did not appear to have any pain with stretches and needed it to prevent further stiffness. LVN 2 stated he thought Resident 16 received RNA services for ROM exercises of both arms and both legs. During an interview on 9/3/2025 at 9:49 am, Certified Nursing Assistant 5 (CNA 5) stated he frequently assisted with Resident 16's daily care. CNA 5 stated Resident 16 required total assistance in daily care and had ROM limitations in both arms and both legs. CNA 5 stated Resident 16 actively moved both arms more than both legs and needed assisted with ROM. CNA 5 stated he assisted with ROM sometimes during daily care but mostly relied on RNA to assist with ROM exercises. CNA 5 stated he was unsure if other CNAs provided Resident 16 with daily ROM exercises because the CNAs were not required to document whether they provided ROM exercises during daily care. During an interview and record review on 9/5/2025 at 11:00 am, the Minimum Data Set Coordinator 1 (MDSC 1) and Minimum Data Set Nurse (MDSN) stated the facility provided RNA and skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant) to maintain, improve, and prevent declines in ROM for the residents in the facility. MDSC 1 and MDSN stated the facility monitored for changes in ROM by staff report, RNA meetings, and JMAs done annually by the Rehabilitation Department (Rehab) and quarterly by the MDS nurses. MDSC 1 and MDSN reviewed Resident 16's MDS, dated [DATE], and confirmed Resident 16 was identified as having functional ROM limitations in both arms and both legs. MDSC 1 and MDSN reviewed Resident 16's JMA, dated 7/3/2025, and confirmed Resident 16 had ROM limitations in both arms and both legs. MDSC 1 and MDSN confirmed the JMA indicated Resident 16 was on hospice care services and ROM was to be provided during daily nursing care. MDSC 1 and MDSN reviewed Resident 16's clinical record and confirmed Resident 16 was not receiving RNA services. MDSC 1 and MDSN stated Resident 16 was at high risk for contracture development because he had ROM limitations in both arms and both legs, required total care, and had limited mobility. MDSC 1 and MDSN stated Resident 16 was a good candidate for RNA services and was unsure why RNA services were never considered. MDSC 1 and MDSN stated they did not follow up with the hospice care nurse to recommend or discuss RNA services but should have to ensure Resident 16 received the appropriate care and services to maintain and prevent a decline in ROM. MDSC 1 and MDSN stated they were unsure if CNAs provided daily ROM exercises since the CNAs did not document if ROM was provided during daily care. MDSC 1 and MDSN stated if a resident who was identified as having ROM limitations did not receive ROM services, it could potentially lead to a functional decline and contracture development. During an interview on 9/5/2025 at 3:33 pm, the Director of Nursing (DON) stated the facility provided RNA and Rehab services to maintain, improve, and prevent declines in ROM for the residents in the facility. The DON stated the facility monitored changes in ROM by staff report, observations during daily care, and JMAs done quarterly and annually. The DON stated it was important staff objectively measured ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor for changes and provide the appropriate services to address any declines. The DON stated if residents who had ROM limitations did not receive the treatment and services to maintain their ROM, it could result in a functional decline. During a review of the facility's undated Policy and Procedure (P/P) titled, Prevention of Decline in ROM, the P/P indicated residents who entered the facility without limited ROM would not experience a reduction in ROM unless unavoidable. The P/P indicated the facility in collaboration with the medical director, DON, and as appropriate physical/occupational consultant established and utilized a systemic approach for prevention of a decline in ROM, including the assessment, appropriate care planning, and preventative care. The P/P indicated the facility would provide interventions, exercises, and/or therapy to maintain or improve ROM. During a review of the facility's undated P/P titled, Joint Mobility Assessment Policy, the P/P indicated the purpose of the JMA was to establish guidelines for the evaluation and monitoring of residents' joint mobility to maintain function, prevent decline, and promote independence and quality of life. The P/P indicated all residents would have their joint mobility assessed at admission, routinely thereafter, and as clinically indicated. The P/P indicated the assessments would be used to develop individualized care plans, guide therapeutic interventions, and monitor changes over time. The P/P indicated nursing staff would document observations related to mobility during routine care and therapy staff would provide details ROM and functional assessments as appropriate.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions for 3 of 3 residents (Residents 16, 156, and 124) by failing to: Develop and implement a care plan to improve, maintain, or prevent a decline in range of motion (ROM, full movement potential of a joint) for Resident 16 who was identified as having ROM limitations in both arms and both legs.Develop and implement a comprehensive person-centered care plan for Resident 124's use of Lorazepam (Ativan, medication used to treat anxiety [a common mental health condition characterized by excessive worry, fear, and nervousness]).Develop and implement a comprehensive person centered care plan for Resident 156's diagnosis of post traumatic stress disorder ([PTSD], a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it) with specific triggers, goals, and interventions. These deficient practices had the potential to negatively affect the delivery of necessary care and services. Findings: 1.During a review of Resident 16's admission Record, the admission Record indicated the facility initially admitted Resident 16 on 7/12/2022 and re-admitted Resident 16 on 9/24/2024 with diagnoses including Alzheimer's disease (a type of disease that affects memory, thinking, and behavior), chronic kidney disease (gradual loss of kidney function), and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 7/3/2025, the MDS indicated Resident 16 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 16 was dependent (helper does all the effort) in eating, hygiene, bathing, dressing, and mobility (ability to move). The MDS indicated Resident 16 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a review of Resident 16's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 7/3/2025, the JMA indicated Resident 16 had minimal ROM limitations (75 to 100% available ROM) in the left shoulder, both wrists, and both hands, moderate/severe ROM limitations (25 to 50% available ROM) in the right shoulder and both ankles, and severe ROM limitations (0 to 25% available ROM) in both hips and both knees. During an observation and interview on 9/3/2025 at 9:35 am, Resident 16 was lying in bed with his body hunched over to the left side of the bed and blankets covering his left arm and both legs. Resident 16 moved his right shoulder and elbow slightly when trying to move the blankets. Licensed Vocational Nurse 2 (LVN 2) entered the room and assisted Resident 16 with removing the blankets. Resident 16's both legs were rotated to the left side of the body with both hips and both knees bent and both toes pointing downwards. LVN 2 stated Resident 16 had limited ROM in both arms and both legs and needed assistance with ROM. LVN 2 stated Resident 16 moved both arms every now and then but rarely moved both legs on his own. During an interview and record review on 9/5/2025 at 2:00 pm, the Minimum Data Set Coordinator 1 (MDSC 1) and Minimum Data Set Nurse (MDSN) stated an individualized care plan was developed for every resident and used as a guideline to ensure proper care was provided for each resident. MDSC 1 and MDSN reviewed Resident 16's MDS, dated [DATE], and confirmed Resident 16 was identified as having functional ROM limitations in both arms and both legs. MDSC 1 and MDSN reviewed Resident 16's JMA, dated 7/3/2025, and confirmed Resident 16 had ROM limitations in both arms and both legs. MDSC 1 and MDSN reviewed Resident 16's care plan and confirmed there was no care plan and interventions in place to maintain or prevent a decline in ROM of Resident 16's both arms and both legs despite ROM limitations being identified on the MDS and JMA. MDSC 1 and MDSN stated the care plan should have included goals and interventions to maintain and prevent a decline in Resident 16's both arms and both legs but did not. MDSC 1 and MDSN stated it was important Resident 16's limited ROM was care planned because Resident 16 had limited ROM in both arms and both legs, required total care, had limited mobility, and was at high risk for contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) development. MDSC 1 and MDSN stated it was important for care plans to be developed, implemented, and accurate to ensure the appropriate care was provided to each individual resident. During an interview on 9/5/2025 at 3:33 pm, the Director of Nursing (DON) stated individualized, person-centered care plans were developed for every resident and were used as a guide for staff to identify the type of care to provide the residents in the facility. The DON stated a care plan with goals and interventions should be developed for all residents who were identified as having ROM limitations upon assessment, screens, and/or by report from the resident or staff. The DON stated it was important for care plans to be developed, implemented, and accurate to ensure the appropriate care was provided to each individual resident. The DON stated lack of care planning could negatively impact the provision of care and services. During a review of the facility's policy and procedure (P/P) titled, “Comprehensive Care plans” revised 1/2025, the P/P indicated the facility would develop and implement a comprehensive, person-centered care plan for each resident, consistent with residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that were identified in the resident's comprehensive assessment. 2. During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted to the facility 5/1/2025 with diagnoses of dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, language, attention, and problem-solving, severe enough to interfere with daily life), history of falling, and anxiety. During a review of Resident 124's MDS dated [DATE], indicated Resident 124 had severe cognitive impairment (difficulties with mental functions like thinking, learning, remembering, and decision-making, affecting skills such as communication and self-help). During a review of Resident 124's Order Summary Report, indicated an order was placed 8/29/2025 for Lorazepam Tablet 0.5 milligrams (mg, a unit of measurement), Give 1 tablet by mouth every 12 hours as needed for Anxiety manifested by (M/B) irritability (a state of feeling annoyed and easily angered) for 14 Days. During a review of Resident 124's care plans, Resident 124's care plans did not address the use of Ativan until 9/5/2025 when the issue was brought to the facility's attention. During an interview on 9/5/2025 at 2:34 p.m., the Director of Nursing (DON), the DON reviewed Resident 124's active physicians orders and stated Ativan was ordered for Resident 124 on 8/29/2025. The DON reviewed Resident 124's care plans and stated the care plan with a focus on Resident 124 had an episode of anxiety m/b irritability did not include interventions for Ativan until it was initiated on 9/5/2025. The DON stated the Ativan interventions should have been initiated when Resident 124 first received the order for Ativan on 8/29/2025. The DON stated a care plan specific to Ativan was important because it addressed and provided proper interventions for the residents and it was to include behaviors and monitoring. During a review of the facility's policy and procedure (P&P) titled “Comprehensive Care Plans) dated 1/2025, the P&P indicated the comprehensive care plan will describe, at a minimum, the following services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 3. During a record review of Resident 156's admission Record, the admission Record indicated Resident 156 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest, and anxiety) and PTSD. During a record review of Resident 156's MDS dated [DATE], the MDS indicated Resident 156 had intact cognitive (thought process) skills for daily decision-making and needed assistance (helper sets up while resident completes the activities) with self-care abilities and mobility such eating, oral hygiene, dressing, and transfers. During a record review of Resident 156's History and Physical (H&P) dated 1/30/2025, the H&P indicated Resident 156 had the capacity to understand and make decisions. During a record review of Resident 156's social service assessment dated [DATE], the social service assessment did not address Resident 156's diagnosis of PTSD, what the triggers are and how the facility can help the Resident 156 receives appropriate care to address and manage trauma related needs. There was no other assessment done after this initial assessment. During a record review of Resident 156's untitled care plan, the untitled care plan indicated PTSD as a diagnosis but the goals and interventions were vague and did not address Resident 156's specific triggers or provide guidance for facility staff on how to avoid retriggering or manage symptoms and behaviors if the trauma is triggered. During an interview on 9/5/2025 at 10:35 a.m. with the Director of Staff Development (DSD), the DSD stated residents with history of trauma or diagnosis of PTSD, should have a person-centered care plan tailored to the residents specific needs . The DSD stated residents should feel safe and at home. The care plan should have interventions to avoid their triggers (a sound, smell, place or memory that suddenly reminds someone of a scary or upsetting experience from the past and make them feel afraid, sad or upset). During a concurrent interview and record review on 8/8/2025 at 10:52 a.m., with the Director of Social Services (DSS), the untitled, undated care plan for Resident 156 was reviewed. The DSS stated there should have been a person-centered care plan for Resident 156's PTSD diagnosis. The DSS stated Resident 156's care plan did not specify what the PTSD triggers are and how to avoid retriggering the trauma. The DSS stated having a person-centered care plan would be helpful for facility staff to avoid retriggering the trauma and their manifestation. During an interview on 8/8/2025 at 2:58 p.m., with the Director of Nursing (DON), the DON stated the importance of having a person-centered care plan was to address the residents' needs, and to provide personalized care for each resident. The DON stated residents should have a personalized care plan because each resident was different with different problems, and different issues. The DON stated the care plan should be person centered to address specific needs the residents may have. During a review of the facility's policy and procedures (P&P) titled Comprehensive Care Plans revised 1/2025, indicated, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment….person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives… the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. During a review of the facility's P&P titled Trauma Informed Care revised 1/2025, indicated, it is the policy of this facility to ensure residents who are trauma survivors receive culturally competent, trauma-info1med care in accordance with professional standards of practice… trauma-informed care is defined as an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma.

Based on interview and record review, the facility failed to ensure employee files were maintained and kept up to date when performance evaluations (a process used by organizations to assess how well employees are performing in their roles) were not completed for three out of six sampled employees.This failure had the potential to adversely impact the quality of care of residents when staff performance is not current.Findings:During a concurrent interview and record review on 9/5/2025 at 10:54 a.m. with the Director of Staff Development (DSD), the employee files for the Director of Nursing (DON), Registered Nurse Supervisor (RNS)1, Licensed Vocational Nurse (LVN) 2, Certified Nurse Assistant (CNA) 4, CNA 5, and the DSD were reviewed. There were no annual performance evaluations for RNS 1, LVN 2, and CNA 4. The DSD stated the importance of doing performance evaluation yearly was to ensure staff are meeting the standard of care to perform the duties as licensed staff in the facility. The DSD stated performance evaluation should be done on a yearly basis. The DSD stated if the performance evaluation was not done, the licensed staff may not be up to date with the standard of practice.During an interview on 9/5/2025 at 2:50 p.m., with the Director of Nursing (DON), the DON stated performance evaluations should be done yearly. The DON stated a performance evaluation was how the facility staff perform throughout the year in their duties, their attendance, their work ethics, and if they were a team player. The DON stated if the performance evaluation was not done, it would affect the staff by not making them aware of what they need to improve on, or what they need to work on in their position.During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, revised January 2025, indicated, the job performance of each employee shall be reviewed and evaluated at least annually. a performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review. performance evaluations may be used in determining employee promotions, shift/position transfers, demotions, terminations, wage increases, etc., and to improve the quality of the employee's work performance. performance evaluations will be completed by the employees' department directors and supervisors and reviewed by the Human Resource Director (is responsible for planning, directing and coordinating human resources activities, policies and programs for a company) and Administrator. Each employee will be given the opportunity to review his/her evaluation with his/her department director and the Human Resource Director.

Based on observation interview and record review the facility failed to protect the resident right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 punched Resident 1 on the left upper cheek. The facility failed to: 1. Intervene when Certified Nursing Assistant (CNA 1) and Licensed Vocational Nurse (LVN) 1 witnessed and heard Resident 1 and Resident 2 having an argument in a loud voice on 2/25/2025, at 6am. 2. Supervise Resident 1 and Resident 2 who were in the patio on 2/25/25. 3. Follow Resident 1's Care Plan titled Resident 1 has episode of aggressive behavior, believes someone is going to hurt him dated 12/29/24, with interventions to remove any resident in the immediate area if Resident 1 became aggressive. These failures resulted in Resident 1 being assaulted (punched) by Resident 2, and Resident 1 sustained a black eye discoloration, upper left cheek laceration (deep cut or tear in skin), fracture (broken bone) of the nasal (nose) bones and fracture of the medial (towards the middle) wall of the left orbit (bones that surround the eye socket) and left maxillary (upper jawbone on the left side of the face), which required evaluation and treatment at a General Acute Care Hospital (GACH) Findings: During a review of Resident 1's Admission Record, the Admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, (a progressive state of decline in mental abilities), schizophrenia ( a mental illness that is characterized by disturbances in thought) anxiety disorder (emotion characterized by feelings of tension, worried thoughts ) and suicidal ideation ( thoughts, or fantasies about ending one's life) During review of Resident 1's Minimum Data Set (MDS a resident's assessment tool) dated 12/4/24, the MDS indicated, Resident 1 had impaired cognitive (ability to think, understand, learn, and remember) ability. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) with toileting hygiene, shower, and personal hygiene. The MDS indicated Resident 1 required moderate assistance with walking 10 feet and had not attempted to walk 50 feet due to medical condition or safety concerns. During a review of Resident 1's History and Physical (H&P), dated 12/29/24, the H&P indicated, Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Care Plan titled Resident 1 has episode of aggressive behavior, believes someone is going to hurt him dated 12/29/24, the Care Plan indicated interventions including staff will decrease stimulation around Resident 1 by providing a calm environment, if the resident became aggressive, remove any resident in the immediate area that may be in danger, provide and encourage appropriate activities for Resident 1 to release some energy. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including essential hypertension ( type of high blood pressure where the cause is unknown and develops gradually), blindness on one eye (lack of vision in one eye), paranoid schizophrenia ( a chronic mental illness characterized by persistent delusions [ fixed false beliefs that are not based on reality] and hallucinations { sensory experiences that are not real}) mood affective disorder (mental health disorder that affects a person's emotional state leading to long hours of extreme sadness), schizoaffective disorder ( a mental disorder that is characterized by disturbances in thoughts) and suicidal ideation. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment. The MDS indicated Resident 2 had delusions. The MDS indicated Resident 2 required moderate assistance with toileting hygiene, shower, upper and lower body dressing, and personal hygiene. Resident 2 required moderate assistance with bed mobility, bed to chair transfer and walking 50 feet with two turns. During a review of Resident 2's Care Plan titled Resident 2 has potential for injury to others related to suicidal ideation dated 9/16/24, the Care Plan indicated interventions including to allow Resident 2 express his feelings, refocus his attention to something positive when the resident was depressed, check the environment for potential hazards, and attempt behavioral intervention if Resident 2 was manifesting behaviors. During a review of Resident 2' s Care Plan titled Resident 2 has epidotes of delusions that is attempting to strike out at staff because Resident 2 believe people are against him dated 9/16/2024, the Care plan indicated interventions including alter resident's environment, provide activities or take resident for a walk if the resident was upset, approach Resident 2 calmly unhurriedly, and attempt to refocus Resident 2 to something positive when the resident is exhibiting behaviors. During a review of Resident 1's Nursing Progress Notes dated 2/25/25 timed at 6:32 a.m., the Nursing Progress Notes indicated Resident 1 notified licensed staff that he had a bloody nose. The Nursing Progress Notes indicated Resident 1 stated that he was hit because he would not give up his cigarettes. During a review of Resident 1's Nursing Progress Notes dated 2/25/25 timed at 7 a.m., the Nursing Progress Notes indicated Resident 1 had swelling on the left lateral upper nose bridge measuring 0.1 centimeters (cm- unit of measurement) by 0.2 cm, left forehead swelling measuring 4.0 cm by 3.0 cm and a left eye black discoloration with swelling measuring 5.0 cm by 2.0 cm. During a review of Resident 1's Nursing Progress Notes dated 2/25/2025 timed at 7:28 a.m., the Nursing Progress Notes indicated Resident 1 had a cut on his nose and a bump on his forehead. The Nursing Progress Notes indicated Resident 1 stated a big black guy hit him after Resident 2 took Resident 1's cigarette. The Nursing Progress Notes indicated Resident 2 stated Resident 1 had kicked him in the past, so he hit Resident 1. During a review of Resident 1's Emergency Department (ED) Report dated 2/25/25 timed at 9:39 a.m., the ED report indicated Resident 1, arrived at the ED with a swollen left eye and complained of pain after being assaulted by another resident. During a review of Resident 1's Computed Tomography (CT -diagnostic imaging procedure) report dated 2/25/25 timed at 2:35 p.m., the CT report indicated Resident 1 had a fracture of the nasal bones and fracture of the medial wall of the left orbit and left maxillary. During a concurrent observation and interview on 3/5/25 at 10:55 a.m., with Resident 1 in the activity room, Resident 1 had a laceration on the left upper cheek close to the nose and left eye with sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision). Resident 1 stated he did not know how he sustained his injury. During an interview on 3/5/25 at 2:15 p.m., with CNA 1, CNA 1 stated on 2/25/25 she witnessed the incident (argument) between Resident 1 and Resident 2 in the smoking patio, while CNA 1 was giving Licensed Vocational Nurse LVN 1 report on the list of resident's risk for elopement (leaving a supervised area without permission or awareness). CNA 1 stated she observed Resident 1 and Resident 2 argue but she (CNA 1) did not intervene because she did not know the argument would escalate (become more intense or serious) as it happened very fast, and Resident 2 punched Resident 1 in the face. CNA 1 stated Resident 1 liked to stay at a particular place in the patio and when another resident was at that place, Resident 1 would scream because he preferred to be the first one at that place. CNA 1 stated Resident 2 was a quiet and not aggressive. During an interview on 3/5/25 at 2:30 p.m., with LVN 1, LVN 1 on 2/25/25 while making rounds with CNA 1, LVN 1 observed Resident 1 and Resident 2 arguing in the patio area. LVN 1 stated he did not know what they were arguing about. LVN 1 stated before he could separate them, Resident 2 punched Resident 1 on his left upper cheek bone, with his fist. LVN 1 stated Resident 1 was very upset and wanted to retaliate (make an attack or assault in return for a similar attack) at Resident 2 when LVN 1 was separating the two residents. LVN 1 stated residents should be separated immediately at the onset of argument and when they start to be aggressive. LVN 1 stated the incident should have been avoided if staff separated both residents as soon as the residents started arguing. LVN 1 stated Resident 1 had behavioral problems, a history of angry outburst, and talked to himself. LVN 1 stated Resident 2 had a diagnosis of schizophrenia and talked to himself. LVN 1 stated both residents should not be left unsupervised. During an interview on 3/5/25 at 3 p.m., with the Director of Staff Development (DSD), the DSD stated when residents were having angry outbursts, the staff nearby or anyone should intervene immediately by separating the residents. The DSD stated there should be staff assigned in the patio to supervise residents because residents are always out in the patio. The DSD stated it was unusual behavior for Resident 2 to punch another resident as he was always quiet. The DSD stated when the staff hear loud and angry exchange or verbal outburst between residents, staff should intervene and deescalate (reduce the intensity of a conflict or potentially violent situation) immediately. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation (undated), the P&P indicated Each resident has the right to be free from abuse, misappropriation of resident property, and exploitation. The P&P, indicated the facility must: a.Train staff in appropriate interventions to deal with aggressive and catastrophic reactions by residents. b.Observe resident behavior and their reactions to other residents, roommates, tablemates. Place residents in accommodations and environments that keep them calm. c.Provide instruction to staff on care needs of residents. d.Assess monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with history of aggressive behaviors.

Based on, interview and record review, the facility failed to ensure the resident, who had impairment (loss of function or ability) on both sides of upper extremity (shoulder, elbow, wrist, and hand) and lower extremity (hip, knee, ankle, and foot), did not sustained injury to left leg during transfer from a wheelchair to a bed for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 4 asked another staff member to assist her with transferring Resident 1 from a wheelchair to bed per care plan titled, Needs Assistance with Activities of Daily Living (ADL-basic tasks that residents need to do to care for themselves such as eating, dressing and toileting ) dated 1/26/2024 and revised on10/14/2024, which indicated Resident 1 required a total assistance of two to three persons for transfers. 2. Ensure staff followed facility ' s policy and procedure (P&P) titled, Safe Resident Handling/ Transfers undated which indicated the residents should be handled and transferred safely to prevent or minimize risks for injury and to provide and promote a safe, secure, and comfortable experience for the resident. These failures resulted in Resident 1 ' s left leg caught on the wheelchair wheels and sustaining a laceration (a deep cut or tear in the skin) to the left posterior (back) lower leg requiring ten sutures (a stitch or row of stitches holding together the edges of a wound). On 11/22/2024 Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of his left leg laceration. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body) following cerebral infarction( stroke -a medical condition that occurs when blood flow to the brain is disrupted) affecting left dominant (preferred) side. During a review of Resident 1 ' s Physical Therapist ' s ([PT]- licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge Summary dated 4/4/2024, the PT Discharge Summary indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with transfers from wheelchair to bed. During a review of Resident 1 ' s Minimum Data Set ([MDS] resident assessment tool), dated 10/14/2024, the MDS indicated Resident 1 had intact cognitive (ability to think, understand, learn, and remember) skills for daily decision-making. The MDS indicated Resident 1 was able to understand others and was understood by others. The MDS indicated Resident 1 had impairment on both sides of upper extremity (shoulder, elbow, wrist, and hand) and lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 1 used a wheelchair for mobility and needed partial/moderate assistance with toileting hygiene, shower, and upper body dressing. The MDS indicated Resident 1needed partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs) with chair/bed to chair transfer (the ability to transfer to and from a bed to a chair (or wheelchair). During a review of Resident 1 ' s Transfer Form dated 11/22/2024 timed at 11:30 p.m., the Transfer Form indicated Resident 1 was transferred to GACH due to skin wound (unspecified location) on 11/22/2024 at 10:20 p.m. During a record review of Resident 1 ' s GACH ' s Emergency Department (ED) documentation dated 11/22/2024, the ED documentation indicated Resident 1 was brought to the emergency room (ER) due to laceration to left lower leg. The ED Documentation indicated Resident 1 had laceration repair with ten sutures. During an interview on 12/4/2024 at 10:30 a.m., Resident 1 stated Certified Nursing Assistant (CNA 4) assisted him in transferring from wheelchair to the bed when his left leg got caught in the wheelchair. Residents 1 stated CNA 4 lifted him by placing one arm under his armpit and with another arm holding his pants. Resident 1 stated when CNA 4 turned him towards the bed, his left leg was caught in the wheelchair ' s wheel. Resident 1 stated CNA 4 called the charge nurse (Registered Nurse 1 [RN 1]) who assessed his left leg as it was bleeding profusely (great extent). Resident 1 stated he was transferred to GACH where he received sutures to his left leg. Resident 1 stated that he required a two-person assistance with transfers because he had paralysis in his left leg and was unable to fully support his body when moving from the wheelchair to the bed. During an interview on 12/4/2024 at 11:20 a.m., CNA 5 stated a resident (in general) who had a stroke (cerebral infarction) with one-sided weakness or paralysis should always be transferred with two-person assistance for safety. CNA 5 stated Resident 1 should have been transferred with two-person assistance to prevent any injury. During an interview on 12/05/24 at 09:25 a.m., CNA 4 stated that on 11/22/2024 around 10 p.m. she transferred Resident 1 from the wheelchair to the bed. CNA 4 stated she held Resident 1 under his armpit with one hand and with another held the resident ' s pants. CNA 4 stated when she transferred Resident 1 in bed the resident ' s left leg got caught on the wheelchair ' s wheels. CNA 4 stated she was not aware Resident 1 had a wound until she removed his pants and saw the resident left leg was bleeding. CNA 4 stated Resident 1 should have been transferred with two-person assistance for safety as he had left sided paralysis. During a concurrent interview and record review on 12/5/2024 at 10:02 a.m., with Licensed Vocational Nurse (LVN 2) Resident 1 Care Plan Needs Assistance with ADL- dated 1/26/2024 and revised on10/14/2024 was reviewed. LVN1 confirmed the care plan indicated Resident 1 required a total assistance with transfer and should be transferred with two to three (2-3) staff assistance. LVN 1 stated Resident 1 had left sided hemiplegia and a stroke (cerebral infarction) and therefore should be transferred with two-person assistance for safety. During a concurrent interview and record review on 12/5/2024 at 10:46 a.m., with MDS Coordinator (MDSC) Resident 1 ' s MDS dated [DATE] was reviewed. The MDS indicated Resident 1 had impairment on both sides of upper extremity and lower extremity.MDSC stated it was not safe to transfer Resident 1 with assistance of one person because the resident had the impairment in both upper and lower extremities. During a review of the facility ' s P&P tiled, Safe Resident Handling/ Transfers undated, the P&P indicated it was the policy of the facility to ensure that resident was handled and transferred safely to prevent or minimize risks for injury and provided and promote a safe, secure, and comfortable experience for the resident. During a review of the facility ' s P&P titled, Safety and Supervision of Residents undated, the P&P indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review, the facility failed to ensure the resident, who was assessed as a high-risk for wandering, did not elope (when a resident leaves a facility without supervision nor authorization) from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Supervise Resident 1 by conducting observations of Resident 1's whereabouts and monitor the resident every shift for episodes of wandering or attempting to elope from the facility as indicted in the resident's untitled Care Plan dated 8/20/2024. 2. Ensure staff responded to the entrance/exit door alarm as Resident 1 was leaving the facility through. 3. Ensure staff followed the facility Procedure and Policy (P&P) titled Wandering Unsafe Resident and have a detailed monitoring plan in place to always know the whereabouts of Resident 1. These deficient practices resulted in Resident 1 leaving the facility unnoticed and placed the resident at risk for unsafe environmental conditions, including extreme heat and/or cold, possible motor vehicle accident, and medical complications such as stroke (a medical emergency a bleeding in the brain due to uncontrolled high blood pressure [force of blood pushing against the walls of blood vessels]) due to missing her high blood pressure medications from 11/4/2024. Resident 1 was found on 11/15/2024 in the neighborhood where her family lives. Resident 1 refused to come back to the facility and refused to be assessed by the Emergency Medical Transport (EMT). On 11/8/2024 at 11:06 a.m., 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 in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to have a system in place to monitor Resident 1's whereabouts and prevent Resident 1's elopement from the facility. On 11/9/2024 the facility submitted an acceptable IJ removal plan (IJRP). After onsite verification of the IJRP implementation through observation, interviews, and record review, the IJ was removed on 11/9/2024 at 11:06 a.m., in the presence of the ADMIN and the DON. The IJPR included the following immediate actions: 1. As of 11/9/2024, Resident 1 has not returned to the facility. The facility has implemented the following measures to locate the resident: a. Local Police Department was notified. A description of Resident 1 was provided, and a missing person's report was filed on11/5/2024. b. Local hospitals in surrounding areas have been called and facility staff will continue to call in search of the resident. c. Resident 1's responsible party (RP) was notified on 11/5/2024. The RP stated that she does not expect a call from Resident 1, as Resident 1 usually waits a few days before she contacts family. The DON will call RP daily for updates. d. Staff will continue to search for resident in the vicinity of the facility, as well as in areas that the responsible party has mentioned Resident 1 frequents. 2. Assigned a Certified Nurse Assistant (CNA) as a Rounder to document at least every hour to identify the whereabouts of the residents who are assessed as a risk for wandering and elopement. The CNA Rounder will document at least hourly on the Resident Location Tracking log to indicate the location of the residents who are assessed as a risk for wandering and elopement. Started on 11/9/2024. 3. Each facility exit door is equipped with a security camera on the outside for monitoring for the safety and wellbeing of the residents. The Administrator, the DON, and/or Registered Nurse (RN) Supervisor will be responsible for monitoring video footage. The RN Supervisor is scheduled 24 hours a day, every day of the week. Started 11/8/2024. 4. The front entrance/exit door had an alarm that was not clearly audible due to a second set of glass doors that lead into the building, which muffled the sound of the alarm on the entrance/exit door. After identifying the root cause of the failure (of Resident 1's successful elopement), the glass doors were outfitted with an audible door alarm that will set off a piercing horn sound when a door is opened after the alarm has been activated. When the activated alarm sounds, all staff in the immediate area will attend to it. Started on11/6/2024. 5. A facility staff (Door Monitor) was assigned to provide continuous 24-hour supervision of the exit door located between stations B and C, where staff enter/ exit the facility. Started on 11/8/2024. 6. The RN Supervisor will be responsible for activating/ deactivating door alarms. The RN Supervisor is scheduled, every day of the week 24 hours a day starting 11/8/2024. The RN Supervisor will conduct rounds at least every two hours to ensure exit doors are properly secured and alarmed. They will document their findings on the Door Alarm Log. 7. The DON initiated in-services to licensed nurses, CNAs, and registry staff regarding the facility's systems on resident supervision and elopement prevention for the wander guard (a wearable device that triggers alarms if close by an exit) system, exit door alarms, security cameras, and Resident Location Tracking log) starting on 11/8/2024. The DON initiated in-services with non-nursing staff, which includes dietary, housekeeping, activities, and administrative staff, on the facility's systems on resident supervision and elopement prevention. The DON initiated in-services to RN Supervisor regarding conducting rounds at least every two hours to ensure exit doors are properly secured and alarmed and proper use of the Door Alarm Log. 8. Staff in-serviced on the need to follow up, develop and implement a care plan for residents who were assessed as a risk for wandering. 9. A Resident Location Tracking log was implemented to document the visual checks at least hourly of each resident who is at risk for wandering and elopement. The log indicates the location of the resident during the hourly rounds. A CNA assigned as a Rounder will document at least every hour on the Resident Location Tracking log to identify the whereabouts of the residents who are assigned as a risk for wandering and elopement starting 11/9/2024. 10. Each exit door is outfitted with an audible door alarm that will set off a piercing horn sound when a door is opened after the alarm has been activated. The RN Supervisor who is scheduled 24 hours a day will be responsible for activating/ deactivating door alarms. When the activated alarm sounds, all staff in the immediate area will respond to it starting 11/8/2024. 11. The DON initiated reassessment of 147 residents in the facility and identified those who are at high risk for wandering and elopement. a. Care plan revisions were done for all 33 residents who were identified as high risk for wandering and elopement on 11/9/2024. b. Developed a list of residents who are at high risk for wandering and elopement. The list is now made available at each station for all incoming staff. At the beginning of each shift, all staff will attend a huddle (a quick meeting to share important information), where the licensed nurse will inform staff of the location of the list. The Director of Staff Development (DSD) and/or designee will inform all registry staff prior to the start of their shift of the location of the list. Started on 11/8/2024. c. At the beginning of each shift, a huddle will be conducted by the licensed nurse to communicate with all incoming staff which residents are at risk for wandering and elopement. Started on 11/8/2024. d. On 11/8/2024, the DON initiated in-services to licensed staff regarding the list of residents who are at risk for wandering and elopement. Findings: During a review of Resident 1's Progress Notes dated 11/5/2024, the Progress Notes indicated on 11/4/2024 between 9:30 p.m. and 10:30 p.m., Certified Nursing Assistant (CNA 2) was unable to locate Resident 1 within the facility. On 11/4/2024 at 11:20 p.m., CNA 2 reported that Resident 1 was missing to Licensed Vocational Nurse (LVN 2). CNA 2 and LVN 2 did not find Resident 1 but found Resident 1's wander guard with the strap broken on her bed side table. The facility staff searched for Resident 1 inside the facility and the surrounding areas outside to locate Resident 1 did not find the resident. During a review of Resident 1's Admission Record, the Admission Record indicated the facility initially admitted Resident 1 to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a chronic and severe mental disorder that affects how the person thinks, feels, and behaves) unspecified, psychosis (a condition that affects the way your brain processes information), paraplegia (the inability to voluntary move the lower parts of the body) and hypertension (high blood pressure). During a review of Resident 1's history and physical (H&P), dated 8/21/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] resident assessment tool), dated 8/30/2024, the MDS indicated Resident 1 required substantial/maximal assistance (helper lifts or hold trunk of limbs and provides more than half the effort) with putting on and taking off footwear and personal hygiene. The MDS indicated Resident 1 used a wheelchair for mobility. During a review of Resident 1's Initial Wandering assessment dated [DATE], the Initial Wandering Assessment indicated the resident had a history of wandering and required frequent monitoring. During a review of Resident 1's Psychiatric (involving mental illness or its treatment) Follow Up Note dated 10/24/2024, the Psychiatric Follow Up Note indicated Resident 1 had episodes of auditory hallucinations (hearing sounds that are not based in reality). During a review of Resident 1's Physician's Order dated 11/1/2024, the Physician's Order indicated for Resident 1 to receive Amlodipine Besylate Oral tablet 5 milligrams ([mg] a unit of measurement of mass) one time daily for hypertension (high blood pressure). During an interview and record review on 11/7/2024 at 10:39 a.m., with LVN 3 and the Director of Nursing (DON) a, Resident 1's Initial Wandering assessment dated [DATE] was reviewed. The assessment indicated Resident 1 had a score of three which indicated Resident 1 had a history of wandering and required frequent monitoring. LVN 3 stated he did not know what severity a score of three meant. The DON stated that any score above a one indicated a risk for elopement. The DON stated a score of three meant the resident was at high risk for wandering and elopement. During a review of Resident 1's untitled Care Plan dated 8/20/2024, the Care Plan indicated Resident 1 had a potential for injury and or accidents related to wandering or attempting to leave the facility unassisted. The goals set for Resident 1 included the resident's potential for injury and or accidents related to wandering or attempting to leave the facility would be minimized daily, with a target date of 11/30/2024. The Care Plan interventions included constant observations of Resident 1's whereabouts, monitor for episodes of wandering or attempting elopement every shift (tally by episodes), redirection, cueing as appropriate and apply Wander Guard alarm (system to alarm staff of a potential elopement when resident attempts to get out of the facility) device and monitor Wander Guard device every shift for placement. During a tour of the facility on 11/6/2024 at 11:00 a.m., a total of six exit doors were observed. During an observation on 11/6/2024 at 11:05 a.m. of Door 1, was a front visitor entrance, Door 1 was equipped with a wander guard monitor sensor and a code padlock (needs a pass code to open the doors). During an observation on 11/6/2024 at 11:07 a.m., Door 2 East, Door 2 was equipped with a wander guard monitor sensor and a code padlock. During an observation on 11/06/2024 at 11:10 a.m., of Door 3, Door 3 was equipped with a wander guard monitor sensor and a code padlock. During an observation on 11/06/2024 at 11:12 a.m., of Door 4, Door 4 was equipped with a wander guard monitor sensor and a code padlock. During an observation on 11/06/2024 at 11:15 a.m. of Door 5, Door 5 was located by Resident 1's room and led to the parking lot. The facility staff use Door 5 to enter and leave the building. Door 5 did not need a pass code to be open and to leave through the door one must press the push bar on the door for 15 seconds to unlock the door, and the alarm will sound for 15 seconds then shuts off. On 11/6/2024 at 12:41 p.m., during an interview with CNA 2, CNA 2 stated that staff are supposed to do a head count of the residents every two hours. CNA 2 stated that Resident 1 liked to use her wheelchair to wheel herself in the middle and around the building. CNA 2 stated that staff check the exits for wandering residents when they hear the alarms but there are alarms going off all the time in the facility, she was not sure if someone responded when Resident 1 left. On 11/6/2024 at 1:00 p.m., during an interview with LVN 2, LVN 2 stated that the Wander Guards are used for residents that attempt to elope. LVN 2 stated that the 3:00p.m. - 11:00 p.m. shift had checked the Wander Guards for function on 11/4/2024, and they were functional. During a telephone interview on 11/6/2024 at 1:40 p.m., CNA 1 stated she was Resident 1's nurse on 11/4/2024 from 3:00 p.m. to 10:30 p.m. CNA 1 stated she asked Resident 1 at 9:00 p.m., if she was ready for bed and Resident one refused. CNA 1 stated Resident 1 wanted to stay in her wheelchair which was very unusual. CNA 1 stated the last time she saw Resident 1 when she was sitting at the nursing station which is close to the employee entrance /exit. During an interview on 11/7/2024 at 4:58 p.m., the DON stated that the facility relied to much on the Wander Guard system to keep residents from eloping. The DON stated the facility should have also implemented additional interventions such as hourly monitoring of resident's whereabouts, designate staff to monitor the entrance and exits, and designated staff to monitor the hallways. The DON stated there was no documentation to indicate Facility staff were monitoring Resident 1, frequently. During a review of the facility's policy and procedure (P/P) titled Wandering Unsafe Resident undated, the P/P indicated the facility will identify residents at risk for harm because of unsafe wandering (including elopement) and staff will include a detailed monitoring plan, as indicated for residents who are assessed to have a high risk for elopement.

Based on observation, interview and record review, the facility's nursing staff failed to provide adequate supervision and adhere to its policy and procedure to ensure one of three sampled residents (Resident A) did not elope (leave without notice or authorization) from a secure facility (a facility type which limits the ability to wander into unsafe areas or outdoors). Resident A, was under a public guardian ([PG] a person appointed and responsible for the care of an individual who are no longer able to make decision or care for themselves) conservatorship (appointed by a legal process), was assessed to be at risk for wandering and elopement and was diagnosed with [CONDITION(S)] (having thoughts or ideas about the possibility of ending one's life). The facility failed to ensure: 1. The employee's door located between station B and C had a functional alarm and was armed every time employees passed through the door. 2. Resident A, who was assessed to have wandering behaviors and was at risk for elopement, had a wander guard device in place in accordance with the facility's policy titled Wander Guard - Equipment Monitoring and Resident A's Wandering Assessment Form. 3. The licensed nurses developed a plan of care for Resident A with interventions to address the resident's wandering behavior in accordance with facility's policy titled Wandering, Unsafe Resident. 4. The nursing staff monitored the resident's whereabouts closely and for the presence of a wander guard as indicated in the resident's care plan titled 48 Hour Baseline Care Plan. This deficient practice resulted in Resident A leaving the facility unsupervised and unbeknownst to the facility staff between 3 a.m. to 5 a.m., on 2/9/2022 through the exit door with a deactivated alarm. Resident A remains missing. This deficient practice had the potential to result in serious harm and/or death to Resident A related to his inability to care for himself and his [CONDITION(S)]. On 2/12/2022 at 4:35 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) due to the failure of the facility to ensure Resident A and other residents' safety by having the alarm on an exit door disactivated, through which Resident A eloped from the facility. On 2/15/2022, the facility submitted an acceptable IJ Removal Plan (IJRP). The IJRP included actions to ensure the facility's staff were responsible for securing the building doors, monitoring/supervising residents to prevent elopement, and monitoring/supervising residents with suicidal ideation as to prevent injuries. The IJRP included the following: 1. Resident A was no longer in the facility. 2. The DON and designee-initiated reassessment of residents at high risk of elopement/wandering. There were seven residents identified as high risk for elopement and wandering behavior. 3. The residents were checked for wander guard placement and their care plans were updated to reflect high risk for elopement and wandering and wander guard placement on 2/13/2022. 4. The DON initiated in-services with all licensed nurses on 2/12/2022 regarding identification of residents with high risk for elopement and wandering with emphasis on applying wander guard if applicable. The DON will provide in-service monthly for three months, and quarterly thereafter. 5. The Director of Staff Development (DSD) initiated an in-service of all Certified Nurse Assistants (CNA) on 2/12/2022 regarding identification of residents with high risk for elopement and wandering with emphasis on how to redirect residents when they are near the exit, wandering or attempting to elope. The DSD will in-service all CNAs monthly for three months and quarterly thereafter. 6. The DON initiated in-services of all licensed nurses on 2/12/2022, regarding developing a care-plan for residents who are at high risk for elopement and wandering and who require a wander guard. All care plans of the seven identified residents with a high risk for wandering and elopement and wander guards were reviewed and updated. The DON will in-service licensed nurses monthly for three months and quarterly thereafter. 7. The facility is in the process of installing cameras at all exits in the facility. The maintenance staff will install cameras for all exit doors at Stations A, B, and C, the front lobby, the exit door in the hallway between Stations A and B, and the exit door in the hallway between Stations B and C. The cameras will be purchased on 2/16/2022 and installation is to begin on 2/16/2022 with a projected completion date of 2/18/2022. The cameras will be up and running on 2/18/2022, and the camera activity will be monitored by the RN Supervisor, ADM, and the DON. 8. The facility implemented a system for checking residents with a wander guard device to ensure they are on and functioning. The licensed charge nurses will check residents with wander guards each shift (6:30 a.m.- 3 p.m., 2:30 p.m.- 11 p.m., and 10:30 p.m.- 7 a.m.) to ensure the wander guard devices are in place, and document in the residents' Medication Administration Record (MAR) during all three shifts. The RN Supervisor or designee will test all wander guard devices with the wander guard tester for proper functioning daily, during the 6:30 a.m.- 3 p.m. shift and as needed. If the wander guard is not functioning, the RN supervisor will replace the existing wander guard with a new one and document on the Wander Guard Monitoring Log effective 2/14/2022. 9. The maintenance staff inspected all exit door alarms, which included: Station A, Station B, Station C, Front Lobby, the exit door in the hallway between Stations A and B, and the exit door in the hallway between stations B and C. No alarms were found to be malfunctioning on 2/14/2022. 10. The ADM in-serviced the maintenance staff regarding inspecting the door alarms weekly and as needed and to report any malfunctioning alarm immediately. The ADM will in-service the maintenance staff monthly for three months and quarterly thereafter effective 2/14/2022. 11. The maintenance staff will inspect all exit door alarms for proper functioning weekly and as needed and record the findings on the Door Alarm Monitoring Log. The maintenance staff will report findings to the ADM immediately for an immediate corrective action. 12. The DSD in-serviced all staff on 2/13/2022 regarding alarm activation on all exit doors. The alarm located in the hallway between Stations B and C will be activated between the hours of 7 p.m. and 6:30 a.m. The alarm located in the front lobby will be activated between the hours of 7 p.m. and 8:30 a.m. All other exit door alarms will always remain activated. The RN supervisor and/or designee will include checking of the doors during staff routine rounds at the start of every shift. The DSD will in¿service all staff monthly for three months and quarterly thereafter. 13. During the hours when the alarm is activated on the exit door located between Stations B and C, the RN Supervisor and maintenance staff will be the only staff with a key to turn the alarm on and off. All staff who need to enter and exit the facility will have to call the RN Supervisor to turn he alarm on and off to enter or exit through that door. A wander guard alarm will be installed at the exit door in the hallway between Stations B and C. The projected installation date will be 2/18/2022. The wander guard alarm will be up and running on 2/18/2022. 14. The alarm on the exit door located between Stations A and B will be always activated. It is currently used as a red zone (for COVID-19 [highly contagious virus]) entrance and exit. The RN Supervisor and the maintenance staff will be the only staff with a key to turn the alarm on and off. The exit door located in the hallway between Stations A and B is equipped with a magnetic locking mechanism that requires a key to deactivate the magnet and open the door. Additionally, the exit door located in the hallway between Stations A and B will be equipped with an alarm. A wander guard alarm will be installed at the exit door in the hallway between Stations A and B with the projected installation date will be 2/18/2022. The wander guard alarm will be up and running on 2/18/2022. 15. Residents headcount and routine check/care rounds will be done by CNAs at the beginning of each shift, every two hours, and at the end of the shift to prevent residents' elopement and other accidents/incidents. 16. On 2/24/2022, the DON and designee reviewed all present residents' medical records for diagnosis of suicidal ideation. No other residents were identified to have diagnosis of suicidal ideation. Initiated 2/14/2022 and ongoing. On 2/15/2022, after an onsite verification and confirmation via observation, interview, and record review to ensure the IJPR was implemented, the ADM was notified the IJ was removed on 2/15/2022 at 6:50 p.m. Findings: During a review of Resident A's Admission Records (Face Sheet), the Face Sheet indicated Resident A was admitted to the facility on [DATE] with diagnoses including metabolic [CONDITION(S)] (a chemical imbalance in the brain), [CONDITION(S)] (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), major depressive disorder (depressed mood with loss of interest causing an impairment in daily life), [CONDITION(S)] (an abnormal condition of the mind that results in difficulties in telling what is real), lack of coordination, and extrapyramidal ([EPS] a condition that causes involuntary muscle movements or spasms that usually occur in the face and neck [usually as a result of taking anti-psych medications). During a review of Resident A's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 2/2/2022, the MDS indicated Resident A was able to make independent decisions that were reasonable and consistent. According to the MDS, Resident A required a limited one-person physical assist to walk in his room, the corridors, and on and off the unit. During a review of Resident A's Initial Wandering assessment dated [DATE], the assessment indicated Resident A was a new admission and ambulated independently with a fluctuating mental status, which met the criteria for 'At risk for Wandering' and required Resident A to be placed on 'Wander Risk' precautions. Further review of the Wandering Assessment Form indicated Resident A was at risk for elopement and the interventions to ensure the resident's safety included personal safety alarm devices, frequent monitoring, identification bracelet, recreational activities, music, and exercise. The Summary/Conclusions/Recommendations section of the Wandering Assessment form indicated to apply a wander guard alarm to alert staff when Resident A attempts to get out of the building unassisted. During a review of Resident A's clinical records there was no documented evidence Resident A had a wander guard alarm in place, a care plan for the wander guard use and evidence it was monitored, as per the assessment. During a review of Resident A's Interdisciplinary ([IDT] group of health care professionals working in a coordinated fashion toward a common goal for the residents) Meeting/Care Conference, dated 12/31/2021, the IDT meeting note indicated prior to admission to the facility on [DATE] Resident A was placed on a 5150 hold (involuntary legal hold in a psychiatric hospital for up to 72 hours due to a danger to self or others) for endangering others safety, threatening to kill and strike random people using his fist with a great force with a strong intent to kill them without any provocation (action that makes someone annoyed or angry). According to the IDT note, Resident A refused to contract for safety (an agreement between the patient and clinician whereby the patient agrees not to harm themselves). During a review Resident A's Licensed Nurses Notes (LNN), dated 1/7/2022 and timed at 1:30 p.m., indicated Resident A was observed with increase agitation, pacing, refusing medications, smoking everywhere in the facility including his room near oxygen concentrator (a device which helps to concentrate the room air into pure, medical grade oxygen). The note indicated Resident A was unable to be redirected, and the resident's physician was called, and an order obtained to transfer Resident A to a general acute care hospital (GACH) for a psychiatric evaluation (to diagnose problems, thought processes and behaviors). During a review Resident A's Mental Status Examination note from the GACH, dated 1/8/2022, indicated Resident A was very agitated, very disheveled (appearance untidy and disorderly), very anxious and paranoid, thought process was disorganized and tangled and the resident's speech was very disorganized. Resident A's attention and impulse control were extremely poor, his concentration, judgement and insight were poor. According to the Mental Status Examination note from the GACH, listed under suicidal/homicidal findings, Resident A was assessed to have [CONDITION(S)] with intent to overdose and jump out into traffic along with homicidal ideations with intent to become aggressive toward staff and others. According to the GACH records, Resident A was transferred back to the facility on [DATE]. During a review of Resident A's Initial Wandering Assessment form upon readmission, dated 1/25/2022, the assessment indicated Resident A ambulated independently with a fluctuating mental status which met the criteria for 'At risk for wandering' requiring Resident A to be placed on 'Wander Risk' precautions. According to the form titled, Elopement Risk Assessment the following interventions were documented to ensure the resident's safety: personal safety alarm devices, picture in the MAR/chart, frequent monitoring, identification bracelet, recreational activities, music, and exercise. The Summary/Conclusions/Recommendations section was left blank. During a review of Resident A's care plan titled 48 Hour Baseline Care Plan, dated 1/25/2022, indicated Resident A was an elopement risk. The goal was for Resident A to have no elopement incidents and the interventions were to monitor the resident's whereabouts closely and for him to have a wander guard. During a review of Resident A's LNN, dated 2/9/2022 and timed at 12 a.m., indicated Resident A was sleeping. At 12:30 a.m. on 2/9/2022, Resident A was seen ambulating around the halls talking to himself. On the same day at 1 a.m., the Resident A was seen following another resident on Station A asking for cigarettes. The LNN indicated attempts were made to redirect Resident A to his room, but he refused to go. According to the LNN, Resident A continued to ambulate along the hallway talking to himself. At 3:15 a.m. on 2/9/2022, a CNA (CNA 2) reported Resident A was still not back in his room. According to LNN a thorough search to locate Resident A was done including inspection of every room, smoking patio, parking lot, outside the facility and all resident's windows, but Resident A was nowhere to be found. During an interview on 2/9/2022 at 5:28 p.m., the Infection Preventionist Nurse ([IPN] a professional who ensures the staff are following procedures to prevent the spread of infections) stated Resident A has been at the facility for a couple of months and was alert to his name, could answer simple questions, and was able to make his needs known. The IPN stated Resident A was transferred to a GACH on 1/7/22 for evaluation and treatment related to behaviors and was readmitted to the facility a couple of weeks prior to the resident's elopement. The IPN stated Resident A had a steady gait (the way a person walks) and usually walked around the facility going from his room to the smoking patio. The IPN stated at approximately 5 a.m., on 2/9/2022 it was reported to the DON that Resident A was missing. The IPN stated the facility's staff searched inside and outside of the building, but did not locate Resident A. The IPN stated the facility does not have cameras inside the building, but the staff thought Resident A must have left the building through the exit door the staff use to enter/exit the building. The IPN stated all doors in the facility have an alarm that should be activated/turned on before 7 p.m. During a tour of the facility on 2/9/2022 at 5:50 p.m., accompanied by the IPN and Registered Nurse Supervisor 1 (RN 1), all entrance/exit doors in the facility were observed with a red alarm box and a keypad. Concurrently, during the tour of the facility, a test of the alarm system was conducted by having the entrance/exit doors pushed open. As doors were pushed open, after approximately 10 seconds, a loud alarm sounded. The staff, who were not aware that a test of the alarm system test was being conducted, came to the site of the activated alarm door. The door where the staff enter/exit was located between Stations B and C near the kitchen, down a corridor that was isolated from residents' rooms and residents' traffic. The staff entrance/exit door was observed with a red alarm box and keypad, which required a code to enter/exit. The code was entered into the keypad and the door opened without an alarm sounding. During an interview on 2/9/2022 at 6:05 p.m., RN 1 stated all staff have the code for the keypad and used it to enter/exit the door. RN 1 stated she has never turned on the alarm to the staff's door during her shift (3 p.m. to 11 p.m.). RN 1 stated the door usually would close itself without an assistance and would latch close. On 2/9/2022 at 6:10 p.m., during an observation of the area just outside the staff entrance/exit door located between Stations B and C was a horizontal guardrail that led to a 2-to-3-foot drop into a ravine (a deep small narrow valley with steep sides) covered with brush, dirt, and trees leading directly to a busy highway. During a telephone interview on 2/12/2022 at 6:16 p.m. the ADM stated staff uses a code to enter/exit the employee door. The ADM stated Resident A may have been hiding out by the staff door waiting for an opportunity to leave the facility. The ADM stated the keypad on the door deactivates the magnet, which allows the door to open, and a key is used to deactivate the alarm. The ADM stated the alarm should be activated/turned on by 7 p.m. every evening. The ADM stated the facility does not have cameras and there was no wander guard alarm (design to prevent residents from eloping by alarming when near an exit door) on the employee entrance/exit door. The ADM stated the RN supervisors on each shift are the only ones who have a key to turn the alarms on/off. During an observation on 2/12/2022 at 6:40 p.m., Dietary Staff 1 (DS 1) was observed entering a code into the keypad of the employee's door. DS 1 then opened the door to its fullest range, and did not look back or around, to determine if any residents were in the vicinity. DS 1 continued to walk out of the door to his destination without ensuring the door was closed. DS 1 walked out of the employee's door leaving the door to close itself. After an approximate 10-seconds the door was observed closed and latched. During an interview on 2/12/2022 at 6:45 p.m., DS 1 stated he should have looked around to make sure there were no residents near the door exit/entrance before he entered the code to open the door and should have made sure the door was closed after he walked out the building. During an interview on 2/12/2022 at 8:47 p.m., and a subsequent interview the same day, at 9 p.m., the DON stated after reviewing Resident A's care plans, she could not find a care plan to address the resident's risk for elopement or wandering behavior. The DON stated she was not aware if Resident A had a wander guard in place because the facility did not use a log to document if a resident had on a wander guard each shift and/or if it was functioning properly. The DON stated if Resident A was assessed as being at risk for wandering/elopement he should have had a wander guard in place. During an interview on 2/12/2022 at 9:38 p.m., CNA 1 stated she was in the hallway on Station A near Rooms 2, 3, and 4 at approximately 11:30 p.m., on 2/8/2022 when she saw Resident A walking around going toward the smoking patio. CNA 1 stated Resident A was wearing a blue shirt and blue pants the last time he was seen. CNA 1 stated she was not sure if Resident A had on shoes and/or a wander guard. During an interview on 2/12/2022 at 9:49 p.m., CNA 2 stated she was assigned to Resident A on the night of 2/9/2022 and saw him going to the smoking patio around 12 a.m. CNA 2 stated the last time she saw Resident A was at approximately 1 a.m., in the bathroom. CNA 2 stated Resident A was wearing a blue shirt, blue pants, socks, and no shoes and she was not sure if he had on a wander guard. CNA 2 stated Resident A always walks inside throughout the building (circling the building) and goes from his room to the smoking patio. CNA 2 stated when she went to look for him and could not find him, she thought maybe the resident was going around the building and reported to the Licensed Vocational Nurse 1 (LVN 1), the nurse in charge. CNA 2 stated she and LVN 1 searched for Resident A and could not find him anywhere. During an interview on 2/12/2022 at 9:56 p.m., CNA 3 stated she clocked in approximately 10:30 p.m. on 2/8/2022 and saw Resident A walking toward the smoking patio. CNA 3 stated the resident was wearing green socks that were slipping off his feet and no shoes. CNA 3 stated she was assigned to Station C; however, she could see Resident A on Station A walking around. CNA 3 stated the last time she saw Resident A was approximately 1 a.m., on 2/9/2022, walking by the smoking patio. During an observation with the DON on 2/12/2022 at 10:30 p.m., employees were observed entering through the staff entrance/exit door using a code entered into the keypad. The alarm did not sound when the door was opened by the staff. During a telephone interview on 2/15/2022 at 1:47 a.m., RN 2 stated Resident A ambulated well and walked around the facility laughing and talking to himself. RN 2 stated usually when he arrives to work, he checks all the doors to make sure all the alarms are turned on. RN 2 stated the alarm on the employee entrance/exit was not turned on because of the high staff traffic through that door. RN 2 stated the staff enter a code into the keypad to enter the building through the employees' entrance/exit. RN 2 stated there are staff who go to their cars for their break during the night and Resident A may have left the building during one of those times. During a telephone interview on 2/15/2022 at 2:03 a.m., LVN 1 stated after clocking in on 2/9/2022 she did her rounds and saw Resident A lying in his bed asleep with the room light on. LVN 1 stated at 12 a.m., on 2/9/2022, Resident A was still in bed. LVN 1 stated at 12:30 a.m., she saw Resident A walking by Station A down the hallway. LVN 1 stated at 1 a.m., she saw Resident A walking behind a resident who was in a wheelchair asking him for cigarettes. LVN 1 stated she told Resident A to go back to bed, but he ignored her and kept walking. LVN 1 stated she went on break around 2:45 a.m., and when she returned from break, CNA 2 reported to her that she could not find Resident A. LVN 1 stated all staff checked everywhere and could not find the resident, she (LVN 1) reported he was missing to the DON. During a review of the facility's policy and procedure (P/P), dated 12/2002 and titled, Wandering, Unsafe Resident, the P/P indicated the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. During a review of the facility's undated P/P titled, Wander Guard - Equipment Monitoring, the P/P indicated the facility would strive to prevent unsafe wandering with frequent monitoring of the equipment that alerts staff to potential elopement by residents (e.g., wander guard). The Nursing staff will use a list of residents using the wander guard as per the physician's order to inspect each wander guard/bracelet as working properly. According to the P/P, the Nursing staff will keep a log of each inspection.

Based on interview and record review, the facility failed to ensure a resident received the necessary care and services and follow the physician's orders, which included STAT (immediate) laboratory test orders, (which included a STAT (immediately) complete blood count ((CBC) a blood test to detect disorders such as, [MEDICAL CONDITION] (low blood) infection) and resident's plan of care for one of two sampled residents (Resident 1). Resident 1, who had a change of condition, which included poor appetite, fever (elevated body temperature) and a decreased oxygen saturation (low oxygen level in the blood). This deficient practice resulted in a 48-hour delay in [DIAGNOSES REDACTED]. Resident 1 was diagnosed with [REDACTED].). Resident 1 was hospitalized for [REDACTED]. Findings: A review of Resident 1's Admission Record (face sheet), indicated Resident 1 was admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Advance Directives (a written statement of a person's wishes regarding medical treatment), dated and signed by Resident 1's family member (FM 1) on [DATE] indicated for the resident not to receive resuscitation (lifesaving measures), but may be hospitalized . A review of Resident 1's Physician Orders for Life-Sustaining Treatment ((POLST) a physician order that outlines a plan of care reflecting a resident's wishes concerning care at end of life), dated and signed by Resident 1's physician on [DATE]. The POLST indicated for Resident 1 not to receive cardiopulmonary resuscitation ((CPR) prolonging life by all medically effective means) but to receive comfort measures, such as pain medications and a transfer to a GACH. A review of Resident 1's revised care plan, dated [DATE] and titled, Resident is a Do Not Resuscitate ((DNR) do not provide treatment for [REDACTED]. A review of Resident 1's revised care plan, dated [DATE] and titled, Resident is at risk for compromised health condition associated by [MEDICAL CONDITION] following [MEDICAL CONDITION] of the left non-dominant side, indicated for the staff to obtain Resident 1's vital signs (measurements which includes body temperature, blood pressure, pulse (heart rate), and respiratory rate), observe changes in condition and notify the physician accordingly. A review of Resident 1's revised care plan, dated [DATE] and titled, Resident has potential for shortness of breath (SOB), chest pains, irregular heart rate, and elevated blood pressure related to compromised (weaken) cardiac (heart) function associated with heart failure, indicated for the staff to observe Resident 1 for episodes of SOB, chest pains, monitor the resident's heart rate and blood pressure and notify Resident 1's physician accordingly. A review of Resident 1's Interdisciplinary Team ((IDT) a group of professionals working toward a resident's goals) note, dated [DATE] indicated Resident 1 was alert and oriented to name, but with confusion and forgetfulness. The IDT note indicated Resident 1 required an extensive to total assistance with activities of daily living ((ADL) routine activities that are done every day such as: eating, bathing, dressing, toileting, transferring and walking). A review of Resident 1's physician monthly physical examination, dated [DATE] indicated Resident 1 spoke clearly, was confused with spurts of yelling out and agitation (feeling or appearing troubled or nervous) as reported by the staff. A review of a Situation, Background, Assessment and Recommendation ((SBAR) an internal communication tool) form, dated [DATE] indicated Resident 1 had a poor oral intake and generalized weakness. The SBAR indicated Resident 1's physician was notified at 12:35 p.m. and orders were obtained for Resident 1 to have a CBC, comprehensive metabolic panel ((CMP) a blood test to determine body's fluid balance and check kidneys and liver function) and a urinalysis ((UA) a urine test to assess all range of disorders including infection). A review of Resident 1's nurses' note, dated [DATE] and timed at 2 p.m. indicated Resident 1 had verbalized weakness, with a poor oral intake, tolerating 50 percent (%) of lunch and Resident 1's blood pressure was ,[DATE] millimeters of mercury (mmHg), (Normal Reference Rate (NRR) ,[DATE]- ,[DATE] mm/hg) and the physician was notified. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's nurses' notes, dated [DATE] and timed at 6:30 p.m. indicated Resident 1 was assessed as being warm to touch, responsive to verbal and tactile stimuli (the ability to sense touch). A review of Resident 1's physician's orders, dated [DATE] and timed at 7:30 p.m., indicated an order for [REDACTED]. A review of Resident 1's nurses' notes, dated [DATE] and timed at 7:30 p.m., indicated Resident 1 received cooling measures that were effective with a body temperature decreased to 99.0 degrees Fahrenheit ((F) a temperature scale) (NRR= 97XXX,[DATE].0 F), the staff placed a call to the contracting laboratory regarding Resident 1's STAT labs and a message was left on the laboratory's afterhours line. A review of Resident 1's nurses' note, dated [DATE] and timed at 10:25 p.m., indicated the staff received an order from a Physician's Assistant ((PA) a health care practitioner who practices medicine under the supervision of a physician) to transfer Resident 1 to an urgent care center (treats injuries or illnesses requiring immediate care but not serious enough for an emergency department (ED) visit) (located 29 miles from the facility). The nurses' note indicated the staff was waiting a bed availability from the urgent care center for Resident 1. A review of Resident 1's nurses' note, dated [DATE] and timed at 11:45 p.m. indicated Resident 1's body temp was 98.9 F, received cooling measures and was easily arousable to verbal stimuli. The nurses' note indicated there was no available beds for Resident 1 at the urgent care center located 29 miles from the facility. A review of Resident 1's nurses' note, dated [DATE] and timed at 3 a.m. indicated no bed availability for Resident 1 at the urgent care center located 29 miles from the facility. A review Resident 1's nurses' note, dated [DATE] and timed at 6:30 a.m. indicated Resident 1's oxygen saturation ((O2) amount of oxygen in the blood) was 90%, (NRR ,[DATE]%) and was receiving two (2) liters of oxygen by nasal cannula (tube though the nose) and was easily arousable to verbal stimuli. A review of an online article by the American Red Cross indicated an oxygen saturation rate of ,[DATE] % is indicative of mild [MEDICAL CONDITION] (not enough oxygen supply). https://www.redcross.org/content/dam/redcross/atg/PDF_s/AdministeringEmergencyOxygenFactandSkill.pdf A review of Resident 1's nurses' note, dated [DATE] and timed at 8 a.m. indicated Resident 1 was observed with a blank stare (without expression) and was not responsive to verbal and tactile stimuli. The nurses' note indicated Resident 1 had labored breathing (abnormal and increased effort to breathe), a heart rate of 130 bpm (NRR= ,[DATE] bpm), received an increased amount of oxygen at four (4) liters of oxygen via nasal cannula. The nurses note indicated Resident 1 was transported by the paramedics to the GACH on [DATE] at 8:20 a.m. (sic) A review of Resident 1's transfer record, dated [DATE] indicated Resident 1 was transferred from the facility to the GACH at 8:20 a.m. (sic). The transfer record indicated Resident 1's baseline mental status was oriented x1, verbally aggressive and a handwritten notation as lethargic, but a line was drawn through the word lethargic. A review of Resident 1's paramedic run sheet, dated [DATE] indicated the paramedics arrived to the facility on [DATE] at 8:33 a.m., and Resident 1's heart rate was elevated at 130 bpm, was in respiratory distress and received two (2) doses of [MEDICATION NAME] (medication that relaxes muscles in the airways and increases air flow to the lungs) 5 mg inhaler (medical device used for delivering medication into the lungs) for rales (rattling sound heard in the lungs) and rhonchi (continuous low pitched, rattling lung sounds that resemble snoring). The paramedic run sheet indicated Resident 1 had a Glasgow Coma Scale ((GCS) an assessment used to determine level of consciousness (alertness/function)) of 10. According to the GCS, a score of 15 is normal and a score between ,[DATE] is indicative of moderate brain damage. A review Resident 1's GACH Emergency department (ED) H/P, dated [DATE] indicated Resident 1 had altered mental status and was lethargic (state of tiredness, weariness, fatigue, or lack of energy) and weak. The H/P indicated Resident 1 had pyuria (pus in the urine) with slightly cloudy urine and an elevated WBC of 24.5 per microliter (uL) (NRR =levels 4.50 -10.00). The ED 's H/P, Resident 1 was given an antibiotic via intravenous (into the veins). On [DATE] at 1:30 p.m., Resident 1's family member 1 (FM 1) stated Resident 1 was verbal until she became ill on [DATE] on the 3 p.m. to 11 p.m. shift. FM 1 was crying and stated on [DATE], she received a call from the staff indicating they were going to transfer Resident 1 to a GACH in another city on a non-emergency basis. FM 1 stated Resident 1 was not eating well, the facility failed to properly assess Resident 1 after emergency labs were drawn and were abnormal. FM 1 stated Resident 1 was transferred to the GACH on [DATE] at 8 a.m. and upon her arrival to the GACH, the physician indicated Resident 1 was bad, had a stroke, MI, was dehydrated (excessive loss of body water), blind (loss of sight) in one eye and could not talk anymore. FM 1 stated Resident 1 expired (died ) 17 days later. On [DATE] at 9:18 a.m., during an interview, Registered Nurse Supervisor 1 (RNS 1) stated Resident 1 was usually alert to her name, able to identify her family and had behaviors of yelling and screaming. RNS 1 stated on [DATE] she received a report from the previous shift (RNS 1) of Resident 1 was reported as being okay. RNS 1 stated on [DATE] she observed Resident 1 slightly slumped over with her eyes opened and was not verbally responsive and had a fixed upward stare. RNS 1 stated on the same day, [DATE] approximately 7:30 a.m., Resident 1 had a change of condition (COC) and the paramedics were called. RNS 1 stated an endorsement from the previous shift indicated Resident 1 had a poor appetite, had some changes, and an elevated body temperature. RNS 1 stated according to the previous nurse's endorsement Resident 1's physician was notified and Resident 1's condition was stable. RNS 1 asked the previous shift RNS (RNS 2) why the paramedics was not called for Resident 1. RNS 1 stated RNS 2 told her she wanted to wait and endorse calling an ambulance for Resident 1, to the oncoming shift because Resident 1 was not in any distress (sic). On [DATE] at 1:20 p.m., during a concurrent interview and nurses' notes from ,[DATE] to ,[DATE], RNS 1 stated Resident 1 had a COC on [DATE] due to having a poor intake and was being monitored. RNS 1 stated Resident 1 did not have the STAT labs drawn per the physician's order dated on [DATE]. On [DATE] at 1:49 p.m., during a telephone interview, Certified Nursing Assistant 1 (CNA 1) stated he no longer worked at the facility. CNA 1 stated he was assigned to Resident 1 on [DATE] on the 11 p.m. -7 a.m. shift and stated Resident 1 had lost a lot of weight. CNA 1 stated Resident 1 was alert to her name, but on [DATE], close to the end of the shift (7 a.m. on [DATE]), he informed the charge nurse that something was different with Resident 1 and she had a fever. CNA 1 stated the next day, on [DATE] at 11 p.m. when he returned to work, Resident 1 had been sent out to the hospital. On [DATE] at 2:58 p.m. and [DATE] at 12:41 p.m. several attempts were made to contact the PA for an interview, who gave a verbal order to transfer Resident 1, who had a change of condition, 29 miles away from the facility to an urgent care. On [DATE] at 3:08 p.m., during an interview, RNS 2 stated in the month of ,[DATE], Resident 1 was being monitored for a previous COC and her condition was stable. RNS 2 stated she could not recall if Resident had a fever in the month of ,[DATE]. On [DATE] at 3:48 p.m., during a concurrent interview and record review of Resident 1's nurses' notes, Licensed Vocational Nurse 1 (LVN 1) stated on [DATE] between the hours of 3 p.m. to 11 p.m., she was called into Resident 1's room by a CNA. LVN 1 stated on the same day ([DATE]), Resident 1 was not eating, but was able to take her medications with sips of water. LVN 1 stated Resident 1 was usually alert and would answer to her name, but on [DATE], Resident 1 appeared to be asleep and had a low-grade body temperature. LVN 1 stated on [DATE] at 7:30 p.m., she called Resident 1's physician, obtained orders from the PA for STAT labs. LVN 1 stated she left a message on the laboratory's answering service, but no one returned her call for the STAT lab work ordered for Resident 1. LVN 1 stated the laboratory technician would usually come to the facility and collect the resident's lab work. LVN 1 stated Resident 1's STAT labs for a CBC, CMP and a urinalysis C/S was not collected. LVN 1 stated Resident 1 had a low-grade body temperature of 99.0 F and cooling measures (applying ice packs, a cool blanket or a cool bath) were performed on Resident 1. LVN 1 stated Resident 1 would normally yell and cry, but on [DATE], Resident 1 was quiet. On [DATE] at 10:20 a.m., during an interview, RNS 2 stated she worked in the facility on [DATE] on the 11 p.m. to 7 a.m. shift on [DATE]. RNS 2 stated on [DATE], Resident 1 could not speak, but was in stable condition. RNS 2 stated Resident 1's vital signs were normal and was not in any distress. RNS 2 stated Resident 1 had a poor appetite and was waiting for bed availability at a hospital in another city. RNS 2 stated she could not recall assessing Resident 1's breath/lung sounds at the time of her assessment, but stated Resident 1 was arousable and there was not anything different about Resident 1. RNS 2 stated on the morning of [DATE] between the time of 7 a.m. to 7:30 a.m. she conducted rounds with the oncoming RNS (RNS 1) and she observed Resident 1 not being in any distress. RNS 2 stated a change of condition was completed when a resident had a new issue and the resident would be monitored for 72 hours. RNS 2 stated Resident 1 was being monitored for a poor appetite. A review of the facility's revised policy and procedure dated 2019 and titled, Verbal Orders, indicated the physician orders may be received by telephone by a licensed nurse or other licensed or registered health care specialist in their own area of specialty. The policy indicated for the staff to use clarification questions to avoid misunderstandings and to follow through with orders by making appropriate contact or notification. A review of the facility's revised policy and procedure dated 2019 and titled, Care Plans Comprehensive indicated care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. A review of the facility's undated policy and procedure titled, Making an Emergency Transfer or Discharge, indicated the facility shall make an emergency transfer or discharge when it is in the best interest of the resident.

Based on interview and record review, the facility failed to follow its policy, resident's plan of care and the physician's order to provide the necessary care and services for the prevention of the development of pressure ulcers for one of two sampled residents who was admitted without a pressure ulcer (Resident 1). Resident 1 developed a sacral (tailbone) Stage III pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (a dry, dark scab or falling away of dead skin)) and ulceration and skin loss of the scrotal (part of the male external genitalia) area, which included accurately assessing for the risk for pressure ulcer development and the use of pressure relieving. These deficient practices resulted in Resident 1 developing two pressure ulcers, delayed in care of the pressure ulcers and the resident being transferred to a general acute care hospital (GACH) due to an elevated body temperature and requiring extensive wound care treatment and antibiotics (used to treat infections). Findings: A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated 8/3/14, indicated a brief interview for mental status (BIMS) score of 4 (0-7 severe impairment), which indicated that Resident 1 had problems remembering and cognition (thought process). The MDS indicated Resident 1 required extensive assistance of one staff member for physical assistance in bed mobility, personal hygiene, and toilet use. The MDS indicated Resident 1's range of motion was impaired at bilateral (relating to two sides) upper and lower extremities and Resident 1 was always incontinent of bladder and bowel (no voluntary control for urination and/or bowel movements). MDS indicated Resident 1 was at risk for developing pressure sores and had no current unhealed pressure ulcers. A review of Resident 1's Nursing Admission Assessment, during for the re-admission, dated 3/10/14 indicated there was no documentation Resident 1 had any pressure sores upon re-admission. A review of the Resident 1's Braden Scale (assessment tool for predicting pressure sore risk), dated 11/7/13 through 2/4/14, indicated Resident 1 had a score of 15. According to the scale, a total score of 15-18 indicated the resident was at mild risk of developing a pressure sore. A review of Resident 1's care plan titled, Decubitus (bedsores) Risk, dated 3/10/14, indicated that the resident would not develop decubitus ulcers for the next three months. The staff's interventions included to check for skin sores, breakdowns, and reddened areas, and use pressure reducing devices and notify the physician of any changes. A review of the Nurses Progress note, dated 3/22/14, and timed at 9 a.m., indicated that a staff reported to the charge nurse that Resident 1 had redness to the scrotal and coccyx (tailbone) areas. A review of Resident 1 physician's orders, dated 4/18/14, a month after readmission, indicated to continue with the treatment to the coccyx (tailbone) area and scrotal area redness with soap, water and zinc oxide (ointment use to treat minor skin irritations) every day and as needed for 30 days. A review of Resident 1's physician progress notes [REDACTED]. The physician's note indicated for the staff to plan for regular hygienic care and apply [MEDICATION NAME] (antibiotic to prevent infections of minor cuts, burns, and scrapes) ointment twice a day for two weeks and to follow-up in six weeks at the clinic. A review of the physician's orders, dated 4/22/14 through 7/2014, did not include the physician's order for [MEDICATION NAME] application for two weeks. A review of Resident 1's short-term care plan titled, Redness/irritation to scrotal area, dated 7/9/14, indicated to keep the area clean and dry after each incontinence, and continue with previous treatment of [REDACTED]. A review of Resident 1's daily flow sheets, dated 6/2014 through 7/2014, indicated the resident had two to three episodes of bladder incontinence a day. A review of Resident 1's physician order, dated 7/22/14, indicated to continue with the treatment to scrotal area redness and irritation with soap, water and zinc oxide twice a day and as needed for 30 days. On 12/22/16 at 11:19 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that wound consults are ordered when the current treatment plans do not have positive results. LVN 1 stated that resident's wound changes are documented on the Skin Integrity Form. At 11:45 a.m., on 12/22/17, during an interview, the medical records director (MRD) stated she was unable to locate Resident 1's Skin Assessment Records, laboratory results, and the certified nurse assistants (CNAs) shower documentation records for 2014. A review of Resident 1's physician orders, dated 8/3/14, and timed at 8:45 p.m., indicated to transfer resident to the nearest GACH's Emergency Department (ED) for further evaluation of a fever of 101.7 (normal reference range (NRR 97.7-99.5)) and cough and congestion. A review of the Emergency Department Course, dated 8/3/14 indicated that Resident 1 was started on two antibiotics of [MEDICATION NAME] one gram and Azithromacycin 500 milligrams intravenously ((IV) into the vein) related to the cough and congestion. A review of the Resident 1's Photographic Wound Record, from the GACH, dated 8/6/14, indicated Resident 1 had several unstageable wound ulcers (unable to stage) to the sacrum, left foot, and scrotum. The pictures indicated Resident 1 had an unstageable sacrum ulcer that was red on the edges and had dark eschar (a slough or piece of dead tissue that is cast off from the surface of the skin), the left foot ulcer had discolorations of dark purplish observed on the inner side of the left foot, and unstageable scrotum ulcer was red in color with skin loss around the front side of the scrotum covering 70 percent (%) with dry eschar. A review of the GACH's Consultation Report, dated 8/7/14, indicated Resident 1 was admitted to the hospital with [REDACTED]. A review of Resident 1's GACH basic metabolic panel ((BMP) a chemistry blood test) from the GACH, dated 8/7/14, indicated Resident 1's [MEDICATION NAME] (protein made by the body) was low at 3.2 gram per deciliter (g/dl)) (NRR is 3.5-5.7 g/dl) and a total protein level was low at 6.2 g/dl (NRR 6.4-8.9). According to the National Pressure Ulcer Advisory Panel (NPUAP), low serum [MEDICATION NAME] and protein puts residents at a higher risk of developing pressure ulcers, because poor nutritional status was a contributing factor in pressure sore development and impaired wound healing. www.npuap.org A review of the skilled nursing facility (SNF), Admission Body Assessment, dated 8/11/14 indicated Resident 1 was readmitted after a five day hospital stay with a scrotal wound measuring eight (8) centimeters (cm) by nine (9) cm and a coccyx wound measuring 3 cm x 2cm x unstageable. On 11/16/17 at 6:55 a.m., during a telephone interview, the Director of Nursing (DON) stated that scrotum pressure sores could develop due to poor genital hygiene and incontinence. The DON stated that offloading (transfer, shift, move) residents, skin assessments, low-air-loss mattress, and wheelchair cushions (pressure relieving devices) can prevent pressure sores. The DON stated that the physicians' orders should be carried-out immediately. On 11/16/17 at 7:19 a.m., during an interview and record review, LVN 1 stated that Resident 1's scrotal redness developed due to poor hygiene. LVN 1 stated after reviewing the clinical record that no orders were found for the use of pressure reducing devices for Resident 1 from 3/2014 through 7/2014 according to facility's policy and procedures for pressure sores. On 11/16/17 at 7:30 a.m., during an interview and record review, the MRD stated that there were no skin assessments found for Resident 1 from 5/2014 through 7/2014 in the clinical record. The MRD also stated that there were no records found to indicate a wound care specialist visited the resident during that same time period. On 11/16/17 at 8:29 a.m., during an interview, the Administrator (ADM) stated that he was not sure why the skin assessments, laboratory results, and wound consultant assessments for Resident 1 were not located. The ADM stated that he was aware that when treatments are not documented, it means they were not done. A review of facility's policy and procedure, titled Pressure Ulcer Risk Assessment, revised 10/2010, indicated that the staff would monitor residents' skin for the presence of developing pressure ulcers on a weekly basis or more if indicated. The policy indicated that residents [MEDICAL CONDITION] were at a higher risk for pressure ulcer development. A review of facility's policy and procedure, titled Prevention of Pressure Ulcers, revised 10/2010 indicated to provide residents' with special mattress containing foam, air, gel, or water as needed. The policy also indicated for the staff to routinely assess and document the condition of the resident's skin and report immediately any signs of a developing pressure ulcer to supervisor.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to three of 24 sampled residents (Residents 2, 4, 17) and two randomly selected residents (Residents 25 and 26). 1a. Resident 17, who was identified by the facility having delusions (false unrealistic belief) and suicidal thoughts due to depression, was not re-evaluated for his ability to make a decision for himself and of being self -responsible to determine the safety and appropriateness of going out on pass or leaves of absence since his readmission on 6/29/15. b. Resident 17 was permitted to go out on pass with a responsible party. However, the resident did not have a responsible party or family members and was allowed to leave the facility unsupervised. c. The facility did not develop a policy and procedure to guide the facility on what measures to take if a resident did not return from pass at the designated time of return when authorized to leave the facility. As a result, Resident 17 left the facility without supervision and was reportedly taken to the acute hospital with extreme [MEDICAL CONDITION]. His heart rate was at 30 beats/minutes (normal heart rate 60-100 beats/minute) and was placed on 1:1 supervision due to suicidal thoughts and alcohol withdrawal. 2. Resident 2, who had severe flexion contractures and pressure sores (bed sore) to the buttock and hip, was not positioned appropriately to prevent further decline in range of motion and promote comfort during a treatment. This deficient practice had the potential to cause discomfort and further contractures. 3. For Resident 4, had a physician's orders [REDACTED]. This deficient practice had the potential to result in fluid overload and other health complications. 4. For Residents 25 and 26, who had physician's orders [REDACTED].¼ cup of wine (a form of alcoholic beverage) every dinner, the facility failed to evaluate the alcohol for possible drug interactions with current medications. This deficient practice placed the residents at risk for potential medication reactions with alcohol. The facility failed to maintain a record of disposition/administration in order to enable accurate reconciliation and monitoring of Resident 25's consumption of wine every night from 11/25/14 to 10/16/15, and for Resident 26 from dates 10/2/15 to 10/16/15. This deficient practice had the potential for [MEDICAL CONDITION] by both facility staff and residents, and increased the potential side effects of alcohol. Resident 26's plan of care did not reflect the risks and an adverse consequence of alcohol use in combination with Resident 26 ' s other medications. This deficient practice had the potential for serious side effect if not monitored. Findings: 1. During the facility tour, conducted with the registered nurse supervisor (RN1), on 10/13/15 at 8:30 a.m., Resident 17 was not observed in the facility. In a concurrent interview, RN 1 stated, The resident was on leave of absence (resident was authorized to leave the facility). On 10/14/15 at 10:40 p.m., during a record review, conducted with the licensed vocational nurse (LVN 3), the Release of Responsibility for Leave of Absence indicated Resident 17 signed out on 10/11/15 at 2:30 p.m. to go to Walmart store and was expected to return at 3:45 p.m. on 10/11/15. LVN 3 stated, during a concurrent interview, Resident 17 had not come back since he left the facility; he left by himself. When asked if Resident 17 left with a responsible party, LVN 3 stated, He does not have a responsible party; he is responsible for himself. A review of the Face Sheet (admission record) indicated Resident 17 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The documented responsible party for the Resident 17 was himself. According to the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 10/9/15, indicated Resident 17 was able to make his needs known, understood others, required supervision (oversight) with ambulation and limited assistance (staff provide guided maneuvering of limbs or other non-weight bearing assistance) with one person physical assist in transfer, dressing, toilet use, and personal hygiene. A review of Resident 17's Physician Orders, dated 6/29/15, indicated the following medications: [REDACTED] 1. [MEDICATION NAME] 5 mg (milligrams) tablet every day for dementia and 2. [MEDICATION NAME] 75 mg orally every day for depression manifested by suicidal ideation. 3. Resident 17 may go out on pass with family and or responsible party (no duration indicated). The physician indicated in the Initial History and Physical, dated 9/5/15, that Resident 17 had fluctuating capacity to understand and make decisions. A review of the Psychotherapy Progress Notes, dated 9/5/15, Resident 17 had irritated mood and when thoughts were challenged, he became irritated and angry. The resident had delusional thoughts and required depressive management. On 9/18/15, there was a physician's orders [REDACTED]. A review of the Resident Care Conference Review, dated 10/9/15, indicated the interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) determined that Resident 17 had periods of confusion and forgetfulness. The resident was placed on fall precaution due to a recent fall on 5/17/15. The IDT identified Resident 17 as depressed manifested by verbalization of worthlessness and yet, the resident was allowed to go on leave of absence independently. In an interview on 10/15/15 at 8:45 a.m., the administrator (ADM) was asked why Resident 17, who was identified by the IDT as high risk for falls and injuries due to unsteady gait, [MEDICAL CONDITION], suicide ideation and was allowed to leave the facility without supervision, the ADM stated, the admission record dated 5/8/14 indicated Resident 17 was the responsible party, so we considered the resident's rights and the physician approved the resident to go out on pass. When asked if the determination to allow Resident 17 to make a decision for himself and of being self- responsible was re-evaluated by the IDT since readmission on 6/29/15, the administrator stated, No, but we should have. On 10/14/15 at 10:50 a.m., in an interview, the director of nursing (DON) stated, Resident 17 usually goes out on 'leave of absence' (out on pass) and sometimes stays out overnight. He sometimes goes out to the liquor store. He is responsible for himself so when he goes out on 'leave of absence', we are not responsible for him. The DON stated Resident 17 left the faciity on [DATE] at 2:30 p.m. but she was not made aware by the facility staff members that Resident 17 had not returned to the facility on [DATE] at 3p.m. The DON stated the police was informed immediately on 10/12/15 at 3p.m. In an interview on 10/14/15 at 11:45 a.m., the registered nurse (RN 1) stated, I was the supervisor when Resident 17 left the facility. When I left the facility at about 11 p.m. (on 10/11/15), the resident had not come back. When RN 1 was asked if she informed the DON or the Administrator that the resident had not returned, she stated, No. I did not but I should have, they have to know. RN 1 stated the facility did not attempt any search because Resident 17 was out on pass. In a follow up interview on 10/15/15 at 11:05 a.m., the ADM was asked if the facility had a policy and procedure to guide the staff on what actions to take if a resident would not come back on the designated time of return, the ADM stated, No. That is not included in our policy. On 10/15/15 at 5 p.m., during an interview, the primary physician stated, Resident 17 was very intrusive, direct and difficult to predict. He does have fluctuating capacity to understand and make decisions, but he should be allowed to leave the facility to go to the store. When asked how he expected Resident 17 would be monitored for signs of depression when he goes out on pass, the physician stated, I could not put a label on his psychiatric issue. I am not a psychiatrist. I just took over his care on September 2015. A review of the plans of care for Resident 17 indicated the following: A plan of care, dated 6/29/15, was developed to address Resident 17's risk for fall and injuries related to unstable gait, history of fall, depression and the use psycho-active drugs (medication that affects brain function, resulting in alterations in perception, mood, consciousness, cognition, and behavior). The facility's goal was to minimize the resident's risk for fall and injuries, and the approach was to assess the resident's risk for fall, anticipate, and intervene for factors causing prior falls such as mobility problem, standing, transferring and walking. A plan of care, dated 6/30/15, was developed to address Resident 17's altered thought processes and compromised memory recall ability related to depression and memory impairment manifested by forgetfulness. The facility's plan of approach included to assess potential dangers to resident's environment. A plan of care, dated 6/30/15, was developed to address Resident 17's episodes of suicide ideation related to depression. The facility's approach/plan indicated to observe the resident's whereabouts and to monitor for the side effects of the medication administered for depression. The plans of care for Resident 17 could not be implemented whenever the resident was allowed to leave the facility without supervision. A review of the acute hospital clinical records indicated that Resident 17 was rescued by the police from the hospital parking lot intoxicated and confused and unable to recall how he got to the hospital. Resident 17 was brought into the emergency room (ER) on 10/13/15 at 2:22 p.m., with the [DIAGNOSES REDACTED]. Resident 17 was placed on 1:1 sitter due to suicide ideation and monitored for alcohol withdrawals. A review of acute hospital laboratory records on 10/13/15 at 4:40 p.m., indicated Resident 17 was extremely intoxicated with serum [MEDICATION NAME] (blood alcohol) level being 271 milligrams per deciliter (reference range: 0-10 mg/dl= negative, 100 mg/dl= 0.1 percent (%), 100-300 mg/dl= extreme intoxication, 300-500 mg/dl= alcoholic stupor (a state of near-unconsciousness), 500 plus (+) mg/dl= alcoholic coma). A review of Resident 17's interview, conducted by the social worker at the acute hospital on [DATE] at 3:51 p.m., indicated Resident 17 attempted to commit suicide twice in the past by running his car off the road and overdosed on [MEDICATION NAME] (a controlled drug for pain relief). The resident stated he thought about dying every day, what's the use and spent the last two days in a hotel room drinking 35 cans of beer trying to drink to death and that his brother committed suicide last year. The acute hospital record indicated Resident 17 was transferred to the Cardiology Unit on 10/19/15 at 9 a.m. for heart monitoring due to slow heart rate of 30 beats per minute. According to the facility's undated policy and procedure titled, Leave of Absence indicated the attending physician in conjunction with the interdisciplinary team makes the decision on the appropriateness of leave. Residents who are out on pass should report back to the facility within the time specified. Failure to return at the time specified may result in revocation of temporary leave of absence order even though; the facility did not have a policy and procedure to guide the staff on what actions to take if a resident did not return to the facility after being out on leave of absence. There was also no policy and procedure guide for staff on what the designated time of return was to be for residents who were permitted to leave the premises on leave of absence. 2. On 10/13/15, at 2:55 p.m., during an observation, Resident 2 was observed with severe flexion contractures to both legs which were long, unusually thin, and visible bony prominences. Resident 2 was asleep in bed and positioned slightly to the right side with the head of bed (HOB) at 10-15 degrees elevated. At 4 p.m., Resident 2 was observed on the same position, to the right side. On 10/14/15, at 10:05 a.m., during a wound treatment observation, in the presence of two licensed vocational nurses (LVN11 and 12), Resident 2 was positioned facing slightly to the right with the HOB flat with one pillow. LVN 12 was observed pulling the resident close to the edge of the bed using linen as a draw sheet (used by staff to move residents in bed) to turn resident to the right side so LVN 11 could start doing the wound treatment on the sacrococcyx area (tail bone). Friction was applied between the bed and Resident 2's back when LVN 12 pulled Resident 2 using the linen. LVN 12 pulled Resident 2's back using her hands closer to her to reposition the resident to a side-lying position without lifting the left leg first and placing a pillow in between the legs. Resident 2's legs were crisscrossed with the left leg overlapping the right leg that made both knees hang on to the edge of the bed while LVN 11 was holding on to the Resident 2's back to prevent him from rolling back to a supine (flat) position during wound treatment. Resident 2 at the same time flinched, while LVN 11 asked the resident if he was in pain but continued with the treatment without providing non-pharmacological interventions (nursing measures) to promote comfort. On 10/14/15, at 10:15 a.m., during an interview, LVN 11 stated Resident 2 could not talk and was unable to communicate needs. LVN 11 stated Resident 2 usually moans when in pain or discomfort. A review of the Admission Record indicated Resident 2 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. thickness skin loss and tissue death usually exposes some fat) to the left hip. A review of the quarterly Minimum Data Set (MDS -a resident assessment and care planning tool), dated 9/18/15, indicated Resident 2 had impaired ability to communicate needs (non-verbal) and impaired understanding of verbal content, incontinent (lacking control) of bowel, and had a suprapubic catheter for urination. The MDS indicated Resident 2 required extensive assistance (weight bearing support and at times requires full staff performance) with bed mobility and was totally dependent on staff with the rest of his activities for daily living (ADL). A review of the care plan, dated 9/5/15, indicated Resident 2 was at risk for pressure ulcer (bed sore). The goal was to have no new pressure ulcer development. The interventions included to handle gently during care and assisting with position changes as needed. Another care plan, dated 9/7/15, indicated Resident 2 had limitations with joint mobility. The goal was to have no further loss of range of motion (ROM) daily. The interventions included positioning Resident 2 to prevent further limitations with pillow as needed and observe for pain and stiffness. 3. A review of Resident 4's Admission Record indicated he was admitted to the facility with [DIAGNOSES REDACTED]. This excess can impair breathing), liver [MEDICAL CONDITION] (a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue) and ascites (the accumulation of fluid in the abdominal cavity, causing abdominal swelling). A review of the Medication Administrative Record (MAR) for the month of October 2015 indicated Resident 4's breakdown of fluid restriction was divided between the dietary and nursing department to meet the fluid restriction of 1000 milliliter (ml) per 24 hours. For the dietary department, Resident 4 was supposed to receive 240 ml for breakfast, 240 ml for lunch, and 240 ml for dinner for a total of 720 ml. The MAR indicated [REDACTED]. The licensed nurses were documenting zeros (meaning, Resident 4 was compliant) on most shifts. On 10/13/15, at 5:45 p.m., during an observation, in the presence of a certified nursing assistant (CNA 8), of Resident 4's left over dinner tray, he had a 240 ml cup of mocha mix and a small bowl of soup approximately 120 ml of fluid. During a subsequent interview, at 5:55 p.m., the licensed vocational nurse (LVN 4) stated that the resident also had 240 ml cup of orange juice per preference every meal times (a total of 600 ml provided by the dietary department during dinner time). LVN 4 stated she would not count the soup as fluids because it was not considered fluids but a food. The MAR for 10/2015 indicated Resident 4 was receiving 237 ml of Boost supplement (a liquid form of nutritional drink) three times a day in between meals at 10 a.m., 2 p.m., and 3 p.m., dated 3/6/15. The addition of the boost supplement in the resident's diet indicated that Resident 4 was receiving a total of 1,431 ml of fluids from the dietary department only. There was no evidence documented in the clinical records that the fluids provided to Resident 4 were adjusted to meet the 1000 ml fluid restriction indicated within 24 hours. During the interview, on 10/13/15, at 5:55 p.m., LVN 4 stated, she did not know if the boost supplement was included in the dietary department's fluid count for Resident 4's 1,000 ml fluid restriction. On 10/14/15, at 8:13 am, during an observation, Resident 4 had a pitcher, filled with ice and water at the bedside table. During the observation, Resident 4 was asked to show his feet. Resident 4 had +2 [MEDICAL CONDITION] on both feet. Resident 4 agreed and stated, Yes, my legs are swollen I think because I have too much fluid in me. I have been unable to pee like I used to. A review of the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/5/15, indicated Resident 4 had clear speech, and was able to express ideas and wants including the ability to have clear understanding of verbal content. The MDS indicated Resident 4 required supervision with eating that included intake of fluids with meals. A review of Resident 4's Monthly Weight Record indicated the resident had been gaining weight for the past four months. Resident 4 weighed 229.6 pounds (lbs.) on 7/2015, 232 lbs. on 8/2015, 235.8 lbs. on 9/2015, and 240 lbs. on 10/2015. During an interview with the dietary supervisor (DS) on 10/14/15, at 9 a.m., the DS stated Resident 4 has been losing weight and that was the reason why a boost supplement (nutritional drink) was added to his diet on 3/6/15. A concurrent review of Resident 4's Monthly Weight Record for 2/2015 indicated a weight of 215 lbs. and a weight gain of 222 lbs. for the following month of 3/2015 when the Boost supplement was ordered. On 10/14/15, at 11 a.m., during an interview, the director of nursing (DON) stated Resident 4 was not being monitored for fluid intake and output. The intake and output of residents who are on fluid restrictions for other reasons are only monitored and documented for the first 30 days only after the order was received. The DON stated the licensed nurses document the intake of the resident's fluid intake for the nursing department. A review of the facility's undated policy and procedure titled, Encouraging and Restricting Fluids, indicated that for residents who had physician orders [REDACTED]. The policy stipulated to Be sure an intake and output record is maintained in the resident's room. The policy did not indicate that the intake and output should be recorded for the first 30 days after receiving the physicians order. 4. On 10/15/15, at 10:35 a.m., during an inspection of drugs and biologicals, labeling and storage, in Nursing Station A medication room, in the presence of a registered nurse (RN1), observed 8 small 187 milliliter (ml) bottles of wine scattered in the refrigerator of the medication room with a handwritten label of Residents 25 and 26 names. During a concurrent record review, RN 1 handed the Medication Administration Record [REDACTED]¼ glass of wine every dinner, for Resident 25, and May have ¼ cup of wine every dinner, for Resident 26. During an interview with RN 1 at the time of the medication room inspection, on 10/15/15, at 10:35 a.m., she stated the bottles of wine were ordered by the physician for these two residents. RN 1 stated the facility staff members do not monitor and document Residents 25 and 26's alcohol consumption. RN 1 stated she did not know what glass or cup was used by the licensed vocational nurses to get an exact ¼ glass or cup amounts of wine as ordered by the physician. A review of the facility's undated policy and procedure titled, Alcoholic Beverages, indicated the nurse supervisor receiving the order must contact the pharmacist to determine if any of the resident's current medications would interact with alcohol. The policy stipulated that the physician must be informed if there is a medication that would interact with the alcohol. a. A review of Resident 25's Admission Records indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 25 had clear speech but had difficulty expressing needs and difficulty understanding verbal content. The MDS indicated Resident 25 was totally dependent (full staff performance every time) with most activities of daily living and required extensive assistance (resident involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing support) with eating. A review of the Medication Administrative Record (MAR) for October 2015 indicated there was a physician's orders [REDACTED].¼ glass of wine every dinner. The MAR indicated [REDACTED]. There was no documented evidence in Resident 25's clinical record to indicate monitoring of alcohol (wine) consumption from 11/25/14 to 10/16/15. On 10/15/15 at 10:35 a.m., during an interview and after reviewing Resident 25's clinical record, the director of nursing (DON) acknowledged that Resident 25 had a physician order [REDACTED]. A review of Resident 25's care plan titled, Resident Plan of Care, dated 8/24/15, indicated Resident 25 may deviate therapeutic diet on special occasions and/or when resident so desires. The interventions included how resident may have ¼ glass of wine every dinner. There was no indication that risks and consequences of alcohol consumption in combination with other medications may have adverse consequences to Resident 25's health. b. A review of Resident 26's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 26 had clear speech but had difficulty expressing needs and difficulty understanding verbal content. The MDS indicated Resident 26 was totally dependent (full staff performance every time) with transfers and required extensive assistance (resident involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing support) with bed mobility and required limited assistance for eating. A review of the MAR for October 2015 indicated Resident 26 was receiving [MEDICATION NAME] 20 mg (medication for management of cholesterol levels) by mouth at bedtime and levetiracetam 1000 mg (medications to manage [MEDICAL CONDITION] disorder) by mouth two times a day. A review of a nursing drug handbook titled, Nursing 2015 Drug Handbook, published by Wolters Kluwer, indicated that [MEDICATION NAME] medication with alcohol use may increase risk of hepatotoxicity (liver failure) and to discourage use together. For levetiracetam medication, the Nursing 2015 Drug Handbook indicated that alcohol use may lead to severe sedation and to discourage use together. A review of the Medication Administrative Record for October 2015 indicated there was a physician's orders [REDACTED].¼ cup of wine every dinner. The MAR indicated [REDACTED]. A review of Resident 26's clinical record did not indicate monitoring of alcohol (wine) consumption from 10/2/15 to 10/16/15. On 10/15/15 at 10:35 a.m., during an interview and after reviewing the clinical record, the DON acknowledged that Resident 26 had a physician order [REDACTED]. The DON acknowledged the order was not checked by the pharmacist for drug interactions prior to administration. The DON stated there was no care plan developed for Resident 26's alcohol consumption while in the facility.

Based on interview and record review, the facility's physician failed to review and evaluate the resident's diabetes condition and management according to the facility's policy and procedure for one of one sampled resident (Resident 1). There was no documented evidence in the physician's progress notes dated 8/21/12 to 5/28/13, that the physician on each visit reviewed and evaluated the resident's diabetes condition and management. The physician did not order the desired parameters for monitoring and reporting information related to diabetes or blood sugar management on 8/21/12. The physician did not follow up and document resident ' s glucose control status at subsequent visits. This deficient practice resulted in Resident 1's blood sugar (BS) levels that were not tested four times a day, abnormal laboratory BS test results that were not properly addressed, diet order that was not reviewed for appropriateness, and insulin (medication to control high blood sugar level) not given according to the sliding scale coverage (amount of insulin based on the result of blood test). Resident 1 was transferred to the acute hospital emergency room (ER) due to a change in the level of consciousness and a blood sugar level of over 1000 milligram per deciliter (mg/dL) (laboratory reference range 70-110 mg/dL). The resident was placed on an insulin drip (given intravenously (IV)) along with frequent testing of the resident's BS and was given bolus fluid (a set amount of fluids that is given immediately and completely) and maintenance (the amount of fluid to be given to replace the amount of fluid lost from the body daily) then later admitted to the intensive care unit (ICU). (Cross Reference to F309) Findings: A review of the Record of Admission indicated Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the acute hospital's "Discharge Summary" dated 8/15/12- 8/21/12, (prior to readmission to the facility) indicated a [DIAGNOSES REDACTED]. A review of the physician's "Continuum of Care - Discharge Report" from the acute hospital dated 8/21/12, indicated, "Physician Orders Active at Time of Discharge" to do finger stick blood sugar test/accucheck before meals (a.c.) at 7:30 a.m., 11:30 a.m., 5:30 p.m., and hour of sleep (h.s.) at 9 p.m. every day, with [MEDICATION NAME](a rapid-acting human insulin used to lower blood glucose) sliding scale coverage. It indicated for blood sugar (BS) less than 60 mg/dL, to give 4 ounces (oz) of fruit juice if able to eat/drink; BS less than 60 mg/dL, to give 1 [MEDICATION NAME] (amp) [MEDICATION NAME] 50% (a fluid and nutrient replenisher given by injection) if unable to eat/drink; for BS 141-200 mg/dL, give 1 unit [MEDICATION NAME] insulin; for BS 201-250 mg/dL, give 2 units [MEDICATION NAME] insulin; for BS 251- 300 mg/dL, give 3 units [MEDICATION NAME] insulin, for BS 301- 350 mg/dL, give 4 units [MEDICATION NAME] insulin; for BS 351- 400 mg/dL, give 5 units [MEDICATION NAME] insulin; for BS greater than 400 mg/dL, give 6 units [MEDICATION NAME]and call the physician. If BS is greater than 180 mg/dL for 2 consecutive readings, call the physician for order to move to medium dose regimen. The physician's order from the acute hospital dated 8/21/12 indicated to transfer Resident 1 to the skilled nursing facility for diabetic management. A review of the facility's admission physician's order dated 8/21/12 did not indicate to test Resident 1's blood sugar level four times a day, before meals and at bed time, and to give insulin medication according to the sliding scale to control high blood sugar level. The physician's order did not indicate diabetic diet order for the resident. According to the physician's progress notes dated 8/21/12 to 5/28/13, there was no documented evidence the physician reviewed and evaluated the resident's diabetes condition and management during each visit. There was no indication the physician reviewed the physician ' s orders for completeness and appropriateness. A review of the facility's physician's order dated 10/1/12 indicated for Resident 1 to have peanut butter and jelly sandwich with 1 cup of milk for snacks at hour of sleep (h.s.-9 p.m.) every day. A review of the facility's Medication Records dated 6/1/13 to 6/30/13, indicated Resident 1 had been given peanut butter and jelly sandwich with one cup of milk for snacks at bedtime (a high calorie and sugar diet and this diet order was not reviewed for appropriateness). According to the Medication Records there was no documented evidence Resident 1's blood sugar levels were taken/tested four times a day, before meals and at bed time, and diabetic medication or insulin was given based on the resident's BS levels (sliding scale coverage) from 8/21/12 to 7/6/13, for a total of 11 months. A review of Resident 1's laboratory results at the facility indicated the following: On 7/30/12, blood glucose (sugar) level was 133 mg/dL (laboratory reference range 65-99 mg/dL). The laboratory result form indicated the result was faxed to the physician's office at 5 p.m. on the same day, message was left for the physician at 6 p.m., and to wait for the physician to call back. On 9/20/12, glucose level was 111 mg/dL. The laboratory result form did not indicate the physician was notified by the staff for the abnormal BS result. On 1/28/13, glucose level was 126 mg/dL. The laboratory result form indicated the result was faxed on 1/29/13 and the physician was notified on 2/1/13 at 7:30 p.m. with no new orders. On 3/20/13, glucose level was 146 mg/dL. The laboratory result form indicated the physician was notified and the results were faxed on 3/25/13. A review of the facility's "Nurses Notes" dated 7/5/13 at 4 p.m., indicated the result of Resident 1's hemoglobin A1C (HgbA1c) level (measure of the overall effectiveness of blood glucose (sugar) control or treatment over the past three months) was 10.2% (according to >www.diabetes.org/living-with-diabetes/treatment-and-care/.../a1c/ <last edited December 10, 2013, the American Diabetes Association suggests an A1C of 7%) and the physician was paged. The on-call physician called back the facility and said to call the resident's primary physician on Monday. A review of the Nurses Notes dated 7/6/13 at 5:30 p.m., indicated the licensed nurse was summoned to assess the resident because the resident appeared lethargic (abnormally drowsy). Blood sugar was checked and the glucometer (or glucose meter- a medical device for determining the approximate concentration of glucose in the blood) indicated "high". At 5:40 p.m., the physician was notified and gave an order to transfer the resident to the emergency room for evaluation. A review of the acute hospital's "Discharge Summary" dated 7/10/13, indicated Resident 1 was confused, brought to the emergency roiagnom on [DATE] with high glucose reading which registered over 1000 mg/dL (laboratory result dated 7/6/13 indicated glucose level was 1042 mg/dL). The resident was started on insulin drip along with bolus fluid and maintenance and was admitted to the ICU. On 3/11/14 at 4:20 p.m., during a telephone interview, the physician stated that Resident 1 was a borderline diabetic (or prediabetic- sugar in the blood is higher than normal but not high enough to be called diabetes). The physician stated he did not know that the licensed nurses were not doing the daily blood sugar checks. He further stated he also missed looking at the daily accuchecks which were supposed to be done so a more aggressive treatment and more management of the resident's abnormal blood sugar could have been done. The physician also stated that he failed to review and evaluate the resident's diabetes mellitus condition and treatment plan. The facility's policy and procedure titled, "Diabetes - Clinical Protocol" revised 10/2012 indicated the physician will follow up on any acute episodes associated with a significant change in blood sugars or deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. The facility's policy and procedure titled, "Diabetes - Clinical Protocol" revised 10/2012 indicated the physician and staff will summarize factors that are contributing to, or conditions that are affected by, the resident's diabetes or glucose intolerance and will assess the impact of diabetes on the individual's function and quality of life. The policy further indicated the physician will order the desired parameters for monitoring and reporting information related to diabetes or blood sugar management, and the staff will incorporate such parameters into the Medication Administration Record [REDACTED]

Based on interview and record review, the facility failed to ensure a resident, who was diabetic, had blood sugar levels tested four times a day, before meals and at bed time, and provided insulin medication accordingly to control high blood sugar level for one of one sampled resident (Resident 1). Resident 1's blood sugar (BS) levels were not tested four times a day, before meals and at bed time, and provided insulin medication according to sliding scale (amount of insulin based on the result of blood test) coverage to control high blood sugar level from readmission on 8/21/12 to 7/6/13, for a total of 11 months resulting in high level of BS and a change in the level of consciousness and subsequent transfer to the acute hospital emergency room (ER). Resident 1's BS in the ER was over 1000 milligram per deciliter (mg/dL) (laboratory reference range 70-110 mg/dL), was placed on insulin (medication to control high blood sugar) drip (given intravenously (IV)) along with frequent testing of the resident's BS and given bolus fluid (a set amount of fluids that is given immediately and completely) and maintenance (the amount of fluid to be given to replace the amount of fluid lost from the body daily) then later admitted to the intensive care unit (ICU). Findings: A review of the Record of Admission indicated Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/4/12, indicated Resident 1 scored 5 out of 15 on the Brief Interview for Mental Status (BIMS, a test for the resident's ability to repeat three words, recall, and orientation to year, month, and day). The MDS also indicated the resident required extensive assistance (resident involved in activity, staff provide weight bearing support) with her activities of daily living (ADLs). A review of the acute hospital's "Discharge Summary" dated 8/15/12- 8/21/12, (prior to readmission to the facility) indicated a [DIAGNOSES REDACTED]. A review of the physician's "Continuum of Care - Discharge Report" from the acute hospital dated 8/21/12, indicated, "Physician Orders Active at Time of Discharge" to do finger stick blood sugar test/accucheck before meals (a.c.) at 7:30 a.m., 11:30 a.m., 5:30 p.m., and at hour of sleep (h.s.) at 9 p.m. every day, with [MEDICATION NAME](a rapid-acting human insulin used to lower blood glucose) sliding scale coverage. It indicated for blood sugar (BS) less than 60 mg/dL, to give 4 ounces (oz) of fruit juice if able to eat/drink; BS less than 60 mg/dL, to give 1 [MEDICATION NAME] (amp) [MEDICATION NAME] 50% (a fluid and nutrient replenisher given by injection) if unable to eat/drink; for BS 141-200 mg/dL, give 1 unit [MEDICATION NAME] insulin; for BS 201-250 mg/dL, give 2 units [MEDICATION NAME] insulin; for BS 251- 300 mg/dL, give 3 units [MEDICATION NAME] insulin, for BS 301- 350 mg/dL, give 4 units [MEDICATION NAME] insulin; for BS 351- 400 mg/dL, give 5 units [MEDICATION NAME] insulin; for BS greater than 400 mg/dL, give 6 units [MEDICATION NAME]and call the physician. If BS is greater than 180 mg/dL for 2 consecutive readings, call the physician for order to move to medium dose regimen. The physician's order from the acute hospital dated 8/21/12, indicated to transfer Resident 1 to skilled nursing facility for diabetic management. A review of the facility's admission physician's order dated 8/21/12 did not indicate to test Resident 1's blood sugar level four times a day, before meals and at bed time, and to give insulin medication according to the sliding scale coverage to control high blood sugar. The physician's order did not indicate a diabetic diet for the resident. A review of the facility's physician's order dated 10/1/12, indicated for Resident 1 to have peanut butter and jelly sandwich with 1 cup of milk for snacks at hour of sleep (h.s.-9 p.m.) every day. A review of Resident 1's plans of care did not include care for diabetes and potential complications such as [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar). A review of Resident 1's laboratory results at the facility indicated the following: On 7/30/12, glucose level was 133 mg/dL (laboratory reference range 65-99 mg/dL), On 9/20/12, glucose level was 111 mg/dL, On 1/28/13, glucose level was 126 mg/dL, On 3/20/13, glucose level was 146 mg/dL. A review of the facility's Medication Records dated 6/1/13 to 6/30/13, indicated Resident 1 had been given peanut butter and jelly sandwich with one cup of milk for snacks at bedtime. According to the Medication Records there was no documented evidence Resident 1's blood sugar level was taken four times daily, before meals and at bed time, using the accucheck machine and diabetic medication or insulin was given based on the resident's BS level (sliding scale coverage) from 8/21/12 to 7/6/13, for a total of 11 months. A review of the facility's "Nurses Notes" dated 7/5/13 at 4 p.m., indicated the result of Resident 1's hemoglobin A1C (HgbA1c) level (measure of the overall effectiveness of blood glucose (sugar) control or treatment over the past three months) was 10.2% (according to >www.diabetes.org/living-with-diabetes/treatment-and-care/.../a1c/ <last edited December 10, 2013, the American Diabetes Association suggests an A1C of 7%) and the physician was paged. The on-call physician called back and said to call the resident's primary physician on Monday. A review of the Nurses Notes dated 7/6/13 at 5:30 p.m., indicated the licensed nurse was summoned to assess the resident because the resident appeared lethargic (abnormally drowsy). Blood sugar was checked and the glucometer (a medical device for determining the approximate concentration of glucose/sugar in the blood) indicated "high". At 5:40 p.m., the physician was notified and gave an order to transfer the resident to the emergency room for evaluation. During an interview on 7/25/13 at 9:10 a.m., the licensed vocational nurse (LVN 1) stated Resident 1 had been admitted and not diagnosed as a diabetic so the facility staff did not do any blood sugar checks on the resident. On 7/25/13 at 3 p.m., during an interview, LVN 2 stated the facility staff did not know that Resident 1 was diabetic and they overlooked the high blood sugar level results done on 7/30/12 and 9/20/12 and stated they were not testing Resident 1's blood sugar. On 7/25/13 at 3:15 p.m., during an interview, LVN 3 stated the facility staff did not know that Resident 1 was diabetic. They overlooked the high blood sugar level results done on 1/28/13 and 3/20/13 and stated they were not testing Resident 1's blood sugar. During an interview on 8/16/13 at 12:45 p.m., the dietary supervisor (DS) stated Resident 1 had been on a regular diet with sugar because there was no diabetic diet ordered for the resident. A review of the acute hospital's "Discharge Summary" dated 7/10/13, indicated Resident 1 was confused, brought to the emergency roiagnom on [DATE] with high glucose (sugar) reading which registered over 1000 mg/dL (laboratory result dated 7/6/13 indicated glucose level was 1042 mg/dL). The resident was started on insulin drip along with bolus fluid and maintenance and was admitted to the ICU. A review of the facility's policy and procedure titled, "Admission Assessment and Follow Up: Role of the Nurse" revised 12/2012, indicated to reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge from the previous institution according to established procedures. According to the facility's policy and procedure titled, "Diabetes - Clinical Protocol" revised 10/2012 indicated the physician and staff will summarize factors that are contributing to, or conditions that are affected by, the resident's diabetes or glucose intolerance and will assess the impact of diabetes on the individual's function and quality of life. The policy further indicated the physician will order the desired parameters for monitoring and reporting information related to diabetes or blood sugar management, and the staff will incorporate such parameters into the Medication Administration Record [REDACTED]

Based on observation, interview, and record review, the facility failed to provide a safe transport by using a defective and non-fitting wheeled shower chair that lacked supporting foot rest resulting in a fall with fracture of both knees for Resident 1. On 9/13/12, Resident 1, who was assessed as unable to walk and requiring total assistance from staff for transfers and bathing, was being wheeled by Certified Nursing Assistant 1 (CNA 1) from her room to the shower room using a broken (the lap bar did not lock to stay in place) and non-fitting (the resident's abdomen size did not allow positioning of the lap bar to go across the abdomen and to lock into place) shower chair that lacked foot rest to support the resident's feet. While trying to go through the entrance door of the shower room, the shower chair tilted forward and the resident fell from the chair to the floor on her knees. On the same day, the resident was transferred to a general acute care hospital (GACH) where she was diagnosed with [REDACTED]. On 9/17/12, the resident was sent back to the facility. Findings: On 10/4/12 at 7:30 a.m., an unannounced visit was made to the facility to investigate a complaint and an entity reported incident regarding Resident 1's fall and injury. On 10/4/12, a review of the clinical record indicated Resident 1 was a [AGE] years old female admitted [DATE], with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - standardized assessment and care planning tool) signed as completed on 7/1/12, indicated the resident was alert and oriented, non-ambulatory, required extensive assistance with one person assist with bed mobility and total assistance with transfers, locomotion and bathing. The resident did not have functional limitation of range of motion (ROM - mobility of the joints) on the lower extremities and used a wheelchair as a mobility device. The Monthly Weight Record dated 8/2/12, indicated the resident weighed 234.5 pounds (lb). The Care Area Assessment (CAA) notes dated 6/30/12, indicated the resident was at risk for falls/injuries due to her compromised mobility, cardiac medication use and incontinence. It also indicated fall precautions would continue to be implemented. The plan of care dated 1/3/12, developed for the resident's risk for falls/injuries included in the approaches to assess environment for wet spots or items below the field of vision and to use the appropriate device as ordered. The plan of care dated 6/30/12, developed for the resident's risk for injuries had a goal for the resident not to have injuries/fall incidents. The approaches included to maintain a safe and hazard free environment. According to the Licensed Personnel Progress Notes dated 9/13/12, timed at 9:45 a.m., the resident was in the shower, slid down from the shower chair and was assisted by the CNA to the floor in a sitting position. At 10:30 a.m., the resident complained of pain on both legs rated 4 over 10 (4/10 - pain rating scale from zero to 10, zero indicating no pain and 10 indicating the worst possible pain). The resident was given Tylenol 650 milligrams (mg). At 11:30 a.m., the attending physician was called and at 1 p.m., the nurse practitioner on call for the physician, ordered to monitor the resident. At 4:30 p.m., the resident complained of pain of 4/10 on both lower extremities and Tylenol 650 mg was given. At 5:10 p.m., the physician was called about the resident's continued pain on both lower extremities. At 5:30 p.m., a physician on call, called back and ordered to medicate the resident with Norco 5/325 mg and to take x-rays of both lower extremities. At 6:10 p.m., Resident 1's family member requested for the resident to be transferred to the hospital. The on-call physician was informed and ordered the resident to be transferred to a GACH. The resident was transferred via ambulance at 7:05 p.m. According to the GACH History and Physical dated 9/14/12, the resident sustained [REDACTED]. The plan was to immobilize the residents' knees and give pain medications. The resident returned to the facility on [DATE]. On 10/4/12 at 10:04 a.m., during an interview, CNA 1 stated on 9/13/12, he transferred the resident from her bed to a big shower chair using a mechanical lift and a shower sling. The resident in the shower chair was pushed (wheeled) to the shower room and while trying to get in thru the shower room entrance door the shower chair tilted forward and the resident fell off the chair. CNA 1 further stated he grabbed the resident and the sling and slowly lowered her to the floor. During the interview, CNA 1 brought the shower chair used during the incident which had a safety lap bar that went across the front area of the chair and had no foot rests. The lap bar was noted to be defective, when snapped into the arm rest, the bar did not stay attached in place (if pulled or pushed). CNA 1 explained he used this particular shower chair because it was large enough for the resident. CNA 1 stated the resident was not using the lap bar because the resident did not like it being used. When asked if the lap bar could fit over the resident's abdomen area, CNA 1 replied, "No." On 10/4/12 at 10:44 a.m., during an interview, the maintenance supervisor stated he and his assistants inspect the shower chairs. However, he did not know the shower chair (used by the resident) was broken. According to the maintenance supervisor, the facility had 21 shower chairs and only two had safety lap bars to protect the resident from falling out of the chairs and only four had foot rests. According to the Monthly Maintenance Equipment Inspection log from 1/2012 thru 9/2012, shower chairs were inspected and oiled; however, due to the lack of identification of each chair, it was not determined which shower chairs were inspected and oiled. On 10/4/12 at 12:10 p.m., during an interview, Resident 1 stated that while CNA 1 was pushing her in the shower chair into the shower room, she slid down, her legs were folded underneath the chair and she hit both of her knees on the floor. The resident stated she slid down because CNA 1 kept pulling and pushing the shower chair back and forth trying to get in through the shower room entrance. The resident indicated the shower chair had a lap bar that could not be used because her abdomen was too big. The resident also stated it was hard for her to hold on to the chair because her left side was weak due to a stroke and the shower chair without foot rests did not help in keeping her in the sitting position. On 10/4/12 at 3:15 p.m., during an interview, the Director of Staff Development (DSD) stated he was not aware CNA 1 used a shower chair with a broken lap bar. The DSD was also not aware the shower chair was not large enough for the resident and the lap bar could not close. The DSD could not provide evidence the CNAs were trained in using shower chairs for residents who had body weakness. According to the facility's policy and procedure on Managing Falls and Fall Risks, dated 4/2006, based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes, to try to prevent the resident from falling and to try to minimize complications from falling.