Every finding on record at Long Beach Healthcare Center

Based on interview and record review, the facility failed to ensure the Director of Rehabilitation ([DOR] oversees the rehabilitation department operations, not required to be a licensed Occupational Therapist [OT] a licensed healthcare professional who evaluates and treats individuals to improve their ability to perform everyday activities safely and independently] and is a Certified Occupational Therapy Assistant [COTA] trained to provide OT services only under the supervision of a licensed OT and cannot independently perform evaluations, assessments, determine the need for assistive devices, or initiate occupational therapy treatment plans) referred one of three sampled residents (Resident 14), who was non weight bearing (no weight placed on the affected leg, foot, or joint), to the OT when Resident 14 requested a drop arm commode (toileting assistive device with arms that lower or release to allow lateral transfers [seated movement from one surface to another without standing or bearing weight]). This Deficient practice resulted in Resident 14 not receiving an evaluation by an OT to determine if a drop arm commode was an appropriate assistive device. Instead of using a regular commode, which the DOR recommended, Resident 14 chose to wear adult diapers for bowel and bladder elimination, which made her feel humiliated and angry. Findings : During a review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE]. Resident 14 had diagnoses including anorexia nervosa (an eating disorder that involves severe calorie restrictions and, often, a very low body weight), polyneuropathy (a disease or dysfunction of many nerves, typically causing numbness or weakness in hands and feet), and abnormalities of gait (a particular way or pattern of walking, running, or moving on foot) and mobility. During a review of Resident 14's History and Physical (H&P), dated 6/25/2026, the H&P indicated Resident 14 had the capacity to understand and make medical decisions. During a review of Resident 14's Minimum Data Set ([MDS] a resident assessment tool), dated 6/29/2026, the MDS indicated Resident 1's cognition (ability to register and recall information) was intact and she was able to understand and be understood by others. During a review of Resident 14's Physician Orders, dated 7/8/2026, the Physician's Order indicated no weight bearing (both legs) until seen by orthopedic specialist (a medical doctor who diagnoses, treats, and helps present problems in the musculoskeletal system). During an interview on 7/29/2026 at 10 a.m., Resident 14 stated since she was non weight bearing as of 7/8/2026 she requested a drop arm commode from the DOR. She previously pivoted onto a standard commode, but once she became non weight bearing she could no longer use the standard commode. The DOR told her she did not need a drop arm commode and could continue using the existing commode by scooting her bottom from the bed onto the commode. Resident 14 stated this was not workable for her because she had significant pain in her wrists, which made scooting difficult. The DOR told her she would make the rehabilitation team aware of her request; however, the rehabilitation team was never made aware of her request. Resident 14 stated because she was unable to obtain the drop arm commode, she began wearing adult diapers to urinate and defecate (to discharge solid or semi-solid waste [feces]). She felt humiliated, angry, and frustrated that her request was dismissed by the DOR. Resident 14 stated she cleaned herself up independently after toileting in the diaper because she was so embarrassed to have anyone else clean her. During a phone interview on 7/28/2026 at 2:27 p.m., the DOR stated Resident 14 asked her for a drop arm commode. The DOR stated she told Resident 14 she did not need a drop arm commode and advised her to position and angle her existing commode to allow her to scoot into it. When Resident 14 informed her (the DOR) that she was unable to use the commode in that manner, she (the DOR) suggested that Resident 14 use a bedpan instead. The DOR stated she should have informed the supervising OT so an evaluation could be completed for Resident 14 because she (the DOR) could not screen or evaluate residents. During an interview on 7/28/2026 at 4:19 p.m., the OT stated the DOR is a COTA and works under the supervision of a licensed OT and could not independently evaluate a resident or initiate OT treatment plans. The OT stated she had not been informed that Resident 14 requested a drop arm commode. The OT stated a drop arm commode is used for residents who could not stand, bear weight, or perform pivot transfers. For a non weight bearing resident, such as Resident 14, a drop arm commode supports safety, maintains dignity, and promotes independence by allowing the resident to transfer from the bed to commode using a lateral scoot rather than standing or relying on a bedpan. She (the OT) should have been notified of Resident 14's request so she could have conduct an evaluation. The lack of referral caused a delay in care and did not uphold the residents' rights to maintain dignity and promote independence. During an interview on 7/29/2026 at 4 p.m., the Director of Nursing (DON) stated she was not aware that Resident 14 had requested a drop arm commode or that the DOR had attempted to address Resident 1's toileting needs without notifying the supervising OT or the nursing department. The DON stated all residents have the right to receive timely assessments and appropriate assistive devices to maintain their dignity, independence, and safety. The DON stated any request for specialized equipment, such as a drop arm commode, must be promptly communicated to the licensed OT for proper evaluation. The failure to notify the OT was inconsistent with facility expectations and residents' rights to receive needed equipment and services. During a review of the facility's Policy and Procedure (P&P) titled, Resident's Rights Policy revised 5/2025, the P&P indicated this organization is committed to protecting and promoting the rights, dignity, privacy, independence and well-being of all residents. During a review of the facility's P&P titled, Dignity revised 10/2025, the P&P indicated each resident is cared for in a manner that promotes and enhances individuality a sense of well-being, satisfaction with life and feelings of self-worth and self-esteem. During a review of the facility's undated Job Description, titled Occupational Therapist Assistant (OTA) the Job Description indicated the OTA works under the supervision of a licensed occupational therapist (OT) to assist with a patient's treatment program in accordance with federal guidelines and state practice acts.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified when one sampled resident (Resident 1), who was diagnosed with hypertension ([HTN] high blood pressure) refused to take his 9 a.m., medications, which included high blood pressure medications. This deficient practice resulted in Resident 1's physician being unaware of Resident 1's refusal to take his medications and the inability of the physician to instruct staff on care options. This deficient practice had the potential for Residen t1's blood pressure to remain elevated and for him to suffer consequences related to prolonged elevated blood pressure readings.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]. Resident 1 had diagnoses including, HTN, congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease ([COPD,]a chronic lung disease causing difficulty breathing), difficulty walking, and lack of coordination. During a review of Resident 1's History and Physical (H&P) dated 4/8/2026, the H&P indicated Resident 1 was oriented to person, place, and time (the resident knows who they are, where they are, who other people are, and knows the date and time). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 7/15/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required set-up and clean up assistance (helper sets up or cleans up; resident completes the activity) from staff for eating, and maximal assistance (helper does more than half the effort) from staff for toileting, dressing lower body, and shower/bathing. During a review of Resident 1's Care Plan titled, Episodes of refusing his 9 a.m., medications and BP (blood pressure), VS (vital sign) check initiated 5/12/2026, the Care Plan's goals indicated for Resident 1 to take his medications on time, understand medication benefits, and comply with vital signs monitoring. The Care Plan's interventions indicated staff were to document Resident 1's refusal, monitor for signs and symptoms of complications related to him refusing his medications and vital signs checks, and to notify the MD for any significant changes promptly. During a review of Resident 1's Order Summary Report (Physician's Orders), dated 7/30/2026, the Physician's Order indicated the following: 1. Metoprolol Succinate ER (extended release) tablet 50 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), give one tablet one time a day for hypertension ([HTN] high blood pressure), hold if the systolic blood pressure ([SBP] the top number of a blood pressure reading) was less than 100 millimeters of mercury ([mmHg] a unit of measurement). 2. Telmisartan oral tablet 40 mg, give 40 mg one time a day for HTN, hold if SBP was below 110 mmHg. 3. Furosemide oral tablet 20 mg, give one tablet one time a day for HTN, hold if SBP was less than 110 mmHg. 4. Aspirin oral tablet chewable 81 mg give one tablet one time a day to prevent blood clots. 5. Ezetimibe oral tablet 10 mg, give one tablet one time a day for high cholesterol. 6. Empagliflozin (a medication used to help the body remove extra sugar and fluid through the urine) oral tablet 10 mg, give one tablet one time a day. Gabapentin (a medication used to relieve nerve pain) 300 mg, give 1 capsule four times a day. During a review of Resident 1's Medication Administration Audit Report ([MAAR], a document used to check whether medications in a facility are being given safely, correctly, and according to required policies) dated 7/29/2026, the MAAR indicated Resident 1's 9 a.m., medications for 7/27/2026 that included Telmisartan 40 mg, Metoprolol Succinate Extended Release 50 mg, Furosemide 20 mg, Aspirin 81 mg, Ezetimibe 10 mg, Gabapentin 300 mg, and Empagliflozin 10 mg were administered on 7/27/2026 at 12:21 p.m. During an interview on 7/27/2026 at 11:38 a.m., Resident 1 stated he had not received his morning medications (7/27/2026), he had blood pressure medications due, and he was concerned his blood pressure would become elevated. Resident 1 stated he had not refused his morning medication, and he would frequently not get his 9 a.m., medications and would have to use his call light to ask the nurse for them. During an observation on 7/27/2026 at 11:51 a.m., Resident 1 activated his call light to request his morning medications. Licensed Vocational Nurse (LVN) 3 entered Resident 1's room to obtain Resident 1's blood pressure. During an observation on 7/27/2026 at 11:57 a.m., LVN 3 entered Resident 1's room and obtained Resident 1's blood pressure. Resident 1's left arm blood pressure was 161/96 with a heart rate of 58. Resident 1's right arm blood pressure was 166/96 with a heart rate of 55 (reference range for blood pressure 120/88 mmHg). During a concurrent interview and record review on 7/27/2026 at 12:10 p.m., with LVN 1, Resident 1's Nursing Progress Notes dated 7/27/2026 were reviewed. The Nursing Progress Notes indicated no documented evidence that Resident 1 refused to take his 9 a.m. medications or that Resident 1's physician was notified when Resident 1 refused to take his 9 a.m. medications. LVN 1 stated Resident 1's 9 a.m. medications were not administered until after 12 p.m., because he refused to take his medications when they were offered at 9 a.m., she did not document his refusal to take his medication, nor did she notify Resident 1's physician of his refusal to take his medications. LVN 1 stated when Resident 1 refused to take his medications, she should have offered the medications three times and documented each refusal. LVN 1 stated it was important to notify the physician because Resident 1's blood pressure was elevated and missed blood pressure medications could cause Resident 1 to become ill.During an interview on 7/28/2026 at 4:17 p.m., and a subsequent interview on 7/30/2026 at 11:45 a.m., Director of Nursing (DON) stated medications could be administered one hour before and one hour after the prescribed medication time. If a resident refused to take their medications, the nurse should document the resident's refusal, explain the risks and consequences of not taking their medication, attempt to give the resident their medication two more times, and if the resident continued to refuse to take their medication, notify the resident's physician. The DON stated Resident 1's blood pressure was high, and refusal to take his blood pressure medications should have been addressed because Resident 1's vital signs were not within range. During a review of the facility's Policy and Procedure (P&P), titled Charting and Documentation revised 7/2017, the P&P indicated . medications administered, changes in the resident's condition, whether the resident refused the procedure or treatment, and notification of family, physician, or other staff, if indicated, were to be documented in the resident's medical record.

Based on interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 did not taunt one of four sampled residents (Resident 1) by telling him to hit me Go ahead and hit me so we can send you out, following an altercation between Resident 1 and LVN 1. Following the altercation LVN 1 continued to be assigned to care for Resident 1. This deficient practice resulted in Resident 1 continuing to receive care from the LVN 1 who verbally abused him and had the potential to cause Resident 1 emotional distress, increased agitation, psychosocial harm, and loss of trust in facility staff.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]. Resident 1 had diagnoses including congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty breathing), difficulty walking, and lack of coordination. During a review of Resident 1's History and Physical (H&P), dated 4/8/2026, the H&P indicated Resident 1 was oriented to person, place, and time (the resident knows who they are, where they are, who other people are, and knows the date and time). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 7/15/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required set-up and clean up assistance (helper sets up or cleans up; resident completes the activity) from staff for eating, and maximal assistance (helper does more than half the effort) from staff for toileting, dressing lower body, and shower/bathing. During a review of Resident 1's Change in Condition (CIC) Evaluation, dated 7/15/2026 and timed at 11:02 a.m., the CIC Evaluation indicated Resident 1 displayed increasing agitation, yelling and screaming towards staff while the nursing staff was providing care for Resident 1's roommate (Resident 10). The CIC Evaluation indicated Resident 1's behavior escalated to throwing a side table towards the charge nurse when the charge nurse moved Resident 1's side table to make room for a shower chair needed for Resident 10. During a review of the facility's Nurse Staffing Assignments, dated 7/2026 the Nurse staffing Assignments indicated LVN 1 was assigned to Resident 1's care following the altercation between them on 7/15/2026 on the following dates: 7/16/2026, 7/18/2026, 7/21/2026, 7/22/2026, 7/23/2026, 7/24/2026, 7/25/2026, 7/27/2026, 7/28/2026, and 7/29/2026. During an interview on 7/27/2026 at 11:38 a.m., Resident 1 stated on 7/15/2026, his overbed table became caught on his bed when the bed was raised, and the overbed table tipped over, and the tray of food fell off of the overbed table. Resident 1 stated LVN 1 accused him of throwing a tray of food at her, but he did not throw the tray at LVN 1. Resident 1 stated LVN 1 told him, Hit me, hit me, so I can get you out of here. The Psychiatric Evaluation Team ([PET] a mobile crisis units that consist of licensed mental health clinicians who evaluate individuals experiencing severe psychiatric distress, provide onsite deescalation and can facilitate voluntary or involuntary hospitalizations) and police were called after the incident, two CNAs, who were in the room when the incident happened, witnessed the incident and explained to PET and police what happened. During an interview on 7/28/2026 at 12:05 p.m., CNA 2 stated she was present during the 7/15/2026 incident involving Resident 1 and LVN 1. CNA 2 stated Resident 1 was eating breakfast when staff were preparing to assist Resident 10 with a shower and needed space to bring a mechanical lift (a device used to lift and/or transfer a person from place to place) into the room. The area was limited in space, and they needed to move Resident 1's overbed table to get the mechanical lift positioned, which Resident 1 agreed to. LVN 1 came into the room, pulled Resident 1's table, and the table jammed under the bed. Resident 1 was eating oatmeal, and his oatmeal slid off the table. Resident 1 was frustrated and began swiping everything off his table onto the floor then pushed the table out of the way. Resident 1 was not trying to throw the tray at LVN 1. CNA 2 stated LVN 1 said to Resident 1, Go ahead and hit me so we can send you out. and then held her hands up to prevent her (CNA 2) and CNA 3 from approaching Resident 1, that's when Resident 1 threatened to hit LVN 1. LVN 1 did not try to deescalate the situation and instead said to them (CNA 2 and CNA 3) Let him hit me if he wants to hit me. CNA 2 stated she was interviewed by the police and told them that Resident 1 did not throw the table at LVN 1. CNA 2 stated she notified the Administrator (ADM) of the incident but she did not tell the ADM what LVN 1 said to Resident 1. During a telephone interview on 7/27/2026 at 2:07 a.m., CNA 3 stated on 7/15/2026 staff were assisting Resident 10 and Resident 1 became upset because staff were in his space and his table was being moved. CNA 3 stated LVN 1 attempted to move Resident 1's table, the table flipped, and items on the table fell to the floor. Resident 1 was upset, but he did not throw the table at LVN 1. CNA 3 stated Resident 1 became angrier when LVN 1 told him, Hit me, hit me, so we can get you out of here. CNA 3 stated staff were not trained to tell residents to hit them so they could get them out of the facility, he could have been taken to the patio for fresh air to calm him down. CNA 3 stated no one reported LVN 1's statement, but there were eyewitnesses. During an interview on 7/28/2026 at 3:19 p.m., LVN 1 stated she was called into Resident 1's room because the gastrotomy tube ([g-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) pump for Resident 10 was beeping, and staff wanted her to disconnect the Resident 10 from the G-tube to take him for a shower. There was limited space in the room, she asked Resident 1 if she could move his table. Resident 1 began yelling, screaming, and became verbally aggressive. LVN 1 did not address what she said to Resident 1. During an interview on 7/28/2026 at 4:17 p.m., the Director of Nursing (DON) stated on the day of the incident (7/15/2026), LVN 1 answered Resident 1's call light, accidentally moved Resident 1's table, and made Resident 1 upset. The DON stated because Resident 1 was upset, he moved the table and the tray fell. The DON stated if LVN 1 said, hit me, hit me, that way we can get you out of her, to Resident 1, that might make him more upset. The DON stated she was not aware that this was what LVN 1 said to Resident 1, had she known, she would have re-educated LVN 1, provided one-to-one in-service training, and reassigned LVN 1 from Resident 1's assignment. The DON stated Resident 1 would not feel good having the nurse who spoke to him that way providing his care, and he could become more upset every time he saw that nurse. During an interview on 7/28/2026 at 4:53 p.m., the ADM stated he was called to Resident 1's room when the incident occurred, he saw food on the floor from Resident 1's tray and heard that Resident 1 had thrown the tray on the floor. Resident 1 told him he did not throw the tray at LVN 1, but he did not hear anything about LVN 1 telling Resident 1, hit me, hit me. The ADM stated if Resident 1 was already angry, LVN 1's statement, hit me, hit me, did not help the situation. The ADM stated he would have taken aggressive action toward LVN 1 if he had known the incident occurred, and LVN 1 would have been removed from the care of the resident. The ADM stated the staff and Resident 1 did not mention to him what LVN 1 said to Resident 1. During an interview on 7/30/2026 at 11:45 a.m., with the DON, and a concurrent review of Resident 1's Nursing Progress Note dated 7/27/2026 and timed at 12:30 p.m., the Nursing Progress Note indicated Resident 1 refused to take medications from LVN 1 and staff should continue to have another nurse give Resident 1 his medications if he allowed it. The DON stated CNA 2 and CNA 3 should have stopped LVN 1 and reported the incident to her and the ADM because as mandated reporters they should report abuse. The DON state she nor the ADM were made aware of what LVN 1 said to Resident 1 and acknowledged that LVN 1 continued caring for Resident 1 which could emotionally affect Resident 1 by seeing her daily. LVN 1's assignment should have been changed and if she had known the altercation occurred between LVN 1 and Resident 1, she would have separated them sooner. During a review of the facility's Policy and Procedure (P&P) titled, Protection of Residents During Abuse Investigations, revised 4/2021, the P&P indicated residents are protected from harm, retaliation, reprisal, discrimination, or coercion during investigations of abuse, neglect, exploitation, and misappropriation of resident property. If the alleged perpetrator is an employee or staff member, the individual is immediately reassigned to duties that do not involve resident contact or are suspended until the findings of the investigation are reviewed by the Administrator. The victim is evaluated for his or her feelings of safety if the victim communicates fear, insecurity, or other concerns, measures are taken to alleviate this, including changing the room assignment or providing more supervision. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, the P&P indicated residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The P&P indicated this includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility will establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. During a review of the facility's undated P&P titled Business Ethics and Conduct and Staff Conduct and Work Rules, the P&P indicated physical, verbal, emotional, or psychological abuse of residents, visitors, or coworkers is strictly prohibited. Staff may not engage in physical altercations or aggressive behavior while on organization property or representing the organization. During a review of the facility's P&P titled Residents Rights Policy, revised 5/2025, the P&P indicated every resident shall be treated with respect and fairness and shall enjoy their rights without discrimination, harassment, abuse, neglect, or retaliation. Residents have the right to be treated with courtesy, dignity, and respect and to live in a safe, secure, and healthy environment, and to be free from physical, emotional, verbal, sexual, or financial abuse. Residents have the right to be free from neglect, exploitation, intimidation, coercion, and retaliation. Staff members shall respect and protect residents' rights at all times, maintain confidentiality, report suspected abuse, neglect, or rights violations immediately, support residents in exercising their rights, and participate in training related to residents' rights and ethical conduct.

Based on interview and record review, the facility failed to ensure an allegation of verbal abuse was immediately reported to the Administrator (ADM) when staff witnessed Licensed Vocational Nurse (LVN) 1 tell one of four sampled residents (Resident 1) to hit me Go ahead and hit me so we can send you out. This deficient practice resulted in the facility's inability to conduct a timely investigation and a delay in reporting the allegation to the California Department of Public Health (CDPH). This deficient practice had the potential for LVN 1 to continue verbally abusing 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]. Resident 1 had diagnoses including congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty breathing), difficulty walking, and lack of coordination. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 7/15/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required set-up and clean up assistance (helper sets up or cleans up; resident completes the activity) from staff for eating, and maximal assistance (helper does more than half the effort) from staff for toileting, dressing lower body, and shower/bathing. During a review of Resident 1's Change in Condition (CIC) Evaluation, dated 7/15/2026 and timed at 11:02 a.m., the CIC Evaluation indicated Resident 1 displayed increasing agitation, yelling and screaming towards staff while the nursing staff was providing care for Resident 1's roommate (Resident 10). The CIC Evaluation indicated Resident 1's behavior escalated to throwing a side table towards the charge nurse when the charge nurse moved Resident 1's side table to make room for the shower chair needed for Resident 10. During an interview on 7/27/2026 at 11:38 a.m., Resident 1 stated on 7/15/2026, his overbed table became caught on his bed when the bed was raised, and the overbed table tipped over, and the tray of food fell off of the overbed table. Resident 1 stated LVN 1 accused him of throwing a tray of food at her, but he did not throw the tray at LVN 1. Resident 1 stated LVN 1 told him, Hit me, hit me, so I can get you out of here. The Psychiatric Evaluation Team ([PET] a mobile crisis units that consist of licensed mental health clinicians who evaluate individuals experiencing severe psychiatric distress, provide onsite deescalation and can facilitate voluntary or involuntary hospitalizations) and police were called after the incident, two CNAs, who were in the room when the incident happened, witnessed the incident and explained to PET and police what happened. During an interview on 7/28/2026 at 12:05 p.m., CNA 2 stated she was present during the 7/15/2026 incident involving Resident 1 and LVN 1. CNA 2 stated Resident 1 was eating breakfast when staff were preparing to assist Resident 10 with a shower and needed space to bring a mechanical lift (a device used to lift and/or transfer a person from place to place) into the room. The area was limited in space, and they needed to move Resident 1's overbed table to get the mechanical lift positioned, which Resident 1 agreed to. LVN 1 came into the room, pulled Resident 1's table, and the table jammed under the bed. Resident 1 was eating oatmeal, and his oatmeal slid off the table. Resident 1 was frustrated and began swiping everything off his table onto the floor then pushed the table out of the way. Resident 1 was not trying to throw the tray at LVN 1. CNA 2 stated LVN 1 said to Resident 1, Go ahead and hit me so we can send you out. and then held her hands up to prevent her (CNA 2) and CNA 3 from approaching Resident 1, that's when Resident 1 threatened to hit LVN 1. LVN 1 did not try to deescalate the situation and instead said to them (CNA 2 and CNA 3) Let him hit me if he wants to hit me. CNA 2 stated she was interviewed by the police and told them that Resident 1 did not throw the table at LVN 1. CNA 2 stated she notified the Administrator (ADM) of the incident, but she did not tell the ADM what LVN 1 said to Resident 1. During a telephone interview on 7/27/2026 at 2:07 a.m., CNA 3 stated on 7/15/2026 staff were assisting Resident 10 and Resident 1 became upset because staff were in his space and his table was being moved. CNA 3 stated LVN 1 attempted to move Resident 1's table, the table flipped, and items on the table fell to the floor. Resident 1 was upset, but he did not throw the table at LVN 1. CNA 3 stated Resident 1 became angrier when LVN 1 told him, Hit me, hit me, so we can get you out of here. CNA 3 stated staff were not trained to tell residents to hit them so they could get them out of the facility, he could have been taken to the patio for fresh air to calm him down. CNA 3 stated no one reported LVN 1's statement, but there were eyewitnesses. During an interview on 7/30/2026 at 11:45 a.m., with the DON, and a concurrent review of Resident 1's Nursing Progress Note dated 7/27/2026 and timed at 12:30 p.m., the Nursing Progress Note indicated Resident 1 refused to take medications from LVN 1 and staff should have another nurse give Resident 1 his medications if he allowed it. The DON stated CNA 2 and CNA 3 should have stopped LVN 1 and reported the incident to her and the ADM because as mandated reporters they should report abuse. The DON stated she nor the ADM were not aware of what LVN 1 said to Resident 1, which was why they did not report the allegation of verbal abuse to CDPH and why LVN 1 continued caring for Resident 1 after their altercation. During an interview on 7/30/2026 at 1:51 p.m., the Administrator (ADM) stated staff were required to report any type of abuse immediately, and they could report directly to him. The ADM stated that on 7/15/2026, staff contacted him during the altercation involving Resident 1; however, they only told him that Resident 1 threw his food tray but did not report that LVN 1 told Resident 1 to hit me. The ADM stated abuse was not tolerated in the facility, he did not report the allegation of verbal abuse because it was not reported to him. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting, revised 4/2018, the P&P indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source, abuse, shall be promptly reported to local, state, and federal agencies, as defined by current regulations. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, will be reported by the facility Administrator or his/her designee to the State licensing/certification agency responsible for surveying/licensing the facility, the local/State Ombudsman, the resident's representative, Adult Protective Services, law enforcement officials, the resident's Attending Physician, and the facility Medical Director. An alleged violation of abuse, neglect, exploitation, or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. Alleged violations that do not involve abuse and have not resulted in serious bodily injury will be reported not later than 24 hours.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 3 remained awake and available to respond to resident care needs during the 11 p.m. to 7 a.m., shift on 7/29/2026 or one sampled resident (Resident 1). This deficient practice resulted in CNA 1 being unaware and unavailable to assist with resident care needs and/or emergencies. This deficient practice had the potential for delayed and/or missed care/emergency response.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]. Resident 1 had diagnoses including congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty breathing), difficulty walking, and lack of coordination. During a review of Resident 1's History and Physical (H&P) dated 4/8/2026, the H&P indicated Resident 1 was oriented to person, place, and time (the resident knows who they are, where they are, who other people are, and knows the date and time). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 7/15/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required set-up and clean up assistance (helper sets up or cleans up; resident completes the activity) from staff for eating, and maximal assistance (helper does more than half the effort) from staff for toileting, dressing lower body, and shower/bathing. During a review of the facility's Grievance Log, dated 5/2026, the Grievance Log indicated on 5/12/2026 Resident 1 had a call light concern. During an interview on 7/27/2026 at 3:23 p.m., Resident 1 stated during the 11 p.m. to 7 a.m., shift staff did not change his brief and did not respond to his call light. Resident 1 stated he filed a grievance regarding the concern with his call light and staff improved answering his call light for a short period of time and then went back to not responding to it. Staff ignored him during the 11 p.m., to 7 a.m., shift when he asked to be change and he was left in soiled briefs and had to wait until morning to get a shower and have his soiled brief changed. During an observation on 7/29/2026 from 3:43 a.m. to 3:53 a.m., on the East Station, CNA 1 was observed covered with a blanket, asleep in a chair outside the shower room at the end of the hallway, he remained asleep for approximately 10 minutes and did not wake when approached. During an interview on 7/29/2026 at 3:53 a.m., CNA 1 stated he was not on break and was not supposed to be asleep while on duty. CNA 1 stated it was important not to sleep while on duty because some residents were fall risks, residents had safety concerns, and he was responsible for monitoring the residents. During an interview on 7/29/2026 at 4:23 a.m., Registered Nurse (RN) 2 stated it was not acceptable for CNA 1 to be asleep while on duty. Staff must be fully awake during their shift because sleeping while on duty was a safety issue. RN 2 stated CNA 1 could fail to hear residents calling out for help and he could not provide care to residents while asleep. RN 2 stated CNA 1 was assigned to the East Station and was covering the area for the CNA 9 who was assigned to Resident 1. During a concurrent observation and interview on 7/29/2026 at 5:31 a.m., with Resident 1, Resident 1 was observed sitting upright in his wheelchair next to his bed, awake and alert. Resident 1 asked, Did you see that CNA (CNA 1) sleeping in the corner this morning? Resident 1 stated CNA 1 frequently sleeps there during the night shift and on multiple occasions he has witnessed CNA 1 asleep while other residents called for assistance and he (CNA 1) did not respond. Resident 1 stated he on previous occasions when CNA 1 provided his care, CNA 1 did not respond when he activated his call light and called out for assistance. He requested that CNA 1 not be assigned to his care because CNA 1 repeatedly slept during the night and did not respond to the call lights. During an interview on 7/30/2026 at 11:45 a.m., the Director of Nursing (DON) stated she was unaware that CNA 1 was sleeping during the 11 p.m. to 7 a.m. shift or that Resident 1 did not want CNA 1 assigned to provide his care because of concerns with CNA 1 sleeping. The DON stated if CNA 1 was sleeping during his shift he would not hear when residents' when they requested assistance by using their call light and residents' were at risk of falling if their call lights were not being answered. During an interview on 7/30/2026 at 1:51 p.m., the Administrator (ADM) stated he was aware of the concerns that Resident 1 had with his call light not being answered, was aware, per Resident 1's report to him that Resident 1 was not being changed, but he was not aware that CNA 1 sleeping during the 11 p.m., to 3 a.m., shift. During a review of the facility's undated Policy and Procedure (P&P), titled Section 3 Staff Conduct, the P&P indicated staff must follow departmental policies, procedures, and perform their responsibilities in an ethical manner and within assigned timeframes. Staff must refrain from engaging in behavior that could endanger others. Staff may not sleep while on duty. During a review of the facility's P&P, titled Daily Work Assignments, revised 8/2006, the P&P indicated all nursing service personnel shall follow daily work assignment and perform assigned duties in accordance with the professional standards of practice and facility policy. CNAs and trainees are expected to carry out their daily assignments in a professional manner and in accordance with established nursing procedures. During a review of the facility's Job Description titled Certified Nursing Assistant (CNA) updated 11/1/2024, the Job Description indicated the Certified Nursing Assistant (CNA) provided essential personal care and support to residents, ensuring their comfort and well-being. The CNA was responsible for supporting residents in their daily activities. The CNA provided AM and PM care, ensuring residents received appropriate support throughout the day. The CNA promptly answered resident call lights and addressed requests with appropriate responses.

Based on observation, interview, and record review, the facility failed to ensure for two of three sampled residents (Resident 1 and Resident 14): 1. Medications prepared for Resident 1 by Licensed Vocational Nurse (LVN) 1 were not administered to Resident 1 by LVN 3. 2. Resident 14's discontinued medication, Gabapentin (a medication that calms overactive nerves in the body) was removed from the Medication Cart immediately after it was discontinued. These deficient practices resulted in LVN 3 administering medications to Resident 1 that she did not prepare, without verifying the order to ensure the correct medication and dosage was given, as well as the discontinued Gabapentin remaining in the Medication Cart and being administered to Resident 14. These deficient practices had the potential for medications errors to occur and for Resident 1 and Resident 14 to receive incorrect medications, harm and, adverse consequences to occur.Findings: During a review of Resident 1's Order Summary Report (Physician's Order) dated 7/30/2026, the Physician's Order indicated the following 9 a.m., medication orders: 1. Aspirin (a medication used to prevent blood clots) oral tablet chewable 81 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), give one tablet one time a day for cerebrovascular accident for ([CVA] stroke, loss of blood flow to a part of the brain). 2. Empagliflozin (a medication used to help the body remove extra sugar and fluid through the urine) oral tablet 10 mg, give one tablet one time a day for heart failure 3. Ezetimibe (a medication used to lower cholesterol levels) oral tablet 10 mg, give one tablet one time a day for hyperlipidemia (elevated levels of fat in the blood). 4. Furosemide (a medication used to lower blood pressure and remove extra fluid from the body) oral tablet 20 mg, give one tablet one time a day for HTN; hold if systolic blood pressure ([SBP, the pressure in the arteries when the heart beats) is below 110 millimeters of mercury ([mmHg] a unit of measurement). 5. Gabapentin 300 mg, give one capsule four times a day for neuropathy (nerve damage that can cause numbness, tingling, weakness, or pain). 6. Metoprolol Succinate (a medication used to lower blood pressure and heart rate) ER (extended release) tablet 50 mg, give one tablet one time a day for HTN; hold if SBP is below 100 mmHg. 7. Telmisartan (a medication used to lower blood pressure) oral tablet 40 mg, give 40 mg one time a day for HTN; hold if SBP is below 110 mmHg. During a review of Resident 1's Medication Administration Audit Report ([MAAR] a document used to check whether medications in a facility are being given safely, correctly, and according to required policies) X dated 7/29/2026, the MAAR indicated Aspirin Oral Tablet Chewable 81 mg, Empagliflozin Oral Tablet 10 mg, Ezetimibe Oral Tablet 10 mg, Furosemide Oral Tablet 20 mg, Gabapentin Capsule 300 mg, Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 mg, and Telmisartan Oral Tablet 40 mg were administered on 7/27/2026 at 12:21 p.m., by LVN 2. During a concurrent observation and interview on 7/27/2026 at 12:10 p.m., with LVN 1, several medication cups were observed on a tray on top of a Medication Cart. The medication cups contained Resident 1's 9 a.m., medications. LVN 1 stated she LVN 2 to give Resident 1 his medications, LVN 2 agreed and was observed entering Resident 1's room to administer Resident 1's 9 a.m. medications. During an interview on 7/28/2026 at 3:19 p.m., LVN 1 stated the nurse who prepares the medications should administer the medications because the person who prepares the medications were aware of what was prepared. During an interview on 7/28/2026 at 3:39 p.m., LVN 2 stated LVN 1 asked her to administer Resident 1's medications after LVN 1 had already prepared Resident 1's medications and placed the medications in medication cups. LVN 2 stated this was not the proper way to prepare and administer medications because of the risk for medication errors. The nurse who prepares the medications for administration should be the one who administers the medication to the resident. During an interview on 7/30/2026 at 11:45 a.m., the Director of Nursing (DON) stated if LVN 1 needed assistance from LVN 3 with administering medications, LVN 1 should have allowed LVN 3 to prepare the medications that she would be administering to ensure she (LVN 3) knew what she was giving to Resident 1. Not following the correct procedure for medication administration could result in a wrong medication administration and harm to the resident. During a review of the facility's undated Policy and Procedure (P&P), titled Administering Medications the P&P indicated individual administering the medication checked the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method/route of administration before giving the medication. During a review of the facility's undated P&P, titled Licensed Nurse (LN) Medication Administration Policy the P&P indicated Licensed Nurses safely prepare, administer, monitor, and document medications according to physician orders, facility policy, state and federal regulations, and accepted standards of nursing practice. Licensed Nurses verified the physician's order before administering any medication. b. During a review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE]. Resident 14 had diagnoses including anorexia nervosa (an eating disorder that involves severe calorie restrictions and, often, a very low body weight), and polyneuropathy (a disease or dysfunction of many nerves, typically causing numbness or weakness in hands and feet), and abnormalities of gait (a particular way or pattern of walking, running, or moving on foot) and mobility. During a review of Resident 14's History and Physical (H&P), dated 6/25/2026, the H&P indicated Resident 14 had the capacity to understand and make medical decisions. During a review of Resident 14's Minimum Data Set ([MDS] a resident assessment tool), dated 6/29/2026, the MDS indicated Resident 1's cognition (ability to register and recall information) was intact and she was able to understand and be understood by others. During a review of Resident 14's Physician's Orders, dated 7/20/2026, the Physician's Orders indicated Resident 1 was to receive Gabapentin (a prescription medicine that calms overactive nerves in the body) oral tablet 100 milligrams ([mg] - a metric unit of measurement, used for medication dosage and/or amount) give one tablet three times a day for neuropathy. During a review of Resident 14's Change of Condition (COC) note that the COC indicated Resident 14 claimed she felt her heart rate elevate after taking Gabapentin. The physician was notified on 7/21/2026 at 10:04 a.m. and gave an order to discontinue the Gabapentin. During a review of Resident 14's Physician Order, dated 7/21/2026 at 11:14 a.m., the Physician's Order indicated Gabapentin 100 mg was discontinued. The Physician's Order was received and confirmed by Registered Nurse (RN) 3. During an interview on 7/29/2026 at 10 a.m., Resident 14 stated on 7/21/2026 she felt like her heart was beating faster after taking Gabapentin. Resident 14 stated her physician discontinued the medication that same day (7/21/2026). Resident 14 stated after the Gabapentin was discontinued on 7/21/2026, several nursing staff continued to place the Gabapentin tablet in a medication cup along with her other medications on at least three occasions, She refused the Gabapentin each time. I kept informing the nursing staff that the Gabapentin had been discontinued., If she had she not questioned the nursing staff, she might have mistakenly taken the medication and experienced side effects again. During an interview on 7/29/2026 at 11:30 a.m., RN 3 stated on 7/21/2026, Resident 14 informed him she felt her heart was beating fast after taking Gabapentin. He notified Resident 1's physician, and the Gabapentin was discontinued on 7/21/2026. RN 3 stated he did not remove the discontinued Gabapentin pills from the drawer but instead instructed Resident 14's assigned medication nurse on that shift to remove the Gabapentin from Resident 14's medication drawer and place it in the discontinued medication bin in the medication room. RN 3 stated the facility's practice was for the licensed nurse receiving a discontinuation order to immediately remove the medication from the cart to prevent a medication error and eliminate the risk of administering unnecessary medication. RN 3 stated he did not follow this process. During an interview with RN 3 and a concurrent observation of the Medication Cart on 7/29/2026 at 11:40 a.m., the Medication Cart was noted to contain Gabapentin 100 mg prescribe to Resident 14. es. RN 3 stated the Gabapentin remained in Resident 14's drawer eight days after it had been discontinued and not removing the Gabapentin placed Resident 14 at risk of receiving medication that had been discontinued and could cause her harm. During a telephone interview on 7/29/2026 at 11:50 a.m., and a subsequent interview at 12 p.m., Licensed Vocational Nurse (LVN) 4 stated on 7/28/2026 she prepared all of Resident 14's 9 a.m., oral medications for administration, placed them in one medication cup and handed the cup to Resident 14 to swallow the pills. Resident 14 informed her that one of the medications in the cup was Gabapentin, which had been discontinued on 7/21/2026. LVN 4 stated she then reviewed Resident 14's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) to verify Resident 14's medications. The MAR did have t Gabapentin listed for administration to Resident 14. LVN 4 stated she did not follow the proper medication administration process, that included confirming each medication and dosage against the MAR. She did not remove the discontinued medication from the drawer because she was busy on that shift. Not following this appropriate process could result in administering discontinued or incorrect medications, placing Resident 1 at risk for harm. During an interview on 7/29/2026 at 4 p.m., the Director of Nursing (DON) stated nurses were required to confirm each medication and dosage against the MAR, and ensure the medication was ordered before preparing and administering the medication Nurses should remove discontinued medications from the Medication Cart and place them in the designated discontinued medication bin to prevent accidental administration. Failure to follow those steps could lead to medication errors, including administering discontinued or incorrect medications. This posed specific harm to Resident 14 because she had previously experienced tachycardia (increased heart rate) after taking Gabapentin. During a review of the facility's Policy and Procedure (P&P) titled, Medication Labeling and Storage, revised 2/2023, the P&P indicated if the facility had discontinued medications the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview and record review, the facility failed to ensure a personal protective equipment (PPE- gown, gloves and masks) trash receptacle had a cover for one of three sampled (Resident 1) who was on contact precautions (infection control strategy to help prevent the spread of infectious agents) for scabies (highly contagious microscopic bug that burrows (digs) into the top layer of the human skin to live and lay eggs causing intense itching).This deficient practice had the potential to spread scabies through cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products). Findings:During a review of Resident1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including multiple sclerosis (MS - a chronic disease that effect the central nervous system affecting the brain spinal cord and optic nerve), depression (feelings of sadness and emptiness) and right sided hemiplegia (paralysis of one side of the body).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/3/2026, the MDS indicated, Resident 1's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 1 was totally dependent (staff does all the effort) with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) such as bathing, dressing and toileting).During a review of Resident 1's History & Physical (H&P) dated 3/17/26, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Physicians Order dated 7/6/2026, the Physicians Order indicated, Resident 1 was on contact precautions (precautions intended to prevent transmission of infectious agents). for presumed (possible) scabies. Staff and visitors to apply gloves and gown prior to entering room and remove before exiting room.During a review of Resident 1's Care Plan titled Resident has presumed scabies on skin dated 7/6/2026, the Care Plan goal indicated for Resident 1 to experience reduced itching and healing of the presumed effected areas. The care plan indicated, to start contact precautions and apply topical steroid cream (medication to help with inflammation and itching) as ordered for itching as needed (PRN).During a phone interview on 7/13/26 at 6:06 p.m. with Family Member 1(FM 1), FM 1 stated Resident 1 was put on contact precautions for scabies on 7/6/2026. FM 1 stated on 7/11/2026 during a visit with Resident 1, FM 1 observed there was no lid on the trash receptacle were the dirty PPE was being placed and felt there should be one for infection prevention since scabies was highly contagious (catch easily).During a concurrent observation and interview on 7/14/2026 at 9:00 a.m. in Resident 1's room with Treatment Nurse 1 (TXN 1), the PPE trash receptacle was observed without a lid. TXN 1 stated a lid was required on the trash receptacle to prevent the spread of infection from cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products), noting that Resident 1 had scabies and it was highly contagious.During a phone interview on 7/14/2026 at 2:00 p.m. with the Infection Preventionist (IP), the IP stated Resident 1 was on contact precautions for scabies and the trash receptacle used for PPE disposal needed to have a lid to contain any organisms that might be on the contaminated PPE. The IP stated there was a potential for cross contamination and for scabies to spread because the trash receptacle was not covered.During an interview on 7/14/26 at 2:22 p.m. with the Director of Nurses (DON), the DON stated Resident 1 was on contact precautions for scabies. The DON explained that used PPE needed to be disposed of in a covered container to contain germs and prevent the spread of infection through cross contamination.During a review of the facility's policy and procedure (P&P) titled PPE Disposal Bin dated 10/2015, the P&P indicated, the purpose was to ensure the safe and proper disposal of personal protective equipment (PPE) and reduce the risk of infection transmission. The P&P indicated, A designated PPE disposal bin shall be placed outside or inside the resident's room, as appropriate, for residents on Transmission-Based Precautions or when indicated. Staff shall discard used gloves, gowns, masks, and other disposable PPE immediately after use in the designated PPE disposal bin before leaving the area, in accordance with facility infection prevention practices. PPE disposal bins shall remain covered (if applicable), clean, in good condition, and not be overfilled.

Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1), who was diagnosed with scabies (highly contagious microscopic bug that burrows (digs) into the top layer of the human skin to live and lay eggs causing intense itching) received the prescribed ivermectin (medication to kill scabies) and permethrin (medication to kill scabies) in a timely manner.This deficient practice resulted in Resident 1 to not feel listened to and caused Resident 1 to suffer from burning and itching due to active scabies mites burrowing into Resident 1's skin.Findings:During a review of Resident1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including multiple sclerosis (MS - a chronic disease that effect the central nervous system affecting the brain spinal cord and optic nerve), depression (feelings of sadness and emptiness) and right sided hemiplegia (paralysis of one side of the body).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/3/2026, the MDS indicated, Resident 1's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 1 was totally dependent (staff does all the effort) with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) such as bathing, dressing and toileting).During a review of Resident 1's History & Physical (H&P) dated 3/17/26, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Change of Condition evaluation ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) dated 2/17/26, the COC indicated Resident 1 complained of itchiness to left thumb, chest and abdomen (stomach area) with trace papular lesions (small solid, raised skin bump) on left thumb, and chest.During a review of Resident 1's Care Plan titled Resident has atopic dermatitis with trace papular lesion to left thumb, lower chest, and abdomen dated 2/17/2026, the Care Plan indicated, Resident 1's rash had been resolved (cleared) on 6/4/2026.During a review of Resident 1's Progress Note dated 6/24/2026, the Progress Note indicated Resident 1 's abdominal dermatitis had resolved and the treatment order was discontinued.During the review of Resident 1's Progress Note dated 6/30/2026, the Progress Note indicated Resident 1 had small bumps on her abdomen. The Progress Note indicated Resident 1 requested an outpatient dermatology (treat diseases of the skin) appointment and had been scheduled to see a dermatologist on 7/6/2026 at 2:30 p.m.During the review of Resident 1's Physician Order dated 7/6/2026, the Physician Order indicated Resident 1 was on contact precautions (precautions intended to prevent transmission of infectious agents). Staff and visitors to apply gloves and gown prior to entering room and remove before exiting room.During the review of Resident 1's Physician Order dated 7/6/2026, the Physician Order indicated permethrin 5% cream was to be applied from the neck down, left on overnight, and rinsed. The medication was placed on hold on 7/6/2026 and resumed on 7/10/26.During the review of Resident 1's Physician Order dated 7/6/2026, the order indicated Ivermectin tablet three milligrams (mg-unit of measure) give three tablets by mouth one time for scabies. The medication was placed on hold on 7/6/26 and resumed on 7/10/26.During a review of Resident 1's Progress Note dated 7/6/2026, the Progress Note indicated Resident 1 had been seen by a dermatologist on 7/6/26 and received new orders for ivermectin and permethrin. The Progress Noted indicated another dermatologist was scheduled to see Resident 1 on 7/7/2026. The note indicated the scabies diagnosis was based solely on visual observation rather than a skin scraping (collects skin to examine under [microscope- instrument used to see things too small to see with the eye]) and microscopic examination.During a review of Resident 1's Dermatologist Progress Note dated 7/6/2026, the Progress Note indicated, Resident 1 had a scabies prep performed on the epigastric (stomach) skin and a dermatoscope (microscopic lens with light) was used showing mites (microscopic eight-legged bug) and ova (eggs) a photo of the mite taken on 7/6/2026 at 2:44 p.m. was provided with the Progress Note. The note indicated, Resident 1 had scabietic nodules (bumps with mites inside) with linear burrows (tiny thread like tracks formed by the female itch mite as she tunnels into the upper layers of the skin) distributed on the body throughout and epigastric skin. The Progress Note indicated, the plan of care was permethrin 5 % topical cream apply from neck down on all skin areas, rinse after 10-12 hours, repeat in one week, ivermectin three mgs by mouth take three tabs once, repeat in one week and triamcinolone acetonide 0.1 % topical cream apply two times a day (BID) to itchy rash areas as needed (PRN).During a review of Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) note dated 7/6/26, IDT note indicated the team met to discuss Resident 1's current papular rash of undetermined (unknown) etiology. The IDT note indicated the team had not objectively confirmed a diagnosis of scabies. The team recommended holding Resident 1's ivermectin and permethrin treatment until a secondary dermatology evaluation and a confirmatory skin scraping were completed. The IDT note also indicated Resident 1's Primary Care Physician (PCP) agreed with the decision. The note indicated neither Resident 1 nor Resident 1's Power of Attorney (POA, the individual authorized to make decisions for the resident) were present at the IDT meeting.During a review of Resident 1's Care Plan titled Resident has presumed scabies on skin, dated 7/6/2026, the Care Plan goal indicated the resident would experience reduced itching and healing of the presumed affected areas. The Care Plan interventions indicated to implement contact precautions and apply topical steroid (medication to help with inflammation and itching) as ordered for itching as needed.During a review of Resident 1's Progress Notes dated 7/11/2026, the Progress Notes indicated, Resident 1's PCP was notified of Resident 1's clinical findings. The note indicated Resident 1's medications were no longer on hold and Resident 1 was provided the medications as prescribed for scabies.During a phone interview on 7/13/2026 at 6:06 p.m. with Family Member 1 (FM 1), FM 1 stated Resident 1's rash began around six months earlier. FM 1 stated Resident 1 had been sent to an outpatient dermatologist on 7/6/2026 and had been diagnosed with scabies. FM 1 stated the facility told Resident 1 they planned to get a second opinion and place the treatment plan on hold. FM 1 stated that it seemed strange because the dermatologist was already the second opinion. FM 1 stated Resident 1's skin was hurting and very itchy. FM 1 stated Resident 1 had been having trouble sleeping, and the rash was itchiest at night. FM 1 stated Resident 1 could not scratch herself because she had MS. FM 1 stated Resident 1 was treated five days after being diagnosed with scabies.During an interview on 7/14/2026 at 8:00 a.m., with Resident 1, Resident 1 stated the rash had been present for a few months. She stated it burned deep in her skin and was itchiest at night. Resident 1 stated she could not scratch herself because she had MS. Resident 1 stated during her dermatology appointment on 7/6/2026, the dermatologist told her she had scabies after performing a skin scraping and examining it under a microscope. She stated she was not treated until 7/11/26. Resident 1 stated TXN 1 told her the facility wanted a second opinion before starting treatment.During an interview on 7/14/26 at 8:30 a.m., Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had the rash for months and the Infection Preventionist (IP) and treatment nurse (TX) were aware. CNA 1 stated Resident 1 had been complaining her skin burned and that she was having trouble sleeping because of the itching. CNA 1 stated the TX nurses had been applying steroid cream (medication to help with inflammation and itching), but the rash never completely went away.During an interview on 7/14/26 at 9:00 a.m., with Treatment Nurse 1 (TXN 1), TXN 1 stated she completed a Change of Condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) for Resident 1 on 2/17/2026 after Resident 1 complained of itchiness on her left thumb, chest, and abdomen, with trace papular lesions on her left thumb and chest. TXN 1 stated she had not cared for Resident 1 for some time, and on 6/30/2026, while providing treatment, Resident 1 asked her for help scheduling an outpatient dermatology appointment. TXN 1 stated Resident 1 still had the same rash she observed in February and reported being uncomfortable and very itchy. TXN 1 scheduled a dermatology appointment for 7/6/2026. She stated when Resident 1 returned from the appointment on 7/6/2026, she had been diagnosed with scabies. TXN 1 stated she contacted the dermatologist's office on 7/6/2026, and the office confirmed they performed a skin scraping and would send the confirmatory results. She stated the Director of Nursing (DON) was present during her call with the dermatologist's office. TXN 1 stated she provided the dermatologist with the electronic fax (e fax) number in the admissions office and told the Admissions Coordinator (AC) to watch for an urgent e fax for Resident 1 because she would not return to work until Friday, 7/10/26. TXN 1 stated she informed Resident 1 that the facility wanted a second opinion and the treatment plan was on hold. TXN 1 stated when she returned to work on 7/10/26, Resident 1 still had not been treated because there had been no follow up with the dermatologist. TXN 1 stated she called the dermatologist's office and had the Progress Note emailed to her work email. After receiving the PN with the confirmatory picture of the scabies mite taken from Resident 1's skin scraping on 7/6/2026, TXN 1 resumed Resident 1's treatment orders on 7/10/2026. She stated Resident 1 received her first scabies skin treatment on 7/11/2026. TXN 1 stated there had been a delay in care and Resident 1 should have been treated on 7/6/2026 when she was diagnosed with scabies.During an interview on 7/14/26 at 10:01 a.m., with the Admissions Coordinator (AC), AC stated she had been informed by TXN 1 on 7/6/2026 to watch for an urgent fax from a dermatologist's office for Resident 1. The AC stated admissions e fax did not receive any fax from the dermatologist's office, and she presumed the matter had been taken care of.During a phone interview on 7/14/26 at 1:29 p.m. with Resident 1's primary care physician (PCP), the PCP stated he was not shown the Progress Note with the confirmatory diagnosis of scabies, including the photo of the mite taken under a microscope, until 7/10/2026. He stated that if he had received that information on 7/6/2026, he would not have agreed to hold Resident 1's scabies treatment for a second opinion and would have treated her aggressively on 7/6/2026. The PCP stated there had been a delay in treating Resident 1's scabies.During a phone interview on 7/14/2026 at 2:00 p.m., with the Infection Preventionist (IP), IP stated on 7/6/2026 she was made aware of Resident 1's scabies diagnosis and was waiting for the dermatologist to fax the confirmatory findings from Resident 1's appointment. The IP stated no one followed up with the dermatologist's office for the Progress Note until 7/10/2026. She stated Resident 1 should have been treated on 7/6/2026 and there was a delay in care because the facility did not follow up sooner with the dermatologist's office. The IP added Resident 1 may have felt unheard and uncomfortable when she repeatedly told staff she was itchy.During an interview on 7/14/2026 at 2:22 p.m., with the DON, the DON stated she had been waiting for a Progress Note with a more definitive diagnosis, which was why Resident 1's scabies plan of care was placed on hold. The DON stated there was a delay in care because no one followed up with the dermatologist until 7/10/2026. She stated Resident 1 must have been uncomfortable from being so itchy.During a review of the facility's policy and procedure (P&P) titled Following Physicians orders dated 4/2018, the P&P indicated, the purpose was to ensure all physician/practitioner orders are accurately received, reviewed, implemented, documented, and monitored in a timely manner to provide safe and effective resident care. The P&P indicated, orders shall be initiated promptly according to the urgency specified by the practitioner. Nursing staff shall ensure, medications are administered as ordered, treatments are performed as ordered and laboratory tests, diagnostic services, and consultations are arranged timely.

Based on observation, interview, and record review, the facility failed to complete a change of condition (COC) and notify the physician timely when two of five sampled residents (Residents 75 and 15) had a significant change of condition in physical status when:1. staff reported Resident 75's repeated refusals to walk during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment and a decline in walking distance.2. staff reported Resident 15's repeated refusals to put on left ankle foot orthoses ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot) during RNA treatment. These deficient practices resulted in Resident 75 and Resident 15 experiencing a change in physical condition without informing the physician timely and a delay in providing alternative interventions and treatments.Findings: 1. During a review of Resident 75's admission Record, the admission Record indicated Resident 75 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to acquired absence of left leg below knee, acquired absence of right leg below knee, and difficulty in walking.During a review of Resident 75's Minimum Data Set (MDS, resident assessment tool) dated 5/25/2026, the MDS indicated Resident 75 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 75 had no functional range of motion (ROM, full movement potential of a joint) limitations in the upper extremity (UE, shoulder, elbow, wrist, hand) and had limitations on both sides of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 75 required set up assistance with eating, oral hygiene and substantial assistance with bathing, lower body dressing and walking 150 feet. The MDS indicated Resident 75 required partial assistance with sit to stand, sit to lying, and chair to bed transfers.During a review of Resident 75's Order Summary Report dated 7/8/2026, the Order Summary Report indicated an order dated 4/20/2025 may participate in Restorative Nursing Program as necessary.During a review of Resident 75's Care Plan Report, the Care Plan Report indicated a care plan revised 7/11/2025 that Resident 75 had the potential to benefit from participation in restorative nursing related to maintain current function. The care plan goal indicated Resident 75 will maintain current level of function through the review date. The care plan intervention/tasks revised on 5/27/2025 indicated to monitor resident on restorative program for tolerance of the program; ambulation (walking) using front-wheeled walker(FWW, type of mobility aid with wide base of support and two wheels in the front) right and left below knee prosthesis (artificial part of the body) as tolerated with skin checks once a day three times a week.During a review of Resident 75's June 2026 Documentation Survey Report (DSR), the DSR indicated Resident 75 walked between 280 feet and 600 feet from 6/1/2026 to 6/20/2026. The DSR indicated Resident 75 refused ambulation on 6/24/2026, 6/29/2026, and 6/30/2026.During a review of Resident 75's July 2026 DSR, the DSR indicated Resident 75 refused RNA ambulation on 7/1/2026, 7/3/2026, 7/4/2026, and walked 25 feet on 7/6/2026, and 75 feet on 7/7/2026.During an observation and interview on 7/6/2026 at 10:15 AM, Resident 75 was sitting in a wheelchair and able to self-propel the wheelchair from the hallway to Resident 75's room. Resident 75 stated he received a new left leg prosthesis a few weeks ago and almost fell using the new left leg prosthesis a couple of weeks ago when walking with staff. Resident 75 stated the left leg was feeling better and started to walk again this week.During an interview on 7/8/2026 at 12:08 PM with Restorative Nursing Aide (RNA 1), RNA 1 stated about two weeks ago Resident 75 was walking with Restorative Nursing Aide (RNA 3) and Resident 75's left knee locked up and he could not walk and had to ask for help to sit down. RNA 1 stated after that day, Resident 75 did not want to walk because of pain, and RNA staff reported it to nursing staff. RNA 1 stated Resident 75 refused at least three times for a couple of weeks. RNA 1 stated Resident 75 walked today, but Resident 75 walked less than usual. RNA 1 stated RNAs need to report if Resident 75 was refusing RNA or if Resident 75 was walking less, because it could mean that something was wrong because of pain or something with the prosthetic.During an interview and record review on 7/8/2026 at 12:17 PM with Registered Nurse Supervisor (RN 1), RN 1 reviewed Resident 75's June 2026 and July 2026 RNA treatment records and stated Resident 75 refused to ambulate on 6/29/2026, 6/30/2026, 7/1/2026, 7/3/2026, 7/4/2026. RN 1 stated he was not aware of Resident 75's refusals to ambulate during RNA. RN 1 stated there was also a decline in the distance Resident 75 ambulated after the refusals. RN 1 reviewed Resident 75's records and stated a COC was not completed for Resident 75. RN 1 stated a COC should have been completed on 7/1/2026 after the third refusal, because there was a change in Resident 75's condition and it was affecting Resident 75's activities of daily living. RN 1 stated because staff did not complete a COC, the facility did not monitor Resident 75's pain or Resident 75's decline in walking.During an interview on 7/8/2026 at 3:26 PM with the Director of Nursing (DON), the DON stated the RNA program was for residents who required maintenance and were at high risk for decline in activities of daily living and contractures. DON stated if a resident was walking before and now could not walk or did not walk the same distance for three days, then it was a COC because this was not the resident's usual condition and the resident was declining. DON stated the facility should complete a COC so the facility could monitor the resident, prevent decline, and provide any interventions needed.During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Resident Mobility and Range of Motion (ROM) Policy, the P&P indicated nursing staff will observe for changes in mobility and report significant changes to the interdisciplinary team (IDT). Significant changes or declines will be reported to the physician, responsible party, and IDT as appropriate.During a review of the facility's P&P revised 3/2018, titled, Acute Condition Changes - Clinical Protocol, the P&P indicated the staff and physician will discuss possible causes of the condition change.the physician will help identify and authorize appropriate treatments.the staff will monitor and document the resident/patient's progress and responses to treatment and the physician will adjust treatment accordingly.During a review of the facility's P&P revised 2/2020, titled, Quality of Care, the P&P indicated key standards of care included ongoing assessment and timely identification of changes in resident condition.2. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side, Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 15's Minimum Data Set (MDS, resident assessment tool) dated 5/25/2026, the MDS indicated Resident 15 was cognitively intact and did not exhibit any behaviors in rejection of care. The MDS indicated Resident 15 had functional limitation in range of motion (ROM, full movement potential of a joint) on one side of the upper extremity (UE, shoulder, elbow, wrist, hand) and on one side of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 15 required set up with eating and oral hygiene, required substantial/maximal assistance in bathing, dressing, sit to lying, and chair to bed transfersDuring a review of Resident 15's Order Summary Report dated 7/8/2026, the Order Summary Report indicated an order dated 4/22/2025 for may participate in restorative nursing program as necessary.During a review of Resident 15's Care Plan Report, the Care Plan Report indicated a care plan initiated 6/12/2024 that Resident 15 had the potential to benefit from participation in restorative nursing related to maintain current function. The care plan goal indicated Resident 15 will maintain current level of function. The care plan interventions/tasks indicated the following: RNA program for LUE passive range of motion (PROM, movement at a given joint with full assistance from another person) once a day three times a week as tolerated, initiated on 6/12/2024; RNA program for splinting using left AFO as tolerated with skin check once a day three times a week; RNA program for LLE active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises as tolerated once a day, three times a week; RNA program for RLE PROM exercises as tolerated once a day, three times a week; RNA program for RUE AAROM once a day, three times a week as tolerated.During a review of Resident 15's June 2026 Documentation Survey Report, the Documentation Survey Report indicated Resident 15 refused RNA program for splinting using left AFO as tolerated with skin check on 6/9/2026, 6/11/2026, 6/16/2026, 6/18/2026, 6/27/2026, and 6/30/2026.During a review of Resident 15's July 2026 Documentation Survey Report, the Documentation Survey Report indicated Resident 15 refused RNA program for splinting using left AFO as tolerated with skin check on 7/4/2026 and 7/7/2026.During an observation and interview on 7/7/2026 at 12:44 PM in Resident 15's room, Restorative Nursing Aide (RNA 2) completed RNA treatment with Resident 15. RNA 2 completed AROM and AAROM on RUE and AAROM and PROM on Resident 15's right hip, knee, and ankle and left arm and legs. RNA 2 stated Resident 15 refused to wear the AFO for the left foot. RNA 2 stated Resident 15's left ankle did not really move up and down. RNA 2 stated she documented that Resident 15 refused to wear the left AFO and reported to the charge nurse. RNA 2 stated maybe the AFO caused discomfort, or it may not fit and that was why Resident 15 was refusing the AFO.During an interview and record review on 7/8/2026 at 10:23 AM with Registered Nurse Supervisor (RN 1), RN 1 stated if a resident on RNA refused to wear a splint after the third refusal, a change of condition assessment should be completed, and the facility should notify the physician. RN 1 reviewed Resident 15's RNA treatment records and stated Resident 15 refused putting on the left AFO three times in a row (6/27/2026, 6/30/2026, 7/4/2026). RN 1 stated a COC should have been completed on 7/4/2026 after the third refusal. RN 1 stated there was a delay in completing a COC for Resident 15's continued refusals in wearing the AFO during RNA treatment. RN 1 stated the purpose of a COC was to document the resident's new condition and baseline and to monitor the resident to see if he was improving or declining in that new condition. RN 1 stated there could be a delay in care if staff delayed completing a COC assessment. RN 1 stated nursing staff should have assessed Resident 15 earlier to see why Resident 15 was refusing to wear the left AFO and if Resident 15 had pain and if a Physical Therapy (a rehabilitation profession that restores, maintains, and promotes optimal physical function) evaluation was needed to evaluate the splint.During an interview on 7/8/2026 at 3:26 PM with the Director of Nursing (DON), the DON stated the RNA program was for residents who required maintenance and were at high risk for decline in activities of daily living and contractures. DON stated if a resident on RNA had multiple refusals to put on a splint, this was considered a COC, and a COC should be completed immediately. DON stated if a COC was not completed timely, then appropriate interventions could be delayed, and the resident could continue to decline.During a review of the facility's policies and procedures (P&P) revised 12/2009, titled, Application and Monitoring of Orthoses, Supports, Braces, and Splints, the P&P indicated report any concerns, refusals, skin issues, discomfort, or damaged equipment to the nurse and therapy department.During a review of the facility's P&P revised 3/2018, titled, Acute Condition Changes - Clinical Protocol, the P&P indicated the staff and physician will discuss possible causes of the condition change.the physician will help identify and authorize appropriate treatments.the staff will monitor and document the resident/patient's progress and responses to treatment and the physician will adjust treatment accordingly.During a review of the facility's P&P revised 2/2020, titled, Quality of Care, the P&P indicated key standards of care included ongoing assessment and timely identification of changes in resident condition.

Based on observation, interview, and record review, the facility failed to ensure staff assisted residents at eye level during mealtimes for three of four sampled residents (Residents 85, Resident 70 and Resident 119.These failures had the potential for Residents 85, Resident 70, and Resident 119 to not be treated with dignity and respect. Findings: Based on observation, interview, and record review, the facility failed to ensure staff assisted residents at eye level during mealtimes for three of four sampled residents (Residents 70, Resident 85 and Resident 119). These failures had the potential for Residents 85, Resident 70 and Resident 119 not to be treated with dignity and respect. Findings: During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was admitted on [DATE] to the facility with diagnoses including Parkinson's Disease with dyskinesia (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) difficulty in walking, and lack of coordination. During a review of Resident 70's Minimum Data Set (MDS- resident assessment tool) dated 6/28/2026, the MDS indicated Resident 70 had moderately impaired cognitive skills (person has trouble remembering things, making decisions, concentrating, and learning new things) and required partial/moderate assistance (helper does less than half the effort) with eating. The MDS indicated Resident 70 had impaired vision (sees large print, but not regular print in newspapers or books). During an observation on 7/7/2026 at 1:03 p.m. in Resident 70's room, Certified Nursing Assistant (CNA) 12 was sitting on a highchair while feeding Resident 70 with his meal. Resident 70 was lying in his bed in an upright position. During an interview on 7/7/2026 at 2:27 p.m. with Certified Nursing Assistant (CNA) 12, CNA 12 stated Resident 70 is unable to feed himself and requires assistance from the staff. CNA 12 stated she did not use a chair that was appropriate to feed a resident within eye level. CNA 12 stated it was important to sit next to the resident within eye level of the resident to ensure proper communication, prevention of choking and maintaining resident's dignity. During a review of Resident 119's admission Record, the admission Record indicated Resident 119 was admitted on [DATE] to the facility with diagnoses including pneumonia(an infection /inflammation in the lungs), dysphagia(difficulty in swallowing), hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side (total paralysis of the arm, leg, and trunk on the left side of the body following a stroke) and epilepsy (long term brain condition that causes repeated seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]). During a review of Resident 119's MDS dated [DATE], the MDS indicated Resident 119 had severely cognitive impairment (a person has trouble with basic brain functions like thinking, learning and making decisions) and was dependent on staff with eating, toileting hygiene, toileting hygiene, bathing and bed mobility. During a concurrent observation and interview on 7/6/2026 at 1:25 p.m. in Resident 119's room with Physical Therapist (PT)1, Resident 119 was sitting on the edge of the bed with legs dangled while PT 1 was standing while feeding Resident 119. PT 1 stated he was feeding Resident 119 because the nursing staff were busy. PT 1 stated he was going to sit the resident up anyway and decided to feed Resident 119. During an interview on 7/8/2026 at 4:04 p.m. with PT 1, PT 1 stated he was standing when he was assisting Resident 119 with his lunch because it was easier for him to balance his movement. PT 1 stated standing over the resident while assisting Resident 119 with his meal would not affect the resident because he brought himself down when he fed Resident 119. During an interview on 7/9/2026 at 11:07 a.m., with Registered Nurse (RN)1, RN 1 stated the staff should be sitting in a chair that was within eye level. RN 1 stated the staff should not be standing up or using a highchair while assisting residents during mealtime. RN1 stated sitting next to the residents and feeding them within eye level helped maintain their dignity, prevent aspiration (when food, liquid or other material enters a person's airway and lungs) and injury to their mouths. During an interview on 7/9/2026 at 3:14 p.m. with the Director of Nursing (DON), the DON stated the staff should get a chair and sit down within eye level next to the resident so they would be able to see their mouths while being assisted or fed to prevent choking and maintain their dignity. During a review of Resident 85's admission Record, the admission Record indicated Resident 85 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to, Parkinsons' disease ((a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (involuntary movements of extremities) with fluctuations, hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side, and dysphagia (difficulty swallowing). During a review of Resident 85's Minimum Data Set (MDS, resident assessment tool) dated 5/10/2026, the MDS indicated Resident 85 required set up or clean up assistance with eating. During a review of Resident 85's Occupational Therapy Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Treatment Encounter Note dated 7/6/2026, the OT Treatment Encounter Note indicated OT provided skilled interventions to facilitate independence with self feeding abilities. During an observation on 7/6/2026 at12:42 PM in the dining room, Resident 85 was sitting at a dining table eating lunch and Occupational Therapist (OT 1) was standing to the right of Resident 85. OT 1 assisted Resident 85 while eating lunch. During an interview on 7/6/2026 at 1:00 PM in the dining room with OT 1, OT 1 stated she was working with Resident 85 with self-feeding and using adaptive equipment during meals. OT 1 stated she stood next to Resident 85 while Resident 85 was eating lunch. OT 1 stated she should have sat down next to Resident 85 to be at eye level. During an interview on 7/8/2026 at 3:26 PM with the Director of Nursing (DON), DON stated staff should sit next to residents at eye level when residents were eating, because staff should be able to see the resident eating the food. During a review of the facility's policies and procedures (P&P) revised 10/2025, titled, Dignity, the P&P indicated residents are treated with dignity and respect at all times.

Based on observation, interview, and record review, the facility failed to provide services to maintain or prevent further decline in joint range of motion (ROM, full movement potential in a joint) in two of 31 sampled residents (Residents 5 and 15) when the facility failed to:1a. Objectively measure Resident 5's ROM impairments in the left shoulder, elbow, wrist and hand during an Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation dated 9/14/2025.1b. Document the application and removal of Resident 5's left elbow extension (straighten the elbow) splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and left resting hand splint (splint to help keep the hand open).2a. For Resident 15, provide a safe wear time parameter for application and removal of a left ankle foot orthosis (AFO, an orthotic device designed to correct or address problems with the ankle and foot).2b. Document the application and removal of Resident 15's left ankle foot orthosis. These deficient practices had the potential to prevent accurate monitoring of Resident 5's ROM impairments and potential for injury, pain, and skin integrity issues to Resident 5 and 15 when wearing splints. Findings:1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following nontraumatic intracerebral hemorrhage (blood vessel in brain ruptures and bleeds into brain tissue) affecting left non-dominant side.During a review of Resident 5's Minimum Data Set (MDS, resident assessment tool) dated 6/20/2026, the MDS indicated Resident 5 was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment). The MDS indicated Resident 5 had functional limitations in ROM in one side of the upper extremity (UE, shoulder, elbow, wrist, hand) and one side of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 5 required set up assistance with eating, substantial assistance with dressing, bathing, chair to bed transfers, and walking 10 feet.During a review of Resident 5's Order Summary Report dated 7/8/2026, the Order Summary Report indicated an order dated 10/21/2025 may participate in Restorative Nursing Program.During a review of Resident 5's Care Plan indicated Resident 5 had the potential to benefit from participation in restorative nursing related to maintain current function. The care plan intervention indicated restorative nursing left UE elbow extension splint and resting hand splint two hours as tolerated once a day three times a week.During an observation and interview on 7/6/2026 at 9:48 AM, Resident 5 was lying in bed. Resident 5 stated he was able to move his legs. Resident 5's left third to fifth fingers were bent and the second finger and thumb were straight. Resident 5 was able to move the left arm up and down a little and was able to move the right arm up and down.1a. During a review of Resident 5's OT Evaluation and Plan of Treatment dated 9/14/2025, the OT Evaluation indicated Resident 5 had impaired ROM in the left shoulder, left elbow/forearm, left wrist, left hand, left thumb, left index finger, left middle finger, left ring finger, left little finger. The OT Evaluation did not indicate objective measurements of the impaired ROM in the LUE joints. During an interview and record review on 7/7/2026 at 3:06 PM with Occupational Therapist (OT 2), OT 2 reviewed Resident 5's OT Evaluation dated 9/14/2025 and stated the OT Evaluation did not indicate any objective measurements for impaired ROM in the LUE. OT 2 stated OT evaluations should document the exact ROM measurements. OT 2 stated she could not tell if Resident 5 had a significant or minimal ROM limitation in the left arm because it was not documented in the OT evaluation. OT 2 stated OTs measured ROM to address contractures or limitations in ROM, because ROM affected activities of daily living, functional mobility such as the ability to comb your hair. OT 2 stated measuring and documenting ROM on an OT evaluation also provided a baseline measurement so that OT could see if there was any improvement or decline in a resident's ROM. During a record review of the facility's policies and procedures (P&P) revised 12/2009, titled, Therapy Evaluation and Discharge Summary, the P&P indicated to ensure timely, complete, and compliant therapy documentation that supports medical necessity, resident-centered care and regulatory compliance.During a record review of the facility's policies and procedures (P&P) revised 7/2017, titled, Resident Mobility and Range of Motion Policy, the P&P indicated the facility will assess, monitor, and support each resident's mobility and range of motion to maintain or improve function and prevent avoidable decline, complications and deficiencies related to mobility.1b. During a review of Resident 5's June 2026 Documentation Survey Report (DSR), the DSR indicated required documentation for Restorative Nursing: LUE elbow extension splint and resting hand splint two hours as tolerated once a day three times a week were 1. Amount of minutes spent providing splint or brace assistance, 2. Did the resident complain of or show sings of pain or discomfort? The DSR did not indicate documentation of application and removal of Resident 5's LUE elbow extension splint or LUE resting hand splint.During an interview and record review on 7/7/2026 at 9:20 AM with Restorative Nursing Aide (RNA 1), RNA 1 reviewed the electronic RNA documentation for splinting and RNA 1 stated for RNA splinting tasks, the electronic documentation system only asked how long RNA staff spent putting on and taking off the splints, but not when the splints were applied and removed. RNA 1 stated there was nowhere to document when RNAs applied and removed a splint. RNA 1 stated it was important to document how long a splint was worn because a splint could cause skin blisters or skin issues if it was worn too long or if a resident could not tolerate the splint for the time ordered, then it could mean a resident could have too much tone or something was happening with a resident. RNA 1 stated none of the residents with RNA splinting had a place to document when a splint was applied and removed. During an interview on 7/7/2026 at 3:06 PM with Occupational Therapist (OT 2), OT 2 stated therapists monitored a resident and established a safe wear time for residents wearing splints, because residents could have skin issues if a splint was worn for too long. OT 2 stated once a resident was able to safely tolerate a splint, then therapy would transition to RNA to put on the splint. OT 2 stated therapists need to tell RNAs how to put on splints, how long to put on a splint, and where to put the splint. OT 2 stated it was important for RNAs to monitor how long a resident wore a splint, because the time wearing the splint could tell you if there was an issue with the fit of the splint.During an interview and record review on 7/8/2026 at 10:23 AM with Registered Nurse Supervisor (RN 1), RN 1 reviewed Resident 5's RNA records and stated the RNA documentation did not track or document when the left elbow splint or left resting hand splint was applied and removed each day during RNA treatment. RN 1 stated the RNA documentation only required documentation on how many minutes an RNA spent putting on or taking off a splint. RN 1 stated it was important for RNAs to document when a splint was applied and removed, because splinting could cause pain and decreased skin circulation. RN 1 stated documentation was communication and if RNA staff did not document how long a resident wore a splint, then you could lose information for communication about the resident.During an interview on 7/8/2026 at 3:26 PM with the Director of Nursing (DON), DON stated residents on the RNA program were at high risk for decline in ADLs and contractures and helped to maintain a resident's function. DON stated RNAs should document when a splint was applied and removed. DON stated the documentation should show if a resident took off a splint early, because the splint wear time tolerance could change from the initial assessment and it could be a change of condition if a resident's tolerance for wearing a splint changed. DON stated it was important for RNAs to monitor and document when a splint was applied and removed, because it was in indication if a resident was tolerating a splint or if the resident experienced any changes. DON stated the facility needed to change the RNA documentation because the facility needed to document how long each resident was wearing a splint.During a record review of the facility's policies and procedures (P&P) revised 12/2009, titled, Application and Monitoring of Orthoses, Supports, Braces, and Splints, the P&P indicated to ensure orthoses, supports, braces, and splints are applied safely and monitored appropriately by RNAs in accordance with physician orders, therapy recommendations, and the resident's care plan. The P&P indicated document: device applied/removed, date and time, resident tolerance, skin condition, any concerns reported.2. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side, Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 15's Minimum Data Set (MDS, resident assessment tool) dated 5/25/2026, the MDS indicated Resident 15 was cognitively intact and did not exhibit any behaviors in rejection of care. The MDS indicated Resident 15 had functional limitation in range of motion (ROM, full movement potential of a joint) on one side of the upper extremity (UE, shoulder, elbow, wrist, hand) and on one side of the lower extremity (LE, hip, knee, ankle, foot). The MDS indicated Resident 15 required set up with eating and oral hygiene, required substantial/maximal assistance in bathing, dressing, sit to lying, and chair to bed transfersDuring a review of Resident 15's Order Summary Report dated 7/8/2026, the Order Summary Report indicated an order dated 4/22/2025 for may participate in restorative nursing program as necessary.During a review of Resident 15's Care Plan Report, the Care Plan Report indicated a care plan initiated 6/12/2024 that Resident 15 had the potential to benefit from participation in restorative nursing related to maintain current function. The care plan goal indicated Resident 15 will maintain current level of function. The care plan interventions/tasks indicated the following: RNA program for splinting using left AFO as tolerated with skin check once a day three times a week.During an observation and interview on 7/7/2026 at 12:44 PM in Resident 15's room, Restorative Nursing Aide (RNA 2) completed RNA treatment with Resident 15. RNA 2 completed AROM and AAROM on RUE and AAROM and PROM on Resident 15's right hip, knee, and ankle and left arm and legs. RNA 2 stated Resident 15 refused to wear the AFO for the left foot. RNA 2 stated Resident 15's left ankle did not really move up and down.During an interview and record review on 7/7/2026 at 9:20 AM with Restorative Nursing Aide (RNA 1), RNA 1 reviewed the electronic RNA documentation for splinting and RNA 1 stated for RNA splinting tasks, the electronic documentation system only asked how long RNA staff spent putting on and taking off the splints, but not when the splints were applied and removed. RNA 1 stated there was nowhere to document when RNAs applied and removed a splint. RNA 1 stated it was important to document how long a splint was worn because a splint could cause skin blisters or skin issues if it was worn too long or if a resident could not tolerate the splint for the time ordered, then it could mean a resident could have too much tone or something was happening with a resident. RNA 1 stated none of the residents with RNA splinting had a place to document when a splint was applied and removed. During an interview on 7/7/2026 at 3:06 PM with Occupational Therapist (OT 2), OT 2 stated therapists monitored a resident and established a safe wear time for residents wearing splints, because residents could have skin issues if a splint was worn for too long. OT 2 stated once a resident was able to safely tolerate a splint, then therapy would transition to RNA to put on the splint. OT 2 stated therapists need to tell RNAs how to put on splints, how long to put on a splint, and where to put the splint. OT 2 stated it was important for therapy to tell RNAs how long to put on a splint to keep the same interventions and time to maintain a resident's function. OT 2 stated it was important for RNAs to monitor how long a resident wore a splint, because the time wearing the splint could tell you if there was an issue with the fit of the splint.During an interview and record review on 7/8/2026 at 10:23 AM with Registered Nurse Supervisor (RN 1), RN 1 stated an RNA program was for residents who needed help with ROM and mobility. RN 1 stated RNAs receive instruction on what treatments to perform from therapy and the RNA tasks should include what splints to put on and how long to put on a splint. RN 1 reviewed Resident 15's RNA documentation records and stated the RNA documentation for the task for putting on a left AFO did not include how long Resident 15 should put on the left AFO. RN 1 stated the RNA task should include how long to put on the left AFO, because RNA treatment was an order that had to be executed and should be written. RN 1 stated RNA or nursing staff should not have to guess how long Resident 15 should wear the left AFO and the time should be written so every staff knew what RNA treatment should be completed. RN 1 stated if the wear time for the left AFO was not written, the RNAs could put on the left AFO for too short of a time or for too long and the facility could not measure the efficacy of the splints. RN 1 stated the RNA documentation also did not track or document when the left AFO was applied and removed each day. RN 1 stated the RNA documentation only required documentation on how many minutes an RNA spent to put on or take off a splint. RN 1 stated it was important for RNAs to document when the splint was applied and removed, because splinting could cause pain and decreased skin circulation.During an interview on 7/8/2026 at 3:26 PM with the Director of Nursing (DON), DON stated residents on the RNA program were at high risk for decline in ADLs and contractures and helped to maintain a resident's function. DON stated the RNA task should indicate how long a resident should put on a splint during RNA, because the RNAs need to know how long to put on a splint. DON stated if there was no wear time indicated in the RNA task, the contracture could worsen because the tolerance for the splint could have changed and could show that a therapist needed to re-evaluate the splint. DON stated the RNA should also document when a splint was applied and removed. DON stated the documentation should show if a resident took off a splint early, because the splint wear time tolerance could change from the initial assessment and it could be a change of condition if a resident's tolerance for wearing a splint changed. DON stated it was important for RNAs to monitor and document when a splint was applied and removed, because it was in indication if a resident was tolerating a splint or if the resident experienced any changes. DON stated the facility needed to change the RNA documentation because the facility needed to document how long each resident was wearing a splint.During a record review of the facility's policies and procedures (P&P) revised 12/2009, titled, Application and Monitoring of Orthoses, Supports, Braces, and Splints, the P&P indicated to ensure orthoses, supports, braces, and splints are applied safely and monitored appropriately by RNAs in accordance with physician orders, therapy recommendations, and the resident's care plan. The P&P indicated devices shall be used only as ordered and directed in the resident's care plan. The P&P indicated apply and remove the device according to therapy instructions and the care plan. The P&P indicated document: device applied/removed, date and time, resident tolerance, skin condition, any concerns reported.

Based on interview and record review, the facility failed to ensure a preadmission screening resident review (PASARR A screening to ensure a person is appropriately placed and receives needed services before entering a nursing facility) Level II was completed for two of three sampled residents (Resident 10 and Resident 16). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident 10 and Resident 16. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 10's PASARR Level I screening dated 5/9/2026, the PASARR Level I screening indicated Resident 10 had serious mental illness and a PASARR Level II screening was required. No PASARR Level II found. During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool) dated 6/22/2026, the MDS indicated Resident 10's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 10 was dependent (helper does all the effort with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a concurrent interview and record review on 7/8/2026 at 10:38 a.m., with the Minimum Data Set Assistant (MDSA), Resident 10's PASARR Level I dated 6/22/2026 was reviewed. The MDSA stated Resident 10's PASARR Level I screening was positive and a Level II PASARR II was required. The MDSA reviewed the Notice of Attempted Evaluation for a Level II PASARR screening that stated it was not completed because the facility staff were unresponsive in two or more separate attempts. The MDSA stated this should not have happened because the PASARR screening determines what the residents may need and assists with creating the residents plan of care. During an interview on 7/9/2026 at 2:01 p.m., with the Director of Nursing (DON), the DON stated it was important the PASARR screenings were done accurately to identify if the resident was appropriately placed at this facility and provide the residents with additional resources. During a review of the facility's policy and procedure titled, PASRR Policy revised March 2019, the P&P indicated, The facility shall ensure that all residents are screened for mental illness (MI) through the PASRR process prior to admission and as required post-admission, in compliance with federal and state regulations. The P&P indicated If Level I is positive, the facility must refer to the state PASRR authority for Level II evaluation. Level II determines need for nursing facility services and need for specialized services. 2.During a review of Resident 's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's was admitted to the facility with diagnoses including Schizoaffective disorder depressive type (is a chronic mental health condition combining schizophrenia symptoms (like hallucinations [hearing things not based in realty] or delusions [believing things not based on realty]) with major depressive episodes), type 2 diabetes mellitus (body's inability to process sugar) with diabetic polyneuropathy (nerve damage caused by chronically high blood sugar levels and metabolic stress), metabolic encephalopathy (a general term for brain dysfunction caused by chemical imbalances or toxins in the body). During a review of Resident 16's MDS, dated 06/012026, the MDS indicated, Resident 16 was severely cognitively impaired (indicating serious challenges with orientation (remembering dates/time) and short-term memory). The MDS indicated, Resident 16 required setup or clean-up assistance (helper sets up; resident completes activity. Helper assists only prior to or following the activity) from staff with eating, oral hygiene, and upper body dressing. During a concurrent interview and record review on 07/08/2026 at 9:12 a.m. with the MDSA, Resident 16's PASRR level I screening dated 12/01/2025 was reviewed. The PASARR Level 1 screening indicated that a severe mental illness, and a level II Mental Health Evaluation was required. The Notice of Evaluation for Level II screening completion dated 12/03/2025 indicated level II assessment was not completed due to Facility staff were unresponsive to two or more separate attempts of communication within 48hours of the Level I screening. As a result of the facility's lack of response, the PASRR Level II case was subsequently closed without completion of the required evaluation. The MDSA acknowledged the importance of timely tracking and follow-up of PASARR evaluations to ensure residents receive appropriate services. The MDSA stated the facility will assign a staff member specifically responsible for tracking PASRR referrals and follow-ups to prevent future occurrences. The MDSA stated staff education/in-service will be provided immediately regarding PASRR tracking and follow-up procedures. During a review of the facility's policy and procedure titled, PASARR Policy revised March 2019, the P&P indicated, The facility shall ensure that all residents are screened for mental illness (MI) through the PASRR process prior to admission and as required post-admission, in compliance with federal and state regulations. The P&P indicated If Level I is positive, the facility must refer to the state PASRR authority for Level II evaluation. Level II determines need for nursing facility services and need for specialized services.

Based on interview, and record review, the facility failed to revise the care plans for two of four sampled residents (Resident 102 and 161) by:Failing to revise the at risk for falls care plan dated 3/27/26 for Resident 102 who was found lying on the floor on 4/22/26.Failing to revise the care plan for Resident 161 to reflect the current plan of care for Resident 161's ruptured blister on the left hip that started on 5/26/26.These deficient practices had the potential for Residents 102 and 161 to not receive the appropriate care and/or services.Findings:1.During a review of Resident 102's admission Record (face sheet) dated 7/6/2026, the admission record indicated, Resident 102 was admitted to the facility on [DATE] with diagnoses including legally blind ( a person's eyesight is so limited that they can't see well enough to do everyday tasks, even with glasses) depression (feelings of sadness and emptiness) and history of falling.During a review of Resident 102's Minimum Data Set (MDS- a standardized assessment and care screening tool). The MDS indicated, Resident 102 had moderate cognitive impairment (memory). The MDS indicated, Resident 102 was totally dependent (staff does all the work) with activities of daily living (ADL's such as bathing, dressing and toileting).During a review of Resident 102's History & Physical (H&P) dated 5/30/2026, the H&P indicated, Resident 102 had fluctuating capacity to understand and make decisions.During a review of Resident 102's Change of Condition evaluation (COC) dated 4/22/2026, the COC indicated, Resident 102 was found lying on the floor.During a review of Resident 102's care plan titled, At risk for fall related to leaning to the left while seated in the wheel chair dated 3/27/2026. The care plan was not revised and updated to reflect Resident 102 had an actual fall on 4/22/2026.During an interview on 7/8/2026 at 9:51 a.m. with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident102 was found on the floor on 4/22/2026 and that the risk for falls care plan was not updated to reflect Resident 102 was found on the floor. LVN 5 stated the care plan needed to be revised after each fall to prevent future falls and to minimize injuries 2.During a review of Resident 161's admission Record dated 7/9/26, the admission record indicated, Resident 161 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including depression (feelings of sadness and emptiness) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania] and lows[depression] that make it difficult to carry out day-to-day tasks and activities).During a review of Resident 161's MDS, the MDS indicated, Resident 161's cognition was intact. The MDS indicated, Resident 161 was totally dependent with ADL's. The MDS indicated, Resident 161 had an unhealed pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).During a review of Resident 161's History & Physical (H&P) dated 5/07/2026, the H&P indicated, Resident 161 had fluctuating capacity to understand and make decisions.During a review of Resident 161's Change of Condition evaluation (COC) dated 5/25/2026, the COC indicated, Resident 161 had scattered open blisters on the left buttock.During a review of Resident 161's care plan titled Scattered open blisters on left buttock dated 5/26/26. The care plan indicated, to provide treatment as ordered and to have a wound consult.During a review of Resident 161's Order Summary Report dated 6/9/2026, the order summary report indicated, Resident 161 had orders for a left hip ruptured blister, clean with normal saline (NS) pat dry pack with calcium alginate (wound dressing) apply Santyl (removes dead tissue) in the deeper area and cover with waterproof adhesive foam dressing change every day and as needed.During a review of Resident 161's Wound Consult assessment dated [DATE], the wound assessment indicated, Resident 161 had a new ruptured blister to the left hip. The wound assessment indicated, to clean the ruptured blister with normal saline (NS) pat dry pack with calcium alginate (wound dressing) apply Santyl (debrides wounds) in the deeper area and cover with waterproof adhesive foam dressing change every day and as needed.During an interview on 7/9/2026 at 10:58 a.m. with Treatment Nurse 1 (TXN 1), TXN 1 stated she should have revised Resident 161's care plan to reflect Resident 161's left hip ruptured blister and the current plan of the care Resident 161 was receiving for the left hip ruptured blister. TXN 1 stated she made a mistake by not revising the care plan to reflect the care that Resident 161 was receiving. TXN 1 stated the care plan is a guide for the nurse on how to provide care to the Resident. TNX 1 stated there was a potential for the wound to worsen when the plan of care is not accurate.During an interview on 7/9/26 at 11:32 p.m. with the Director of Nurses (DON), the DON stated care plans need to have the interventions revised when there are changes in the level of care the residents will be receiving. The DON stated care plans are the guide the nurses use when providing care to the resident. The DON stated there was a potential for residents to decline when the plan of care is not revised to reflect the interventions the residents should be receiving.During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and a timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated the care plan interventions are derived from a through analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review the facility failed to ensure one of one sampled residents (Resident 9), had a care plan created, initiated, and implemented for the use of Dilantin(medication used to control seizures). This deficient practice had the potential to result in the side effects not being identified and addressed.Findings:During a review of Resident 9's admission Record (a document containing demographic and diagnostic information) (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to epilepsy (recurrent unprovoked seizures), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (muscle weakness or a partial loss of movement on one side of the body), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 9's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 9 had the capacity to understand and make decisions. The H&P indicated Resident 9 was recently hospitalized at a General Acute Care Hospital (GACH) from 3/7/2026 to 3/10/2026 due to a high Dilantin level.During a review of Resident 9's Minimum Data Set (MDS-a resident assessment tool), dated 4/23/2026 the MDS indicated Resident 9 had the ability to express ideas and wants. The MDS indicated Resident 9 needed substantial to maximal assistance with toileting showering, dressing, personal hygiene, and transferring.During a review of Resident 9's Order Summary, the Order Summary indicated on 5/12/2026 Resident 9 had an order for Dilantin 100 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) to be given three times a day for seizures.During an interview on 7/8/2026 at 10:42 a.m. with Certified Nursing Assistant (CNA) 11, CNA 11 stated Resident 9 was hospitalized a couple of months ago for an elevated Dilantin level. During a concurrent interview and record review on 7/08/2026 at 1:33 p.m. with Licensed Vocational Nurse (LVN)1, Resident 9's Care Plans were reviewed. LVN 1 stated Resident 9 was hospitalized on [DATE] for elevated Dilantin level of 28.4. LVN 1 stated Resident 9 does not have a Care Plan for Dilantin. LVN 1 stated Resident 9 should have a Care Plan for Dilantin. LVN 1 stated Care Plan are important to follow for positive outcomes and monitor for no decline in the residents condition.During a concurrent interview and record review on 07/09/2026 at 10:37 a.m. with Registered Nurse (RN) 2, Resident 9's Care Plans were reviewed. RN 2 stated she does not see a Care Plan for Dilantin documented in resident 9's chart. RN 2 stated Resident 9 should have a care plan for Dilantin. The RN 2 stated the care plans are the responsibility of the licensed staffDuring a review of the facility's policy and procedure (P&P), titled Care Plans, Comprehensive Person-Centered date revised 3/2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on interview and record review, the facility failed to clarify and follow physician orders for one of three sampled residents (Resident 134) by failing to:Clarify frequency (number of times) for administration of Resident 134's Nicotine patch (medicated adhesive patch that you stick to your skin to help you quit smoking).Clarify frequency for administration of Resident 134's Diclofenac (medication used to treat pain).Check Resident 134's blood sugar three times daily per doctor's orders.These deficient practices had the potential to cause medication errors and/or inadequate treatment for Resident 134 and placed Resident 134 at risk for increased pain, hypoglycemia, and hyperglycemia.Findings:During a review of Resident 134's admission Record, the admission Record indicated Resident 134 was admitted to the facility on [DATE].During a review of Resident 134's History and Physical (H&P) dated 6/29/2026, the H&P indicated Resident 134 was recently hospitalized for Diabetic Ketoacidosis (DKA- a life-threatening diabetes complication when your body doesn't have enough insulin to turn sugar into energy causing an imbalance) Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN- high blood pressure). The H&P indicated Resident 134's cognition (ability to think, understand, learn, and remember) was intact.During a concurrent interview and record review on 7/8/2026 at 3:18 p.m., with Registered Nurse (RN) 1, Resident 134's orders and Blood Sugar Summary were reviewed. RN 1 stated Resident 134 had orders to check fingerstick blood sugars three times a day. RN 1 stated the orders to check Resident 134's blood sugars three times a day were not being followed but should have been to prevent Resident 134 from developing DKA, hypoglycemia (low blood sugar), or hyperglycemia (high blood sugar). RN 1 reviewed Resident's 134's blood sugar vitals summary and stated Resident 134's blood sugars were only being checked one or two times a day.During a concurrent interview and record review on 7/8/2026 at 4:19 p.m., with Licensed Vocational Nurse (LVN) 4, Resident 134's Inpatient Discharge Instructions and Medication Administration Record (MAR) were reviewed. LVN 4 stated the Inpatient Discharge Instructions (from the GACH) were the admitting orders they followed when a resident is admitted . LVN 4 stated Diclofenac 1% topical gel to apply four times a day and Nicotine 14 milligrams (mg- unit of measurement) to apply once a day in the morning were put in as PRN (as needed) but ordered by the admitting doctor as scheduled. LVN 4 stated the admitting orders were put in incorrectly.During an interview on 7/9/2026 at 2:01 p.m. with the Director of Nursing (DON), the DON stated a Nicotine patch is not ordered as PRN. The DON stated it was important Resident 134 received the Nicotine patch daily as ordered because he could have potentially gone through nicotine withdrawals. The DON stated Resident 134 not receiving the pain medication cream could cause Resident 134 to experience uncontrolled pain. The DON stated the nurses should be following doctors' orders for checking Resident 134's blood sugar three times a day because not doing so could result in uncontrolled diabetes and DKA.During a review of the facility's policy and procedure (P&P) titled, Following Physician Orders, revised 4/2018, the P&P indicated, To ensure all physician/practitioner orders are accurately received, reviewed, implemented, documented, and monitored in a timely manner to provide safe and effective resident care.

Based on observation, interview and record review, the facility failed to ensure two of four sampled residents' (Resident 32 and Resident 113) fingernails were trimmed and free from accumulation of unknown substances underneath their fingernails.This failure resulted in Resident 32 and Resident 113's fingernails to have irregular edges, accumulation of dark brown substance under the fingernails, and had the potential to cause infection and impaired skin integrity. Findings: During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including rheumatoid arthritis (a chronic progressive disease- causing inflammation in the joints and resulting in painful deformity and immobility) and muscle weakness. During a review of Resident 32's Minimum Data Set (MDS- a resident assessment tool) dated 4/21/2026, the MDS indicated Resident 32's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 32 required moderate assistance (helper does less than half the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 113's admission Record, the admission Record indicated Resident 113 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) and hypertension (HTN- high blood pressure). During a review of Resident 113's MDS dated [DATE], Resident 113's cognition was moderately impaired. The MDS indicated Resident 113 was dependent (helper does all the effort) with ADLs. During an observation and interview on 7/6/2026 at 9:28 a.m., in Resident 113's room, Resident 113's fingernails were observed to be untrimmed with some dark brown deposits underneath the fingernails. Resident 113 stated she would like her fingernails trimmed. During an observation on 7/6/2026 at 9:58 a.m., in Resident 32's room, Resident 32's fingernails were observed to be untrimmed with some dark brown deposits underneath the fingernails. During a concurrent observation and interview on 7/7/2026 1:01 p.m., with Certified Nurse Assistant (CNA) 5, in Resident 32's room, CNA 5 stated Resident 32's fingernails were long and needed to be trimmed. CNA 5 stated it was important to keep the residents' fingernails clean and trimmed to prevent bacteria from building up under their fingernails and to prevent them from scratching themselves. During a concurrent observation and interview on 7/7/2026 at 1:22 p.m., with CNA 6, in Resident 113's room, CNA 6 stated Resident 113's fingernails were long and dirty and should be kept clean and short because bacteria can form under their fingernails and they could cut themselves from scratching which could potentially result in an infection. During an interview on 7/8/2026 at 11:33 a.m., with the Infection Prevention Nurse (IPN), The IPN stated it was important resident nails are kept trimmed and clean because the residents could scratch themselves which could cause an infection. During an interview on 7/9/2026 at 2:01 p.m., with the Director of Nursing (DON), the DON stated cleaning and trimming fingernails was one of the CNA tasks and is required to be done when a resident's fingernails are observed as being long and unclean. The DON stated long, dirty fingernails can result in infection if a resident scratch themselves and breaks skin. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, revised 2/2018, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care included daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse for one of three sampled residents (Resident 160) when Resident 110 kicked Resident 160 on 6/27/2026.This failure resulted in Resident 110 kicking Resident 160 and had the potential for Resident 160 to feel unsafe and unprotected.Findings:During a review of Resident 110's admission Record, the admission Record indicated Resident 110 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and mental and behavioral disorders.During a review of Resident 110's Minimum Data Set (MDS- a resident assessment tool) dated 6/29/2026, the MDS indicated Resident 110's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 110 required setup assistance (helper assists only prior to or following the activity) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 160's admission Record, the admission Record indicated Resident 160 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thoughts) and severe intellectual disabilities (when a person has very limited reasoning, learning, and problem-solving skills).During a review of Resident 160's MDS dated [DATE], the MDS indicated Resident 160's cognition was moderately impaired. The MDS indicated Resident 160 was dependent (helper does all the effort) with ADLs.During an interview on 7/7/2026 at 3:16 p.m., with Housekeeper (HK) 1, HK 1 stated he saw Resident 110 kick Resident 160.During a phone interview on 7/8/2026 at 12:47 p.m., with Registered Nurse (RN) 3, RN 3 stated HK 1 told her he witnessed Resident 110 kick Resident 160. RN 3 stated when she spoke with Resident 110, Resident 110 admitted to kicking Resident 160 because he thought Resident 160 took his snacks and phone.During a review of the facility's policy and procedure (P&P) titled, Residents Rights, revised 5/2025, the P&P indicated, This organization is committed to protecting and promoting the rights, dignity, privacy, independence, and well-being of all residents. Every resident shall be treated with respect and fairness and shall enjoy their rights without discrimination, harassment, abuse, neglect, or retaliation. The P&P indicated, Residents have the right to live in a safe, secure, and healthy environment. Residents have the right to be free from physical, emotional, verbal, sexual, or financial abuse.

Based on interview and record review, the facility failed to ensure the Notice of Proposed Transfer/Discharge form was provided to the Office of the State Long-Term Ombudsman (public advocate for residents in long-term care facilities) at the time of transfer to the General Acute Care Hospital (GACH) for one of three sampled residents (Resident 12).This deficient practice had the potential of Resident 12 being denied additional protection from being inappropriately discharged and access to an advocate who could inform them of their options and rights. Findings: During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and cerebrovascular accident (CVA- stroke, loss of blood flow to a part of the brain). During a review of Resident 12's Minimum Data Set (MDS- a resident assessment tool) dated 6/20/2026, the MDS indicated Resident 12's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 12 was dependent (helper does all the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During an interview on 7/8/2026 at 10:28 a.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 stated the licensed nurses are responsible for completing and providing the Ombudsman with the Notice of Transfer/Discharge at the time the resident is transferred. LVN 8 stated the Ombudsman needs to be notified of a residents transfer and discharge, so they are not only aware but also to ensure the transfer is safe. During a concurrent interview and record review on 7/9/2026 at 8:48 a.m., with Registered Nurse (RN) 2, Resident 12's Notices of Proposed Transfer/Discharge were reviewed. RN 2 stated Resident 12's Notice of Proposed Transfer/discharge date d 3/24/2026 was faxed to the Ombudsman on 7/7/2026 (105 days later). RN 2 stated Resident 12's Notice of Proposed Transfer/discharge date d 5/16/2026 was faxed to the Ombudsman on 7/7/2026 (52 days later). RN 2 states both Notices of Proposed Transfer/Discharge should have been faxed to the Ombudsman at the time of transfer/discharge to ensure it's a safe transfer/discharge. During an interview on 7/9/2026 at 2:01 p.m., with the Director of Nursing (DON), the DON stated Resident 12's Notice of Proposed Transfer/Discharge form should have been completed and faxed to the Ombudsman immediately when Resident 12 was transferred to the GACH. The DON stated it is important the Ombudsman is made aware at the time of transfer to ensure it is appropriate. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, revised 4/2025, the P&P indicated, Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record.

Based on interview and record review the facility failed to ensure one of one sampled residents (Resident 9), change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) was documented when Resident 9's Dilantin (medication used to control and prevent seizures) (phenytoin) level is 10 to 20 microgram/milliliter (mcg/mL-measures mass and volume) dropped to less than 2.This deficient practice had the potential to result in a delay of care and services for Resident 9.Findings:During a review of Resident 9's admission Record (a document containing demographic and diagnostic information) (Face Sheet- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to epilepsy (recurrent unprovoked seizures), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (muscle weakness or a partial loss of movement on one side of the body), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 9's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 9 had the capacity to understand and make decisions. The H&P indicated Resident 9 was recently hospitalized at a General Acute Care Hospital (GACH) from 3/7/2026 to 3/10/2026 due to a high Dilantin level.During a review of Resident 9's Minimum Data Set (MDS-a resident assessment tool), dated 4/23/2026 the MDS indicated Resident 9 had the ability to express ideas and wants. The MDS indicated Resident 9 needed substantial to maximal assistance with toileting showering, dressing, personal hygiene, and transferring.During a review of Resident 9's Order Summary, the Order Summary indicated on 5/12/2026 Resident 9 had an order for Dilantin 100 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) to be given three times a day for seizures.During a record review on 7/08/2026 at 1:33 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 9's Lab Result Report, dated 5/12/2026, was reviewed. The Lab Result Report indicated Resident 9's Dilantin level was less than 2. LVN 1 stated the doctor was informed of the Dilantin level but there was no change of condition documented for a Dilantin level less than 2.During a concurrent interview and record review on 7/09/2026 at 10:37 a.m. with Registered Nurse (RN) 2, Resident 9's Lab Result Report, dated 5/12/2026, was reviewed, the Lab Result Report indicated Resident 9's Dilantin level was less than 2 (normal Dilantin level is 10 to 20). RN 2 stated we missed that lab result. RN 2 stated the licensed nurses should have documented a COC immediately for Dilantin less than 2 and informed the resident and the resident's family.During a review of resident 9's Care Plan Titled, Resident 9 has a Seizure Disorder Related to Stroke, date initiated 1/19/2024, the Care Plan indicated a goal the resident would maintain lab values within therapeutic range per medical doctor (MD) thorough review date. The Care Plan indicated interventions and tasks to obtain and monitor lab diagnostic work as ordered.During a review of the facility's policy and procedure (P&P), titled Acute Condition Changes - Clinical Protocol date revised 3/2018, the P&P indicated, . Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool) for one of three sampled residents (Resident 92) was accurate by failing to code Resident 92's fall on 3/24/2026. The MDS assessment conducted on 5/6/2026 indicated the resident did not have any falls.This failure had the potential to negatively affect Resident 92's plan of care and placed Resident 92 at risk for future falls and injuries.Findings:During a review of Resident 92's admission Record, the admission Record indicated Resident 92 was initially admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including end stage renal disease (ESRD-irreversible kidney failure) hemiplegia (weakness on one side of the body) and hemiparesis affecting right dominant side (total paralysis of the arm, leg, and trunk on the right side of the body), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and gastrostomy(a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 92's MDS dated [DATE], the MDS indicated Resident 92 had severely impaired cognitive skills (a person has trouble with basic brain functions like thinking, learning and remembering) for decision making. The MDS indicated Resident 92 was dependent on staff with dressing, toileting hygiene, bathing and personal hygieneDuring a review of Resident 92's Change of Condition (COC-a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status which without immediate intervention, may result in complications or death) dated 3/24/2026 at 6:36 p.m., the COC indicated Resident 92 was found lying on the floor face down beside the bed and sustained a bump on right temporal (temple )area, abrasion(scrape) on the right hip and back. The COC indicated the physician and family member were notified.During a review of Resident 92's MDS dated [DATE], the MDS indicated the resident had no history of falls since admission, reentry (readmission) or prior assessment.During a concurrent interview and record review on 7/9/2026 at 10:13 a.m. with Registered Nurse (RN) 1, Resident 92's COC dated 3/24/2026 and MDS Section J(section in the MDS that document specific health issues and symptoms that directly impact resident's overall quality of life) dated 5/6/2026 were reviewed. RN 1 stated Resident 92 was found on the floor face down with right temporal bruise but without changes in level of consciousness (LOC- how awake and alert a person is). RN 1 stated the MDS indicated Resident 92 had no falls since admission or reentry. RN 1 stated the fall that occurred on 3/24/2026 was not coded correctly. RN 1 stated MDS assessment should be accurate to prevent recurrence of fall for better resident's care.During a concurrent interview and record review on 7/9/2026 at 11:23 a.m. with the Director of Minimum Data Set (DMDS), Resident 92's MDS dated [DATE] and COC dated 3/24/2026 were reviewed. The DMSD stated the MDS dated [DATE] did not reflect the fall of Resident 92 on 3/24/2026. The DMDS stated the fall that happened on 3/24/2026 should be reflected on the MDS conducted on 5/6/2026. The DMSD stated Resident 92's MDS assessment should be accurate to provide a true assessment or picture of the resident's condition.During an interview on 7/9/2026 at 3:02 p.m. with the Director of Nursing (DON), the DON stated Resident 92 had an episode of fall this year. The DON stated inaccurate MDS assessment would lead to inaccurate care planning that could affect Resident 92's care.During a review of facility's policy and procedure (P&P) titled, Comprehensive Assessments, revised 10/2023, the P&P indicated error in assessment is an assessment where resident's overall clinical status is not accurately represented or miscoded and results in an inappropriate plan of care.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who required a two-person assist with transfers from a sitting to standing position and from a chair to bed, was assisted by Certified Nursing Assistant (CNA 1) and another staff member conducting a full body lift to transfer Resident 1 from a chair to her bed. This deficient practice resulted in Resident 1 standing up and attempting to transfer from a chair to her bed without assistance and falling to the floor. Resident 1 was transferred to a General Acute Care Hospital (GACH) where she was diagnosed with bilateral (both sides) acute distal fibular fractures (a sudden traumatic break in the lower end of the calf bone) of both ankles. 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's diagnoses included diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), morbid obesity (overweight), and extrapyramidal movement disorder ([EPS] drug induced movement disorders' primarily side effects of antipsychotics [medications that help people who have severe mental health issues] and other mental and emotional conditions], causing involuntary spasms, tremors, rigidity, and restlessness). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/1/2026, the MDS indicated Resident 1's cognition (the ability to think and reason) was intact. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort by lifting or holding trunk or limbs) when going from sitting to standing.During a review of Resident 1's Fall Risk Evaluation, dated 11/16/2025, the Fall Risk Evaluation indicated Resident 1 was at moderate risk for falls.During a review of Resident 1' s Weight Summary report, dated 3/4/2026, the Weight Summary report indicated Resident 1 weighed 219 pounds ([lbs] a unit of measurement) and was four feet 10 inches tall. The Weight Summary report indicated Resident 1's body mass index ([BMI] a quick calculation using a person's weight and height to estimate their total body fat) was 45.8. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 3/4/2026, and timed at 2:28 p.m., the SBAR indicated at 9:38 a.m., after Resident 1 was transferred from a chair to her bed both of her legs became weak, and she was eased to the floor. The SBAR indicated at approximately 3 p.m., Resident 1 complained of pain in both her legs and had swelling to her right ankle along with a bluish discoloration.During a review of Resident 1's Physician's Orders, dated 3/4/2026, and timed at 4:24 p.m., the Physician's Order indicated Resident 1 may be transferred to a GACH.During a review of Resident 1's Transfer Form, dated 3/4/2026, and timed at 5:34 p.m., the Transfer Form indicated Resident 1 was transferred to a GACH.During a review of the GACH's admission Record, dated 3/4/2026, the admission Record indicated Resident 1 was admitted to the GACH on 3/4/2026 at 5:37 p.m.During a review of the GACH's ED (Emergency Department) Note, Physician (ED Note), dated 3/4/2026, the ED Note indicated Resident 1 presented with bilateral ankle pain and stated she fell when getting out of her shower chair that morning (3/4/2026). The ED Note indicated Resident 1 had significant diffuse swelling (a generalized accumulation of fluid in body tissues that causes widespread puffiness, tight skin, and reduced movement) and ecchymosis (bruising resulting from bleeding underneath the skin) to her right ankle and her left ankle was assessed likely swelling. The ED Note indicated the X-ray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) showed an acute distal fibular fracture of both ankles.During a review of the GACH's Radiology (a medical specialty that uses imaging to diagnose and treat diseases) report, dated 3/4/2026, and timed at 6:08 p.m., the Radiology report indicated Resident 1 had displaced fractures (a broken bone where the pieces have moved out of their normal alignment) of the left and right distal fibula.During a review of the GACH's Orthopedic Consultation note, dated 3/7/2026, and timed at 2:05 p.m., the Orthopedic Consultation note indicated Resident 1 had bilateral bimalleolar fractures (a severe, unstable ankle injury involving fractures of both the inner and outer parts of the ankle). The Orthopedic Consultation note indicated the plan was for Resident 1 to undergo an Open Reduction and Interna Fixation ([ORIF] a surgery to fix a broken bone where the surgeon makes an incision to realign the broken bone pieces into the correct position by using hardware such as screws, plates, or rods to hold the bone in place while it heals) of both ankles.During a review of the GACH's Physician's Progress Note, dated 3/11/2026, and timed at 10:04 p.m., the Physician's Progress Note indicated the Pulmonologist (a medical doctor specialized in diagnosing and treating diseases of the respiratory system) recommended a closed reduction (a non-surgical orthopedic procedure used to realign a fractured or dislocated bone to its natural position without making an incision) for Resident 1's ankle fractures instead of surgery because it was safer. The Physician's Progress Note indicated on 3/5/2026 Resident 1 had two doses of morphine (a medication primarily used to treat moderate to severe pain) 3 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) and a rapid response team (specialized healthcare professionals called to a hospital patient's bedside when they show early signs of decline to provide immediate critical care to prevent heart attack or respiratory failure) was called to place Resident 1 on a Bilevel Positive Airway Pressure ([BiPAP] a noninvasive ventilator used to assist breathing by delivering pressurized air through a mask) machine due to her labored breathing (abnormal, effortful breathing that requires more energy than usual, often indicating serious respiratory distress) and was administered one ampule (a small sealed glass vial containing a single dose of medication) of Narcan (a medication used to reverse opioid (a class of drugs used for severe or chronic pain management) overdoses by blocking opioid receptors in the brain to restore breathing within minutes). The Physician's Progress Note indicated Resident 1 would likely run into problems postoperatively (after surgery) such as difficult extubating (removing a breathing tube from a patient's airway, signaling the end of mechanical ventilation) and respiratory acidosis (a condition occurring when the lungs cannot remove enough carbon dioxide [a colorless odorless, non-flammable gas) due to the use of narcotics. During a review of the GACH's Progress Note Physician (Physician's Note), dated 3/10/2026, the Physician's Note indicated the Pulmonologist ordered Boniva (a prescription bisphosphonate medication used to treat or prevent osteoporosis in women after menopause by strengthening bones and reducing fracture risk), vitamin d2 (a supplement essential for calcium absorption, bone health, and treating deficiencies), Calcium (a supplement for bone health, muscle function, and nerve transmission) to treat osteopenia (a condition where bones have low bone density, a measurement of the amount of calcium and other minerals packed into a segment of bone, indicating its strength and durability) and bilateral casts on her ankles.During a concurrent interview on 3/12/2026 at 4:11 p.m., with the MDS Specialist and a review of Resident 1's at risk for falls Care Plan, dated 6/2/2023, the at risk for falls Care Plan indicated Resident 1 was at risk for falls related to (r/t) her diagnosis of hypotension (abnormally low blood pressure, typically below 90/60 mmHg), neuropathy (damage to the nerves outside the brain and spinal cord, often causing weakness, numbness, and pain, typically in the hands and feet), generalized weakness, obesity, a history of falls requiring a one person assist for transfers, and an EPS movement disorder. The at risk for falls Care Plan's goal indicated Resident 1would have a reduction in the risk for falls. The at risk for falls Care Plan's intervention included safe resident handling, transfer resident with a full body lift using a two person assist. The MDS Specialist stated despite the Care Plan's initiation date of 6/2/2023 the at risk for falls Care Plan was current and accurately indicated Resident 1 required two-person assistance when transferring from a chair due to her obesity and having poor strength in her lower extremities. During an interview on 3/13/2026, at 10:19 a.m., Licensed Vocational Nurse (LVN) 1 stated on 3/4/2026 at approximately 9:30 a.m., she was informed by CNA 1 that Resident 1 fell when transferred from a shower chair to her bed. LVN 1 stated she assessed Resident 1 and at the time of her fall she was without pain or swelling, but at approximately 2 p.m., CNA 1 reported to her that Resident 1 had pain and swelling to her right leg. LVN 1 stated she was not aware of Resident 1's Care Plan but Resident 1 likely required two-person assistance with transfers due to her obesity and muscle weakness. During an interview on 3/13/2026, at 11:27 a.m., CNA 1 stated on 3/4/2026 in the morning (exact time unknown) after showering Resident 1, she brought her back to her room on a shower chair. Resident 1 stood up using a walker, she was next to her bed where she held onto the bed's side rail. CNA 1 stated Resident 1 would normally pivot (a technique used to move a patient with limited mobility between two surfaces by having them stand or partially stand, rotate on one or both feet, and sit down) in order to get onto her bed, but instead Resident 1 screamed for help and stated her legs felt weak. CNA 1 stated she got behind Resident 1, yelled for help, and eased Resident 1 onto the floor where she landed on her bottom with her knees and feet bent. CNA 1 stated she worked with Resident 1 for four years and usually assisted Resident 1 during transfers alone without assistance because Resident 1 was able to help by walking on most days. CNA 1 stated prior to Resident 1 transferring she would ask her how she felt to determine if she was able to stand or not. If Resident 1 felt tired, she (CNA 1) would ask for assistance transferring Resident 1. CNA 1 stated she was not aware Resident 1's Care Plan indicated she required two-person assistance with transfers. During an interview on 3/13/2026, at 3 p.m., the Director of Nursing (DON) stated CNA 1 should have asked for assistance when she transferred Resident 1 from the shower chair to her bed on 3/4/2026. The DON stated the licensed nurses should have communicated Resident 1's need for a two person assist during transfers to prevent Resident 1 from falling. During a review of facility's P/P titled Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and try to minimize complications from falling. Risk factors include conditions such as lower extremity weakness and functional impairments, and medical conditions such as neurological disorders, and balance/gait disorders. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on interview, and record review, the facility failed to prevent unplanned weight loss (a weight loss greater than 5 % in one month) of 29 pounds ([lbs.] 18.59 % percent [%] in 6 months) from 1/2025 to 5/25 for one of three sampled residents (Resident 116). The facility failed to: 1. Ensure Registered Dietician's (RD- expert on diet and nutrition) recommendations for Resident 116's weekly weights, protein supplement ( boost protein [ nutrients body needed] intake ), double portions for breakfast, appetite stimulant (medication that stimulates appetite) and to have a blood test done for a complete metabolic panel (CMP- blood test that measures 14 different substances in the blood) and a prealbumin (blood test used to indicate nutritional deficiencies) were carried out. 2. Ensure a Change of Condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) for severe weight loss was completed on 1/2025 when Resident 116 had a weight loss of 10 lbs. (6.4 % loss), on 2/2025 when Resident 116 had a weight loss of 8 lbs. (11.5% loss), 4/2025 when Resident 116 had a weight loss of 9 lbs. (17.3% loss) and on 5/2025 when Resident 116 had a weight loss of 2 lbs. (18.59% loss), total of 29 lbs. in 6 months. 3. Ensure facility's staff followed Resident 116's care plan titled, Altered in Nutrition dated 3/14/2025 to monitor and report Resident 116's weight loss and poor oral intake to the physician. 4. Ensure there were weekly interdisciplinary team (IDT- a group of professionals from different disciplines who work together to achieve a common goal) weight variance meetings from 1/2025 through 5/2025 to address Resident 116 weight loss. 5. Develop a comprehensive care plan with interventions to prevent Resident 116's weight loss. These failures resulted in Resident 116's severe weight loss of 29 lbs. (18.59 % of body weight) in 6 months. Findings: During a review of Resident 116's admission Record, the admission Record indicated Resident 116 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), kidney transplant (replaces a failing kidney with a healthy one from a living or deceased [dead] donor) legally blind (vision loss), gastro-esophageal reflux (GERD- burning sensation in chest, heartburn). Resident 116 was discharge from the facility on 2/5/2025 to the general acute care hospital (GACH) due to altered mental status (a change in a person's mental function or level of consciousness, encompassing a range of symptoms from mild confusion to coma [a deep state of unconsciousness, where a person is alive but unable to respond to their environment ]) and readmitted back on 2/10/2025. During a review of Resident 116's Registered Dietician (RD) Food and Nutrition Assessment initiated on 12/10/2024 and completed on 12/30/2024, the Food and Nutrition assessment indicated Resident 116's weight was 156 lbs. on 12/7/2024 and the resident was consuming 76% to 100% of her breakfast, lunch and dinner. Resident 116's re-admission weight on 2/10/2025 was 140 lbs. The RD's Food and Nutrition assessment also indicated Resident 116 should have been consuming 1775 to 2125 calories (a unit of energy used to measure the energy content of food) per day to maintain her admission weight. The RD's Food and Nutrition assessment also indicated that Resident 116 had a low pre albumin level and RD's recommendation was to start 30 milligrams (mg - unit of measurement) of sugar free protein supplement two times a day (BID). During a review of Resident 116's Order Summary Report dated 2/10/2025, the Order Summary Report indicated an order for Fortified (a diet in which certain essential nutrients have been added to foods to improve their nutritional value) Consistent Carbohydrate Diet (CCHO- diet f or resident with diabetes). During a review of Resident 116's History and Physical (H&P) dated 2/11/2025, the H&P indicated Resident 116 had the capacity to understand and make decisions. During a review of Resident 116's Minimum Data Set (MDS - a resident assessment tool) dated 4/13/2025, the MDS indicated Resident 116 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 116 needed partial to moderate assistance (helper does half the work) with activities of daily living (ADLs- activities such as bathing, and dressing a person performs). The MDS indicated Resident 116 height was 62 inches (unit of measurement) and weighed 138 lbs. The MDS indicated Resident 116 was on a therapeutic diet (specialized meal plans designed to treat or manage specific medical conditions by controlling nutrient intake) and the resident had no weight loss of 5% in the last month or loss of 10 % or more in the last six months. During a review of Resident 116's Weights and Vitals Summary from 12/2024 through 5/2025, the Weights and Vitals Summary indicated Resident 116's weight was as follows: 1.On 12/7/2024 Resident 116 weight was 156 lbs. 2.On 12/16/24 Resident 116 weight was 150 lbs. (3.85 % weight loss). 3.On 1/1/2025 Resident 116 weight was 146 lbs. (6 .4 % weight loss). 4.On 2/4/2025 Resident 116 weight was 138 lbs. (11.5 % weight loss). 5. On 2/10/2025 (readmission weight) Resident 116 weight was 140 lbs. (9.7 % weight loss). 6. On 4/3/2025 Resident 116 weight was 129 lbs. (17.31 % weight loss). 7. On 5/22/2025 Resident 116 weight was 127 lbs. (18.59 % weight loss). During a review of Resident 116's RD's recommendations dated 3/6/2025, the RD recommendation indicated to have the resident's weekly weights for two weeks. During a review of Resident 116's RD's recommendations dated 3/10/2025, the RD recommended was to discontinue Health Shakes (beverage, intended to be a healthy addition to a diet) and, provide snack three times a-day (TID) and to give 30 milliliters (ml-unit of measurement) of liquid protein (essential nutrient for the structure, function, and regulation of the body's tissues and organs) daily. During a review of Resident 116's RD's Weight Change Note dated 3/10/2025 the RD's Weight Change Note indicated Resident 116 weight was stable at 138 lbs. and it was discussed in IDT meeting. RD's recommendation indicated to have the resident's weekly weights for two weeks. During a review of Resident 116's RD's recommendations dated 3/11/2025, the RD's recommendation indicated to check CMP and prealbumin, weekly weights for two weeks and double portions at breakfast. During a review of Resident 116's Multidisciplinary Quarterly Care Conference dated 3/12/2025, the Multidisciplinary Quarterly Care Conference indicated Resident 116 was consuming between 26% to 50% of her breakfast, lunch and dinner. Resident 116's weight goal was 150 lbs., and she weighed 138 lbs., and that the family had requested for the resident to have a snack three times a day. During a review of Resident 116's care plan titled Alteration in Nutrition dated 3/14/2025 and revised on 5/22/2025 the care plan focus indicated that Resident 116 had lost 9.0 lbs. between 3/2025 through 4/2025. The care plan goal indicated for Resident 116 to consume 75% of her meals. The care plan interventions indicated to notify Resident 116's doctor and family of weight gain or loss of 5% or 5 lbs. in one month. On 5/19/2025 Resident 116 was started on Glucerna (nutritional shake ) one time a day, ordered on 5/18/2025. During a review of Resident 116's Situation, Background, Assessment, and Recommendations ([SBAR] a technique which is used to facilitate prompt and appropriate communication within the care team) communication form dated 3/31/25, the SBAR indicated Resident 116 had no appetite and had lost nine lbs. in two month (2/4/2025- 4/3/2025). The SBAR indicated to have recommendation from Resident 116's primary doctor and RD consult. During a review of Resident 116's RD's recommendations dated 4/7/2025, the RD's recommendation was to do weekly weights for four weeks, check CMP, prealbumin and to call the medical doctor ( MD) for an appetite stimulant. During a review of Resident 116's RD's Weight Change Note dated 4/07/2025 the RD's Weight Change Note indicated Resident 116's weight was 129 lbs. and that she was refusing meals and had a significant weight loss for in one month and three months. The RD's Weight Change Note indicated Resident 116 was at risk for further weight loss due to her refusal of meals and poor food intake. The RD's Weight Change Note indicated the RD attempted to discuss appetite and meal refusal and weight loss with Resident 116 on 4/7/2025, but she was asleep, and Resident 116's response was I know speak English. The RD informed Resident 116 she would have a Spanish speaking staff follow up with her. The RD's Weight Change Note also indicated that further weight loss would be undesirable. The RD recommendations were to do weekly weights for four weeks, check CMP, prealbumin and to call the medical doctor (MD) to request an appetite stimulant. During a review of Resident 116's Order Summary Report (summary of active, completed, discontinued, on hold or struck out physician orders) from 12/01/2024 through 5/31/2025, the Order Summary Report indicated Resident 116 was started on a protein supplement on 1/30/2025 which was discontinued on 2/10/2025. The Order Summary Report indicated Resident 116 was started on Glucerna on 5/19/2025. During a review of Resident 116's Medication Administration Record (MAR) dated 2/31/2025, the MAR indicated that Resident 116 had an order dated for a protein supplement 30 ml two times a day to start on 1/30/25 and was discontinued on 2/10/2025. During a review of Resident 116's, CMP results report dated 4/7/2025, the CMP results report indicated Resident 116's albumin was 3.0 grams per deciliter (g/dL-reference range is 3.5 to 5.7 g/dL). During an interview on 5/20/2025 at 11:28 a.m., with Resident 116's Family Member 1 (FM1), FM1 stated Resident 116 had lost a lot of weight since her admission to the facility on [DATE]. FM 1 stated they had been bringing Resident 116 lunch and dinner every day because she does not like the food at the facility as it was too sweet and she has DM. FM 1 stated the facility has not told them how much weight Resident 116 had lost but FM 1 knows it was a lot because last month (April) her eyes were sunken in prior to Resident 116's doctor discontinued a medication (unknown). FM 1 stated he had informed someone in the facility (unknown) that Resident 116 wanting a protein shake in the morning because she refuses to take her medication without food. FM 1 stated they live very far from the facility and cannot bring her breakfast that was the reason they requested a protein shake because Resident 116 will not take her medications until FM 1 bring her food. During a concurrent interview and record review on 5/22/2025 at 7:47 a.m., with the Assistant Director of Nurses (ADON) Resident 116's clinical record (Weights and Vitals Summary, COC documentation and IDT meeting notes) were reviewed, from 12/2024 through 5/2025. The ADON stated that in December Resident 116's admission weight was 156 lbs. and that in April the resident's weight was 129 lbs. The ADON stated the only documentation she could find was a COC that was done on 3/31/2025 for a 9.0 lb. weight loss. The ADON stated there should have been a COC done in 1/2025, 2/2025, and 4/2025 when Resident 116 continued to have a weight loss. The ADON stated Resident 116 should have had IDT meetings for weight loss and a comprehensive care plan should have been developed when Resident 116 started losing weight in 1/2025. The ADON stated the RD should have brought this resident's weight loss to IDT weight variance meetings in 1/2025 when Resident 116 had a 10 lbs. weight to discuss interventions to prevent the resident's future weight loss and to keep a better track of the resident's condition. During a concurrent interview and record review on 5/22/2025 at 9:15 am with the RD, Resident 116's weights and RD's recommendations from 12/2024 through 5/2025 were reviewed. The RD stated that Resident 116 did have a weight loss of 10 lbs. in 1/2025 and had lost 6.4% of her body weight with no RD recommendations. The RD stated that in 2/2025, Resident 116 had lost another 9.0 lbs. and lost 11.5% of her body weight with no RD recommendations. The RD stated she did not know about the resident's weight loss until 3/2025 when Resident 116 weighed 138 lbs. and that was the reason why nothing was done for Resident 116's weight loss in 1/2025 and 2/2025. On 3/6/2025 RD's recommendation for weekly weights for two weeks was not done. On 3/10/2025 RD's recommendation to give 30 ml of a protein supplement TID was not done. On 3/11/2025 RD recommendation for weekly weights for two weeks, double portions for breakfast and a blood work for CMP and pre albumin, were not done. RD stated that in 4/2025 Resident 116 had lost another 9.0 lbs. and had lost 17.3% of her body weight. RD stated she had recommended on 4/7/2025 to do weekly weights for four weeks, give an appetite stimulant and to do a pre-albumin level and those intervention were not done. The RD stated a weight loss of 5 % in one month 7.5 % in three months and 10% in 6 months constitute a significant weight loss, and a weight loss greater than 7.5% in 3 months and greater than 10% was a severe weight loss. The RD stated Resident 116 was receiving 300 calories a day less than estimated needs in 1/2025, 160 calories a day less in 2/2025 and 70 calories a day less in 4/2025. The RD stated she did not talk to Resident 116 or FM 1 regarding her weight loss because Resident 116 could not speak English. RD stated there were no IDT meetings done for Resident 116's weight loss and that there should have been IDT meetings starting 1/2025 when the weight loss was first identified to prevent further weight loss. The RD stated there was no comprehensive care plan for Resident 116's weight loss and that there should have been one. The RD stated Resident 116's weight loss was preventable, sadly the facility dropped the ball with Resident 116's care. During an interview on 5/23/25 at 11:50 a.m., with the Director of Nurses (DON), the DON stated she was informed of Resident 116's weight loss on 3/31/2025, and she had been trying to find any documentation regarding Resident 116 weight loss. The DON stated that Resident 116 had significant weight loss from 12/2024 through 4/2025. The DON stated that there should have been a COC done for Resident 116's weight loss to inform Resident 116 doctor and the family member. The DON stated that Resident 116 should have had a comprehensive care plan put in place in 1/2025 when Resident 116 lost 10 lbs. The DON stated that RD was responsible for addressing Resident 116's weigh loss during weekly IDT weight variance meetings and her failure to do so resulted in Resident 116's weight loss going unnoticed. The DON also stated that Resident 116 weight loss could have been prevented if appropriate interventions had been implemented. During a review of the facilities Policy and Procedure (P&P) titled, Weight Assessment and Intervention dated 3/2022, the P&P indicated residents are weighed upon admission and at intervals established by the interdisciplinary team .Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time .Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met .The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia (loss of appetite) , weight loss or increasing the risk of weight loss .Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. During a review of the facilities P&P titled, Care Plans Comprehensive Person Centered dated 3/2022, the P&P indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan, includes measurable objectives and timeframes .When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. During a review of the facilities P&P titled, Change in a Resident's Condition or Status dated 7/2017, the P&P indicated, the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc. 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an), significant change in the resident's physical/emotional/mental condition; a need to alter the resident's treatment significantly. During a review of the facilities P&P titled ,Resident Food Preferences dated 2/2021, the P&P indicated, individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes .The Dietitian and nursing staff, assisted by the Physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. The Dietitian will discuss with the resident or representative the rationale of any prescribed therapeutic diet. During a review of the facilities P&P titled, Nutritional Assessment dated 10/2017, the P&P indicated, as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The nutritional assessment will be conducted by the multidisciplinary team.

Based on observation, interview, and record review, the facility failed to notify the physician of a change of condition (COC) for one of three sampled residents (Resident 2). The facility failed to: 1. Notify Resident 2's physician when Resident 2, who was receiving Aspirin [ASA] used as a blood thinner to prevent a stroke) and Clopidogrel Bisulfate ([Plavix] a medication used to prevent blood clots [blood cells that clump together and could obstruct the flow of blood]), sustained a head injury on 5/4/2025, that resulted in an abrasion, (a scrape of the top layer of the skin), a laceration (a cut with a jagged or torn wound that is caused by a sharp object), a small bump with substantial (large in size, number, or amount) bleeding to his head. 2. Notify Resident 2's physician, following Resident 2's head injury, to obtain an order for the discontinuance of Aspirin and Clopidogrel Bisulfate to prevent bleeding in the resident's brain. Resident 2 continued to receive blood thinners from 5/4/2024 through 5/9/2025 daily. 3. Notify Resident 2's physician following Resident 2's head injury (5/4/2025), when Resident 2 exhibited noticeable changes in behavior that included decrease in appetite, drowsiness, and being less talkative that were not his typical behaviors. 4. Follow Resident 2's untitled Care Plan dated 4/25/2025, that indicated to monitor, document and report adverse reactions of anticoagulant therapy to include lethargy, loss of appetite, and sudden changes in mental status. These deficient practices resulted in a delay in evaluation and treatment for Resident 2 following an injury and bleeding to his head on 5/4/2025. Resident 2 was transferred to a General Acute Care Hospital (GACH) on 5/9/2025 (four days after the injury to his head) via 911 when he was found lethargic and unarousable by Resident 2's Family Member (FM) 1. Resident 2 was diagnosed with a subarachnoid hemorrhage (a life threatening condition where bleeding occurs in the space between the brain and the tissue covering the brain) and was transfused (a procedure where blood or blood components are administered through an intravenous line ([IV] a flexible plastic tube inserted into the vein to administer medications, blood products and fluids) with one unit (refers to a single bag of blood) of platelets (small, colorless, cell fragments found in the blood that play a crucial role in blood clotting). 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 including Alzheimer's disease (a progressive disorder that affects memory, thinking, and behavior), and a history of falling. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 5/2/2025, the MDS indicated Resident 2 had moderate cognitive impairment (noticeable but mild memory and thinking problems). The MDS indicated Resident 2 required maximum assistance (helper does more than half the effort) with toileting hygiene, and substantial assistance (helper does more than half the effort) with dressing, and personal hygiene. During a review of Resident 2's Physician's Order, dated 4/25/2025, the Physician's Orders indicated to administer the following medications and to monitor for signs and symptoms (s/s) of bleeding such as hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) every shift, and notify the physician if s/s occur: 1. Aspirin 81 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) once a day to prevent a cerebral vascular accident ([CVA - stroke] loss of blood flow to a part of the brain) 2. Clopidogrel Bisulfate 75 mg once a day for CVA prevention. During a review of Resident 2's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/2025 and 5/2025, the MAR indicated Resident 2 received Aspirin 81 mg and Clopidogrel 75 mg once a day from 4/26/2025 through 5/9/2025. During a review of Resident 2's untitled Care plan, dated 4/25/2025, the Care Plan indicated Resident 2 was on antiplatelets ([Aspirin and Clopidogrel] medications that prevent blood form sticking together). The Care Plan's goal indicated Resident 2's risk for adverse reactions (an unintended and harmful effect that occurs as a result of taking a medication) related to the medications use would be minimized. The Care Plan's interventions indicated to monitor, document and report adverse reactions of anticoagulant therapy to include lethargy, loss of appetite, and sudden changes in mental status. During a review of Resident 2's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents), dated 5/4/2025 and timed at 7 p.m., the SBAR indicated Resident 2 hit his head on a shelf. The SBAR indicated Resident 2 was sitting at the edge of the bed, something hit him, but he (Resident 2) did not remember what it was. The SBAR indicated Resident 2 sustained a small cut and a small bump on the front of his head. During a review of Resident 2's Nursing Progress Note, dated 5/9/2025 and timed at 1:50 p.m., the Nursing Progress Note indicated Resident 2's Family Member (FM) 1 was observed in Resident 2's room at 12:55 p.m., screaming and trying to wake up Resident 2. The Nursing Progress Note indicated Resident 2 was lethargic. During a review of Resident 2's SBAR, dated 5/9/2025, the SBAR indicated Resident 2 was lethargic and unarousable at 12:55 p.m., and was transferred to the GACH via 911. During a review of Resident 2's Emergency Medical Services (EMS) form, dated 5/9/2025, the EMS form indicated Resident 2's blood pressure (BP) upon arrival was 86/42 millimeters of mercury ([mmHg] a unit of pressure commonly used to measure BP, normal BP is typically between 90/60 mmHG and 120/80 mmHG) During a review of the GACH's admission record, dated 5/9/2025, the GACH's admission record indicated Resident 2 arrived at the GACH at 2:38 p.m., due to bleeding in the brain, altered mental status, low BP, and monitoring for long-term blood thinner use. During a review of the GACH's Emergency Department's (ED) Provider Notes, dated 5/9/2025 and timed at 7:10 p.m., the ED Provider Notes indicated Resident 2 had an abrasion to the front scalp (the skin covering the head, excluding the face) with strips of surgical tape and a band aid in place. During a review of the GACH's Assessment/Plan Note dated 5/9/2025, the Assessment/Plan Note indicated Resident 2 received one unit of platelets for transfusion in the ED. During a review of the GACH's Imaging Note, dated 5/10/2025 and timed at 5:26 a.m., the GACH's Imaging Note indicated Resident 2 had a possible subarachnoid hemorrhage. During a review of the GACH's Consult note, dated 5/10/2025 and timed at 7:47 a.m., the GACH's Consult note indicated Resident 2 had a left parietal (on top of the head) traumatic subarachnoid hemorrhage. During an interview on 5/14/2025 at 9:27 a.m., and a subsequent interview at 9:40 a.m., FM 1 stated on 5/4/2025 (time unknown), she received a call from Registered Nurse (RN) 1 saying that Resident 2 scraped his head when bending over looking pictures, there was some bleeding, but he did not have to go to the GACH. FM 1 stated on 5/9/2025 around 1 p.m., she came to pick up Resident 2, he was sitting on his walker in the hallway and was having difficulty speaking. FM 1 stated Resident 2 pointed to his groin, letting her know he need to go to the bathroom, she took him to the bathroom and while walking he became very unstable, he began to slump over, and she had to brace him using her knee to prevent him from falling. FM 1 stated, Resident 2's eyes rolled back, and he stopped breathing, so she called for help and asked RN 1 to call 911. During an observation on 5/14/2025 at 12:48 p.m., in Resident 2's room, Resident 3's (Resident 2's Roommate) shelf was observed on the floor at the foot of Resident 3's bed. The shelf was made of a flimsy (light and easily moved/not stable) plastic material and was approximately three feet high with four individual shelves. The edges of the shelf was ridged (marked or formed with narrow raised bands) and corroded (metals or other material slowly destroyed or weakened by chemical action). During an interview on 5/14/2025 at 10:29 p.m., RN 1 stated on 5/4/2025 after dinner, he was informed by a staff member (unknown who this was) that Resident 2 had an accident. RN 1 stated he went to Resident 2's room and saw blood on the floor and observed Resident 2 sitting on his bed bleeding from his forehead. RN 1 stated Resident 2 told him something hit his face, but he (Resident 2) was not able to fully explain what it was. RN 1 stated he spoke to Resident 3, who witnessed some of the incident. RN 1 stated Resident 3 told him that Resident 2 bent down to look at pictures that were on his (Resident 3's) shelf when he (Resident 2) stood up he was bleeding. RN 1 stated he called Resident 2's physician on 5/4/2025 (time unknown), left a voicemail and sent the physician a text message but he (RN 1) received no response from the physician. RN 1 stated he did not work the next day and was unsure if anyone followed up with Resident 2's physician. RN 1 stated he should have followed up with the physician or medical director when he received no response from Resident 2's physician. During an interview on 5/14/2025 at 12:13 p.m., Certified Nursing Assistant (CNA) 5 stated on 5/8/2025 she noticed Resident 2 was acting differently from the previous day (5/7/2025), he was sleepy all day, less talkative, only got up to eat meals then wanted to go back to bed. CNA 5 stated on 5/9/2025 Resident 2 did not want to eat breakfast or lunch, he was arousable but sleepy, he yelled and wanted to hit her when she tried to assist him back to bed. CNA 5 stated she notified licensed Vocational Nurse (LVN) 5 of Resident 2's sleepiness on 5/8/2025 and she notified RN 1 that Resident 2 did not want to eat on 5/9/2025 in the morning after breakfast. During an interview on 5/14/2025 at 12:31 p.m., LVN 4 stated on 5/4/2025 at approximately 7 p.m., she heard Resident 2 yelling for help, when she went to his room she observed him bleeding from his scalp. LVN 4 stated Resident 2 had an abrasion, a laceration and a small bump on his scalp. LVN 4 stated she did not call Resident 2's physician because RN 1 told her he would call the physician. LVN 4 stated she remembered receiving a report that Resident 2 had a fall on 5/4/2025. LVN 4 stated she was not told to withhold Resident 2's Aspirin and Clopidogrel so she continued to administer both medications to Resident 2, as ordered, until 5/9/2025 when he was transferred to the GACH. LVN 5 stated, typically when a resident falls, has a suspected head injury and was receiving blood thinners, an order for labs (a medical procedure where a sample of blood, urine, or other fluids or tissues are analyzed to help diagnose or monitor a health condition) and/or imaging diagnostics (use of various technologies to create visual pictures inside the body to help diagnose, treat, or monitor a health condition) is obtained to rule out possible bleeding to the brain. During an interview on 5/14/2025 at 2:34 p.m., the Director of Nursing (DON) stated the licensed nurses continued to administer blood thinners, Aspirin and Clopidogrel, to Resident 2 after the injury to his head on 5/4/2025. The DON stated the licensed nurses should have called Resident 2's physician to notify him of Resident 2's head injury and to obtain an order to hold the Aspirin and Clopidogrel. The DON stated blood thinners could cause excessive bleeding and a possible brain bleed. During an interview on 5/14/2025 at 4:44 p.m., LVN 3 stated on 5/4/2025 she worked 11p.m. to 7a.m., and was informed about Resident 2's accident by RN 1 and LVN 4. LVN 3 stated she did not call Resident 2's physician because she was told RN 1 already called him. During an interview on 5/14/2025 at 4:45 p.m., Nurse Practitioner (NP) 1 stated he did not remember any report about Resident 2. NP 1 stated if a Resident was on blood thinners, had an accident/head injury, he would have recommended sending Resident 2 out to the GACH for a CT scan (computed tomography, a diagnostic imaging procedure that uses a combination of x-rays to produce images inside of the body) to make sure there is no intracranial (inside the skull) bleeding. During an interview on 5/15/2025 at 9:32 a.m., the Physician Assistant (PA) 1 stated on 5/4/2025 he was on call covering for Resident 2's physician but did not receive any calls about Resident 2. PA 1 stated Resident 2 was receiving blood thinners and was 90% more likely to sustain a brain bleed than those who were not receiving blood thinners following a head injury. PA 1 stated had he been informed that Resident 2 had a head injury he (Resident 2) would have been sent him to the hospital right away to get a CT scan to make sure he did not have a brain bleed. During an interview on 5/15/2025 at 2:50 p.m., Housekeeping (HK) 1 stated on 5/4/2025 he was asked by Certified Nursing Assistant (CNA) 6 to clean Resident 2's room. HK 1 stated he went to Resident 2's room and observed a shelf (at the foot of Resident 3/s bed), and approximately six inches in front of the shelf was a puddle of blood with a towel placed over it. HK 1 stated the blood on the floor was approximately the size of a baseball with little drops of blood scattered around the it. HK 1 stated he did not see blood on the shelf but stated he was not sure if anyone had already cleaned it from the shelf. During a review of the facility's undated Policy and Procedure (P/P), titled Change in Resident's Condition of Status the P/P indicated the nurse will notify the attending physician or physician on call within 24 hours (except in medical emergencies) when there has been an accident, a significant change in the resident's physical/emotional/mental condition, and the need to transfer to the hospital. The P/P indicated prior to notifying the physician the nurse will make detailed observations and gather pertinent relevant information. During a review of the facility's P/P titled Accidents and Incidents-Investigating and Reporting dated 3/2018, the P/P indicated the nurse supervisor, charge nurse, or department director shall document the time of the injured person's attending physician being notified, as well as the time the physician responded and his or her instructions.

Based on interview, and record review the facility failed to protect the residents right to be free from physical abuse for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not leave the room when on [DATE] Resident 1 and Resident 2 had verbal argument to prevent physical altercation (punched Resident 1 in the head 10 times) between both residents. 2. Ensure facility investigated CNA 2's grievance dated [DATE] about witnessing Resident 1 being upset towards Resident 2 and had an argument. The facility to develop preventative measure to safeguard both residents from possible physical altercation. 3. Develop a comprehensive care plan for Resident 1's aggressive behavior and Resident 2's room dominating behavior (wants the room to himself and tries to impose his own rules) with intervention to prevent physical altercation between the residents. 4. Ensure Social Service staff and/or Social Service Director (SSD) conducted three-day follow up visits after Resident 2 was cohorted with Resident 1 in one room on [DATE] to evaluate their compatibility as roommates. These failures resulted in Resident 1 being assaulted by Resident 2 on [DATE]. Resident 2 punched Resident 1 in the head 10 times with his fists. As a result, Resident 1 sustained 4.0 centimeter ([cm] unit of measurement) by 2.0 cm elevated blue and green discoloration to the left side of the forehead. On [DATE] Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) like activity where the resident was diagnosed to have a subdural hematoma (brain bleed), and herniation of the brain (medical emergency where part of the brain tissue moves or protrudes through a rigid structure in the skull) and Resident 1 expired on [DATE] at 08:06 a.m. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including seizures, presence of a ventriculoperitoneal (connection between the brain's ventricles and the peritoneal [space in the abdomen] cavity [space]) shunt ([VP]) a device that allows drainage of excess cerebrospinal fluid ([CSF](relating to the brain and spine), history of other mental and behavioral disorders, peripheral neuropathy (disease causing numbness or weakness in the hands and feet) and essential hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 did have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS]- resident assessment tool) dated [DATE], the MDS indicated Resident 1 was cognitively (ability to think, understand, learn, and remember) intact and needed substantial assistance (helper does more than half the work) with activities of daily living ([ADL's] - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated Resident 1 was not able to walk. During a review of Resident 1's Change of Condition (COC), dated [DATE], and timed at 6:53 p.m., the COC form indicated Resident 1 was involved in a resident-to-resident altercation. The COC indicated Resident 1 reported being struck by Resident 2. The COC indicated Resident 1 was observed with a bump (an elevated area on the skin) measured 4.0 cm by 2.0 cm with blue and green discoloration to the left side of Resident 1's forehead. During a review of Resident 1's Psychosocial/Social Services Note dated [DATE] and timed at 11:48 a.m., the Psychosocial/Social Services Note indicated that Resident 1 stated that Resident 1 and Resident 2 did not like each other. The Psychosocial/Social Services Note indicated Resident 1 could not remember the reason for Resident 1 and Resident 2's argument, and by the time Resident 1 realized there was Resident 2 in front of him, Resident 2 started hitting Resident 1 in the face 10 times. The Psychosocial/Social Services Note indicated Resident 1 used his hand to protect his face. During a review of Resident 1's Psychosocial/Social Service Note dated [DATE] and timed at 12:19 p.m., the Psychosocial/Social Service Note indicated Resident 1 complained of a headache. During a review of Resident 1's Nurses Progress Notes dated [DATE] and timed at 7:57 p.m., the Nurses Progress Notes indicated Resident 1 left side forehead had a purplish skin discoloration measured 3.0 cm by 2.0 cm with slight swelling. On [DATE] Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of seizure like activity where the resident was diagnosed to have a subdural hematoma, and herniation of the brain. During a review of GACH's Computed Tomography Scan (CT scan- imaging test used to detect internal injuries) dated [DATE], indicated Resident 1 had a large right hemispheric (half of the brain) hyperacute (unusually severe) /acute (sudden) subdural hematoma with brain herniation. During a review of GACH's Admission Record dated [DATE] the GACH's Admission Record indicated Resident 1 expired on [DATE] at 08:06 a.m. During a review of Resident 2 ' s Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD]-a chronic lung disease causing difficulty in breathing), type 2 diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 2's H&P, dated [DATE], the H&P indicated, Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Psychosocial/Social Services Note dated [DATE], the Psychosocial/Social Services Note indicated that Resident 2 room was changed due to roommate (Resident 4) incompatibility. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment. The MDS also indicated, Resident 2 needed set up or clean up assistance (helper sets up and cleans up) with ADL's. During a review of Resident 2's COC form, dated [DATE] and timed at 7:07 p.m., the COC indicated Resident 2 was involved in a resident-to-resident altercation resulting in Resident 1 being struck by Resident 2. The COC indicated Resident 2's physician was informed with recommendations including to monitor Resident 2 for aggressive behavior, emotional distress and psychiatric (mental and behavior) evaluation. During a review of CNA 1's Statement dated [DATE], The CNA 1's Statement indicated CNA 1 was present in the room during the incident (verbal altercation) involving Resident 1 and Resident 2. The CNA 1's Statement indicated Resident 2 verbalized I am done Mamas. Resident 1 began saying inappropriate words (unknown). CNA 1 left Resident 1 and Resident 2's room. During a review of Resident 2's Psychosocial/Social Services Note dated [DATE], the Psychosocial/Social Services Note indicated that Resident 2 stated that Resident 1 was talking bad about him and laughing. The Psychosocial/Social Services Note indicated Resident 2 did not remember what was said, he just felt like he needed to do something to Resident 1, so he went to his bed side and thinks he hit Resident 1 on his face three times. The Psychosocial/Social Services Note indicated Resident 2 stated he does not get along with Resident 1. During an interview with Resident 1 on [DATE] at 4:00 p.m., Resident 1 stated that he and Resident 2 have not been getting along well, and the staff was aware of the situation. Resident 1 stated that Resident 2 insists he turns off his television and lights by 8 p.m. Resident 1 stated Resident 2 wants the room to himself and tries to impose his own rules. Resident 1 stated, he refrained from speaking up his concerns (Resident 2's behavior towards Resident 1) to facility staff because he felt this was his room and space and does not want to move to another room. Resident 1 stated that he did not remember what triggered the argument between Resident 1 and Resident 2 on [DATE]. Resident 1 stated he remembered was when Resident 2 approached the side of his bed and began hitting him on the head and face with his fist. During an interview on [DATE] at 12:20 p.m., with Resident 3 (roommate of Resident's 1 and Resident 2), Resident 3 stated he witnessed the altercation between Resident 1 and Resident 2. Resident 3 stated Resident 2 called CNA 1 mama, mama, mama then Resident 1 said she was not your mama. Resident 3 stated, when CNA 1 left the room, Resident 2 got out of bed went over to Resident 1's bed and started hitting him on the head multiple times. Resident 3 stated, Resident 1 does not like when Resident 2 calls the CNA's mama. During an interview on [DATE] at 12:49 p.m. with CNA 2, CNA 2 stated that she had taken care of Resident 1 and Resident 2 multiple times. CNA 2 stated Residents 1 and 2 argued a lot. CNA 2 stated Resident 1 was the aggressor as he gets upset and jealous if CNA 2 spend more time with Resident 2. CNA 2 stated last month (December) Resident 1 got into an argument with Resident 2 when CNA 2 gave Resident 2 two cups of coffee. CNA 2 stated Resident 1 does not like when Resident 2 calls CNA 1 mama. Resident 1 thinks it was unprofessional for Resident 2 to call the CNA's mama. CNA 2 stated she told the Registered Nurse Supervisor (RNS) about the argument on [DATE] and was advised to do a grievance report and give it to Social Services Director ([SSD]- promotes the welfare of others). CNA 2 stated she filled out the grievance and gave it to the Registered Nurse Supervisor (RNS) but could not remember exactly what she wrote on the grievance report. CNA 2 stated she had not heard anything from SSD regarding her grievance report. During an interview on [DATE] at 3:42 p.m. with CNA 1, CNA 1 stated that she had taken care of Resident 1 and 2 multiple times. CNA 1 stated on [DATE] she went to Residents 1 and 2 room to see if the residents were done with dinner. CNA 1 stated Resident 2 said yes mama, Resident 1 responded stop calling her mama. CNA 1 stated she took Resident 2 dinner tray out of Resident 2's room, when I heard a noise coming from Resident 1 and 2's room. CNA 1 stated when she got back to the room Resident 2 was standing over Resident 1's bed. CNA 1 stated she immediately separated the residents and called the Assistant Director of Nurses (ADON) to come to the room. CNA 1 stated she should have reported to the charge nurse about Resident 1 telling Resident 2 to stop calling her mama, she just did not get a chance as it happened so fast. CNA 1 stated staff should inform licensed staff right way when a resident has an issue with another resident because the residents could end up having a physical altercation. During a concurrent interview and record review on [DATE] at 1:59 p.m., Grievance Record dated [DATE], was reviewed with RNS. RNS stated, CNA 2 told him about the verbal argument regarding coffee between Resident 1 and 2. RNS stated he directed CNA 2 to write it down on a grievance form and that he would turn it to SSD. RNS stated he talked to Resident 1 and 2 about the verbal argument and neither resident was mad. RNS confirmed there was no documentation in Resident 1 and 2's clinical record regarding the incident on [DATE]. During a phone interview on [DATE] at 10:40 a.m. with Resident 1's Family Member (FM) 1, FM 1 stated that Resident 1 had an issue with Resident 2 wanting Resident 1 to turn the television and lights off early (8 p.m.) and Resident 1 would not do it. FM 1 stated she was looking for another facility for Resident 1. During a phone interview on [DATE] at 11:05 a.m. with Resident 2's FM 2, FM 2 stated Resident 2 would complain that Resident 1 would talk too loud to Resident 2. FM 2 stated Resident 2 was hardheaded and have a lot of health concern. During a concurrent interview and record review on [DATE] at 8:30 a.m. with SSD Resident 2's Psychosocial/Social Services Note dated [DATE] was reviewed. The Psychosocial/Social Services Note dated [DATE], indicated Resident 2 was moved to a new room because of roommate incompatibility. The SSD stated Resident 2's room change was due to previous roommate said that Resident 2 was too loud and made too much noise and wanted him to be moved. SSD stated that was the reason why Resident 2's room was changed and cohorted with Resident 1. SSD stated that there was no documentation of SSD's conversation with Resident 2 and did not follow up with Resident 2 regarding his behavior (too loud and made too much noise). SSD stated there was no care plan initiated to address Resident 2's behavior. During a concurrent interview and record review on [DATE] at 8:37 a.m. with SSD, the Grievance Record dated [DATE] was reviewed. The Grievance Record was completed by CNA 2 and indicated that Resident 2 was upset with Resident 1 because Resident 1 told Resident 2 Why did you get two coffees. The Grievance Record indicated Resident 2 responded You need to mind your own business. The grievance report investigation indicated the SSD spoke with both residents but did not discuss the concern and both residents stated everything was okay. The recommendation/resolution was to make sure if in the future any concerns presented, to address it with the residents (Resident 1 and Resident 2). The SSD stated that she went to Resident 1 and Resident 2's room and neither resident had concerns regarding coffee and that there were no issues between them. The SSD stated she did not talk to CNA 2 about the grievance she wrote and further investigate. The SSD stated she never documented in Resident 1 and Resident 2's records about CNA 2's grievance because it was staff member who file the grievance and not a resident. The SSD stated she used the grievance record documentation as her clinical documentation and keeps the grievance records in her office. The SSD stated she never discussed the grievance with the Director of Nurses (DON) because there were no concerns between the residents. During a concurrent interview and record review on [DATE] at 10:05 a.m. with the Assistant Director of Nursing (ADON), reviewed CNA 2's Grievance Record dated [DATE]. The ADON stated that she had not seen the grievance record until today [DATE]. The ADON stated she was not aware that Resident 1 and Resident 2 had an argument on [DATE]. The ADON stated that all grievances need to be discussed with the nursing staff. The ADON stated Resident 1 and Resident 2 should have COC, care plans for behavior monitoring and a three-day room visit by social service staff. The ADON stated SSD should have done 3-days of follow up room visits with both Residents 1 and Resident 2 to ensure both residents were safe. During a concurrent interview and record review on [DATE] at 10:05 a.m. with the ADON, the SSD Progress Note dated [DATE] for Resident 2 was reviewed. The SSD Progress Note indicated Resident 2 had a room change on [DATE] due to roommate (previous roommate before Resident 1) incompatibility. There was no other documentation found in the clinical record. The ADON stated SSD should have done room visits after the room change to ensure that Resident 2 was compatible with his new roommate (Resident 1). During a concurrent interview and record review on [DATE] at 11:01 a.m. with the Director of Nursing (DON), the SSD Progress Note dated [DATE] for Resident 2 was reviewed. The SSD Progress Note indicated Resident 2 had a room change on [DATE] due to previous roommate (Resident 4) incompatibility. The DON stated the behaviors between Resident 2 and the previous roommate (Resident 4) should have been care planned. The DON stated the SSD should have done a three-day room visits to make sure Resident 2 liked his new roommate (Resident 1) and to ensure their cohorting compatibility. During a concurrent interview and record review on [DATE] at 11:01 a.m. with the DON, the CNA 2 Grievance Record dated [DATE] was reviewed. The DON stated she had not been made aware of this grievance record until [DATE] and was not aware that Resident 1 and Resident 2 had any previous grievances. The DON stated the grievance should have been brought to her attention so she could have discussed it and come up with a resolution for Resident 1 and Resident 2. The DON stated this grievance should have been documented in the clinical record by the RNS and the SSD. The DON stated a COC should have been done and SSD should have a three-day follow up room visits with both residents and a care planned. The DON stated Resident 1 and Resident 2 behaviors should have been monitored. The DON stated any incident of altercation between residents should be addressed right away and manage the situations before it could be escalated, and an altercation occurs. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention Program revised ,d+[DATE], the P&P indicated Protect our residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Identify and assess all possible incidents of abuse. During a review of the facility's P&P titled Residents Rights dated ,d+[DATE] indicated Federal and State laws guarantee certain basic rights of this facility. These rights include the residents right to be free from abuse, neglect, misappropriation of property and exploitation. During a review of the SSD's job description dated ,d+[DATE] indicated the SSD reports the following in accordance with established facility procedures and regulatory standards, accidents and incidents, resident grievances, complaints, allegations of resident abuse and or misappropriation of resident property.

Based on interview and record review, the facility failed to ensure the resident, who had diagnosis of diabetes mellitus (a chronic disease where the body is unable to regulate processing of sugar in the blood) received the prescribed amount of insulin Novolin R (medication used to control the blood sugar level in diabetic patients. Novolin R is a short-acting form of insulin that starts to work in 30 minutes and lasts for several hours in the body) based on the insulin sliding scale (a dosing regimen that prescribes how much insulin to give for different levels of blood sugar) as ordered for one of five sampled residents (Resident 1). Resident 1 received 80 units (a standard quantity of measurement) of insulin Novolin R instead of 8 units (10 times the prescribed dose), for a blood sugar level of 303 milligrams per deciliter [(mg/dl) a unit of measurement)]. The blood sugar level reference range is 80-100 mg/dl. This deficient practice resulted in Resident 1's transfer to an acute care hospital (GACH) for monitoring of blood sugar levels and correction of insulin induced hypoglycemia (a condition that occurs when the blood sugar level in a body is very low) for which the resident was given an intravenous (IV) injection of 25 grams (gm) of Dextrose 50% [a solution of glucose (the main type of sugar in the blood and the major source of energy for the body's cells) in sterile water used to restore low blood sugar levels back to normal] and subsequently transferred to the Intensive Care Unit (ICU) for close monitoring. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and diabetic polyneuropathy (nerve damage related to having diabetes), Dysphagia (difficulty swallowing) and right-side Hemiplegia/Hemiparesis (severe weakness). During a review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 07/06/2022, the MDS indicated Resident 1's cognitive (process of thinking) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required one-person assistance with bed mobility, toilet use, bathing personal hygiene, and eating. During a review of Resident 1's Physician Orders (PO) dated 3/28/2022, the PO indicated Resident 1 had an order for insulin Novolin R solution 100 units/ml to administer subcutaneously (beneath all the layers of the skin) before meals for diabetes mellitus based on a Novolin R sliding scale as follows: 1. For blood sugar level 0-150 mg/dl - administer 0 units. 2. For blood sugar level 151-200 mg/dl - administer 2 unit. 3. For blood sugar level 201-250 mg/dl- administer 3 units. 4. For blood sugar level 251-300 mg/dl-administer 6 units. 5. For blood sugar level 301-350 mg/dl- administer 8 units. 6. For blood sugar level 351-400 mg/dl-administer 10 units. 7. For blood sugar level greater than 400 mg/dl- administer 12 units. During a review of Resident 1's medication administration record (MAR) for September 2022, the MAR indicated Resident 1 received 80 units of insulin Novolin R on 9/28/22 at 11:30 a.m., for a blood sugar level of 303 mg/dl obtained via a fingerstick (blood sugar test). Resident 1 should have received 8 units of Novolin R for blood sugar level of 303 mg/dl in accordance with the physician's order for Novolin R on the sliding scale. During a review of Resident 1's Change in Condition (COC) evaluation dated 9/28/2022 at 4:29 p.m., the COC indicated Resident 1 was transferred to the GACH due to concerns of insulin administration. During an interview on 10/13/2022 at 12:01 p.m., the license vocational nurse (LVN 2) stated that the five rights (a standard of nursing practice to ensure safe medication administration to prevent medication errors) verification must be done before giving any medication, to ensure proper care of patients, and prevent medication administration errors, and harm to residents. According to the National Institute of Health [(NIH), a governmental agency for national health research] 'health care professionals, especially nurses, know the five rights of medication use: the right patient, the right drug, the right time, the right dose, and the right route-all of which are generally regarded as a standard for safe medication practices.' https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2957754/#:~:text=Most%20health%20care%20professionals%2C%20especially,standard%20for%20safe%20medication%20practices. During an interview on 10/13/2022 at 12:01 p.m., LVN 2 stated that the five rights are: right resident, right medication, right dosage, right time, and right method/route of medication administration. LVN 2 stated when administering insulin, a nurse must be extra careful because it is a high risk medication, due to possible severe side effects such as hypoglycemia. LVN 2 stated that an overdose (an excessive and dangerous dose of medication) of Insulin can result in the resident having hypoglycemic (low blood sugar) episode with side effects including cold and clammy skin, shaking, fast heartbeat, nervousness, irritability and confusion, dizziness leading to possible loss of conscious, seizures and death. During an interview on 10/13/2022 at 12:58 p.m., LVN 4 stated she was present the day of the incident. LVN 4 stated that she noticed LVN 1 was walking up and down the hallway and looked nervous. LVN 4 asked LVN 1 what had happened and LVN 1 stated I think I gave 80 units of insulin instead of 8 units. LVN 1 stated she used a tuberculin syringe [(TB) a syringe used to measure and deliver a specific amount of tuberculin vaccine and features decimal calibration {standardized markings} in milliliters) to administer the Novolin R. LVN 4 then asked LVN 1 to show the syringe she (LVN 1) administered Novolin R to Resident 1 with. LVN 4 stated LVN 1 showed a TB syringe like the one she used to administer Novolin R. LVN 4 stated after LVN 1 showed her the syringe she (LVN 4) notified the Registered Nurse (RN 1) supervisor. The TB syringe is a device used to deliver a certain amount of medication in the skin layer. The TB syringe holds up to 1.0 milliliter (ml) of fluid/medication and has calibration with 0.1 ml increments (markings). The insulin syringe is used to deliver insulin to tissue under the skin and holds up to 1.0 ml of insulin. The insulin syringe has calibration in units increments, where one unit of insulin is equal to one hundredth of 1.0 ml (1.0 ml equals to 100 insulin units, therefore 0.1 ml of TB syringe equals to 10 units of insulin). According to American Journal of Nursing the insulin syringes are measured in insulin units, whereas the tuberculin syringes feature decimal markings of milliliters https://journals.lww.com/ajnonline/fulltext/2000/01000/interchangeable_syringes_.48.aspx#:~:text=Tuberculin%20syringes%20aren't%20usable,feature%20decimal%20markings%20of% Throughout this investigation LVN 1 was not reachable for interview by phone. During an interview on 10/13/2022 at 1:14 p.m., LVN 3 stated there is a difference between an insulin syringe and a TB syringe. Both syringes have different colors and TB syringes are calibrated in milliliters whereas insulin syringes are calibrated in units. Both syringes are a different size. LVN 3 stated that insulin and TB syringes should be stored separately to prevent their utilization errors. During an interview on 10/13/2022 at 2:27 p.m., the MDS Nurse (MDSN), stated that RN 1 and himself went to assess Resident 1 after LVN 4 informed him about the administration of Novolin R in excessive amount. The MDSN stated Resident 1 was alert and oriented, and that the physician was notified that Resident 1 was given the wrong dose of Novolin R. The MDSN stated the physician ordered to call 911 and transfer the resident to GACH. During an interview on 10/13/2022 at 3:15 p.m., the Director of Nursing (DON), stated the licensed nurses must use the 'five rights' of medication administration, before giving any medications to a resident. When nurses administer insulin, they must be extra careful and double check the insulin dose in the syringe before administering it to a resident. The DON stated, ideally, a verification of the insulin dose in syringe should be done with another licensed nurse. DON stated due to a lack of staffing in the facility, that was not possible. The DON stated an overdose of insulin can result in the resident losing consciousness. According to the National Institute of Health (NIH) the Institute for Safe Medication Practices recommends a 2-nurse double-checking procedure when preparing insulin for administration https://pubmed.ncbi.nlm.nih.gov/ During an interview on 10/25/2022 at 2:22 p.m., with the medical doctor (MD 1) of Resident 1, MD 1 stated, Resident 1 had to be transferred to the GACH immediately because Resident 1's blood sugar would start dropping and Resident 1 would start developing symptoms of hypoglycemia. If measures to correct low blood sugar were not taken right away, serious physical and mental changes would occur in Resident 1's body, including death. The MD stated, there was a medication error because what was given was not what he prescribed. The LVN did not follow the orders that the MD wrote. During an interview on 10/26/2022 at 1:34 p.m., the facility's Pharmacist Consultant (PC), stated insulin was used to manage blood sugar levels in diabetic patients. The PC stated that there are different types of insulin, the two different types are short-acting (a type of insulin whose onset [the length of time it takes for a medicine to start to work]) starts within 15-30 minutes and has a duration time (the length of time that medication works) of 2- 4 hours and long-acting insulin (a type of insulin whose onset starts within 2 hours and lasts up to 24 hours). The difference between the two insulin types is that in short acting insulin the onset of insulin action between 15 to 30 minutes, whereas the long-acting insulin onset of action take up to 2 to 4 hours. The PC stated that if someone was overdosed on insulin, the patient would become hypoglycemic and possibly go into a coma or die if not treated immediately. The PC stated with a short-acting insulin the adverse effects would occur immediately and with a long-acting insulin the adverse effect would occur much later. According to https://diabetes.org/healthy-living/medication-treatments/insulin-other-injectables/insulin-basics regular or short-acting insulin usually reaches the bloodstream within 30 minutes after injection, peak (time when medication most effective) anywhere from two to three hours after injection, and is effective for approximately three to six hours. Long-acting insulin reaches the bloodstream several hours after the injection and tends to lower glucose levels up to 24 hours. During a review of Resident 1's GACH records dated from 9/28/2022 to 10/1/2022, the GACH records indicated Resident 1's blood sugar on arrival to the emergency roiagnom on [DATE] at 3:05 p.m., was 206 ml/dl. The emergency room physician ordered blood sugars to be checked every 30 minutes and to start Dextrose 10% [(D10) a solution used to replenish sugar levels to counteract the insulins effects of steadily declining blood sugars] intravenous solution. The GACH records indicated that on 9/28/2022 at 8:07 p.m., Resident 1's blood sugar level dropped to 58 ml/dl indicating that Resident 1 was hypoglycemic and was then given 25 grams of Dextrose 50% and subsequently transferred to ICU for close monitoring. Resident 1 was then transferred out of the ICU on 9/29/2022 to the medical floor and was discharged from the GACH on 10/1/2022. During a review of the facility's policy and procedure (P/P) titled Administering Medications, revised April 2019, the P/P indicated that the individual administering the medication checks the label THREE times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. During a review of the facility's policy and procedure (P/P) titled Insulin Administration, revised September 2014, the P/P indicated that the type of insulin, dosage requirements, strength, and method administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. The P/P also indicated insulin syringes must match the unit dose (e.g., 100 unit/mL insulin must be administered in a 100 unit/mL insulin syringe). The P/P indicated to check and re-check that the type of insulin on the vial matches the type of insulin ordered and to double check the order for amount of insulin and to recheck the amount of insulin drawn into the syringe matches the amount of insulin ordered.

Based on interview and record review, the facility failed to provide supervision and adhere to its policy and procedure for one of three sampled residents (Resident 1) to ensure the resident did not elope (leave without notice or authorization) from the facility. Resident 1 was assessed as a high risk for elopement and had a history of elopement from the facility on 6/17/2022. Resident 1 eloped from the facility for the second time on 8/28/2022 at 6:00 a.m. The facility failed to: 1. Ensure the facility had a system in place to monitor front entrance door from 10 p.m. to 7 a.m. daily to prevent residents with impaired cognitive status to elope from the facility. 3. Ensure the facility staff followed the facility's policy and procedure titled 'Safety and Supervision of Residents' to provide Resident 1 with supervision to prevent the resident to sustain harm resulted from elopement. This deficient practice resulted in Resident 1 eloping from the facility on 8/28/22 and being exposed to harsh environmental conditions including excessive heat and/or cold, possible motor vehicle accident, medical complications including malnutrition, dehydration, stroke, heat stroke and possible death. Resident 1 was located on 8/31/2022, 10 miles away from the facility and was found unconscious on a street by a bystander and admitted to a general acute care hospital (GACH) where the resident was diagnosed with dehydration (condition where the body loses too much water and other fluids that it needs to work normally) and [CONDITION(S)] (critically high levels of sodium in the blood, which can lead to excessive thirst, fatigue, confusion, and seizures). On 9/1/2022 at 2:40 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Administrator (ADMIN) and the Director of Nursing (DON) due to the facility's failure to have a system in place to prevent Resident 1's repeated elopements from the facility. On 9/2/2022 at 4:19 p.m. the facility submitted an acceptable IJ removal plan (IJRP). After verification of IJRP implementation through observation, interviews, and record reviews, the IJ was removed on 9/2/2022 at 4:53 p.m., in the presence of the ADMIN and DON. The IJPR included the following immediate actions: 1. The resident who eloped, Resident 1, is currently at the hospital and after speaking with The Veterans Administration will assist in finding a secured unit more suitable for him. 2. While 1-on-1 (one staff member assigned to specifically monitor the resident) staff monitoring for the two residents at risk for elopement will be monitored 24/7 until systemic changes have taken place. 3. Certified Nursing Assistance (CAN)/designee to relieve assigned 1-on-1 staff monitoring the two residents at risk for elopement during breaks. 4. All facility's entry and exit ways, including emergency exits, will be monitored by the maintenance staff each shift for proper function. 5. Continue to ensure wander guards are in place and functioning. Immediate Systemic Changes included: 1. Preadmission elopement risks identification will be completed by reviewing resident's medical history for elopement risk factors and a history of wandering/elopement prior to admission. If elopement history is identified, but assessment indicates that this is no longer a risk, the facility will consider admitting the resident. If the Elopement is new or assessment indicated history with continued risk, the facility will not consider admission of this patient. 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 diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), [CONDITION(S)] (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), and a history of falls. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 6/18/2022, the MDS indicated Resident 1's cognitive (process of thinking) skills for daily decision-making were moderately impaired. The MDS indicated that Resident 1 required supervision on bed mobility, toilet use, bathing personal hygiene, eating, walking, and needed supervision with getting dressed. The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) when he walked in his room, the corridors and on/off the unit. The MDS indicated Resident 1 had a behavior that placed him at significant risk of getting to a potentially dangerous place (e.g., the stairs, outside of the facility) occurring one to three days. During a review of Resident 1's History and Physical (H&P) dated 6/12/2022, the H&P indicated Resident 1 was alert to his name and was confused at times. The H&P indicated Resident 1 had a history of fall with an abrasion to his right knee and a laceration to his forehead that required sutures. The H&P indicated Resident 1 had no capacity to understand and make decisions. During a review of Resident 1's elopement risk assessment (ERA) dated 6/19/2022, the ERA indicated Resident 1 scored 18 (a score of 10 or above is considered a high risk for elopement, zero to three equals a low risk, four to nine equals a medium risk) During a review of Resident 1's Nursing Progress Note (NPN) dated 8/28/2022, and timed at 5:34 p.m., indicated Resident 1 was reported missing to the local police department. On 8/31/2022 at 8:03 a.m., during an interview with the screener (SCR), staff who sits at the facility's front entrance and screens people for signs and symptoms of Covid-19 [a highly contagious [CONDITION(S)] infection] upon entrance to the facility, stated the front entrance is not monitored after 10 p.m. and is locked from the outside from 10 p.m. to 7 a.m. daily, and an alarm is activated during that time. SCR stated although the front door is locked from the outside from 10 p.m., to 7 a.m., it can be pushed open from inside. During an interview with the Cook (CK) on 8/31/2022 at 11:02 a.m., the CK stated that on 8/28/2022 heard the Rehabilitation (a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment) room alarm door, leading to outside the facility, going off around 5:30 a.m. The CK stated that he went to check the door and did not see anybody. The CK stated he reported to nurse supervisor that the Rehabilitation room door alarm was triggered. The CK stated that he went outside and did not see anyone. The CK stated the nurse supervisor had the keys to the Rehabilitation room door and was the only one to turn off the alarm. The CK stated that everyone was responsible to check the doors if an alarm goes off. During an interview on 8/31/2022 at 11:46 a.m., the ADMIN stated that the Rehabilitation room door and the front door alarms were sounding at the same time and it was viewed on the surveillance camera how staff was going to both doors. The ADMIN stated that Resident 1 has previously told his conservator that he did not want to be at the facility. The ADMIN stated that alarms are important and that all staff should respond to them when triggered. During an interview with the ADMIN on 9/19/2022 at 10:08 a.m., the ADMIN stated staff were not monitoring that exit at the time Resident 1 eloped. The ADMIN stated he does not know what system facility had before him taking over the facility to ensure the front door was monitor for residents not to leave unnoticed. The ADMIN stated the screener leaves at 8 p.m., and staff assigned to the South station are responsible to monitor the front door when the screener is gone. The ADMIN stated, it is unrealistic for someone to monitor those doors 24 hours a day, 7 days a week. During an interview with LVN 5 on 9/19/2022 at 3:46 p.m., LVN 5 stated she is the charge nurse for the South station. LVN 5 stated she does her computer work at the receptionist desk so she can monitor if resident wants to leave, or someone wants to come in. LVN 5 stated that is her system, she does not know how staff on 11:00 p.m. to 7:00 a.m. shift monitors the front door. During an interview on 8/31/2022 at 3:12 p.m., the Director of Staff Development (DSD) stated Resident 1 would wander around the facility and was alert but also confused at times. The DSD stated that after Resident 1 eloped the first time on 6/17/2022, the facility implemented more door alarm checks and in-serviced staff on residents' elopement. The DSD stated that it is everyone's responsibility to watch the doors and if an alarm is triggered, staff should go outside to see if any residents have left. During an interview on 8/31/2022 at 3:30 p.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 liked to wander the facility and asked for his conservator. LVN 2 stated that Resident 1 did not have the ability to make decisions and if not supervised there was a risk of Resident 1 getting seriously injured. During a concurrent interview and record review with the DON on 9/1/2022 at 1:38 p.m., the H&P of Resident 1 was reviewed. The DON confirmed that the H&P indicated that Resident 1 did not have the capacity to make decisions. The DON stated Resident 1 has verbalized in the past that he wanted to go back to his board and care facility. During an interview with the Registered Nurse Supervisor (RN 1) on 9/1/2022 at 4:50 p.m., RN 1 stated that on 8/28/2022 at around 5:30 a.m. two alarm doors were going off, the front door and the door by the Rehabilitation department. RN 1 stated when the alarms were going off, she asked CNA 1 to go check on Resident 1 because he was an elopement risk and CNA 1 reported back that the resident was not there. RN 1 stated staff started to look for Resident 1 throughout the facility. RN 1 stated staff went also to the train station in search of Resident 1. RN 1 stated once they were unable to locate Resident 1, she notified the proper authorities. RN 1 stated that Resident 1 had verbalized to her in the past that he wanted to leave the facility. RN 1 was unable to verbalize why the resident was not placed on a 1:1 and stated, 'I do not have an answer for that'. RN 1 stated that Resident 1 could be in danger because the area around the facility is 'not safe' and with the current weather condition could be at risk for a heat stroke or dehydration. According to the Accuweather report for Long Beach area from 8/28/2022 to 9/3/2022 https://www.accuweather.com/en/us/long-beach/ /september-weather/ 1, the temperature was in the high 80's-degree Fahrenheit ( F) to middle 90's F during the day, and high to middle 60's F during the night. During an interview with an officer of the Long Beach Police Officer (LBPD) on 9/1/2022 at 5:05 p.m., the LBPD officer stated the surrounding area is not safe, there are numerous theft and robberies that occur and that the local metro train brings in a lot of people who commit crimes in the area. The LBPD officer stated it is dangerous for a resident who needs supervision and leaves a facility. The resident can be assaulted, robbed, or get into an accident. According to https://crimegrade.org/safest-places-in-long-beach-ca Long Beach city's overall crime grade for violent crimes for zip code , where the facility was located, the crime grade indicated an D- grade (meaning crime is much higher than the average US city). During a review of Resident 1's GACH's Emergency Department (ED) admission documents dated 8/31/2022, the ED notes indicated that Resident 1 was admitted for dehydration (condition where the body loses too much water and other fluids that it needs to work normally) and [CONDITION(S)] (critically high levels of sodium in the blood, which can lead to excessive thirst, fatigue, confusion and seizures). During a review of the facility's policy and procedure (P/P) titled Wandering & Elopements, revised 3/2019, the P/P indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent them harm while maintaining the least restrictive environment for residents. During a review of the facility's P/P titled Safety and Supervision of Residents, revised 7/2017, the P/P indicated 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 nutrition interventions were evaluated to prevent unplanned weight loss and meeting resident's desirable body weight for three of three sampled residents (Resident 69, Resident 75 and Resident 95) when: 1. Resident 69's nutrition status was not assessed since April 2020 and nutrition interventions were not re-evaluated for its effectiveness. 2. Resident 75's nutrition interventions were not reassessed and the Registered Dietitian (RD) consult order that was telephone ordered by the physician was not communicated to the RD. 3. Resident 95's nutrition interventions were not evaluated to reflect resident's desired weight goal to promote weight gain. These deficient practice resulted in Resident 69 to experience a significant unplanned weight loss of 7 lbs. (6.4%) in April 2021; Resident 75 had an unplanned severe weight loss of 35 lbs., 21% weight loss in 6 months from August 2020 to February 2021 and severe weight loss of 16 lbs. (11%) in 6 months from September 2020 to March 2021, and continued to experience an unplanned weight loss of 4 lbs. (3%) from March to April 2021. This deficient practice also had the potential to increase risk for undesirable weight loss in Resident 95. Findings: 1. During a review of Resident 69's Admission Record, the Admission Record indicated Resident 69 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 69's Minimum Data Set (MDS, an assessment and care-screening tool), dated March 4, 2021, indicated Resident 69 was able to eat with limited assist. During a review of Resident 69's Order Summary Report, the report indicated resident was on a regular diet with mechanical soft texture (foods are finely chopped to appropriate bite sizes) and to add fortified (ways to increase protein and calorie) cereal at breakfast and fortified soup at lunch and dinner. During a meal observation on April 7, 2021, at 8:15 AM, observed Resident 69's breakfast tray was left on the cart outside of the resident's room and it contained chopped pancakes, ground meats and a bowl of cereal. An interview with Resident 69 on April 7, 2021, at 8:16AM regarding why foods were still on the breakfast tray outside and if she ate breakfast, Resident 69 stated she ate the banana and yogurt that was on the tray. During a meal observation on April 8, 2021, at 8:10 AM, observed Resident 69 eating banana and yogurt and she did not eat scrambled eggs, toast and cereal that were on the tray. During an interview with Certified Nurse Assistant 3 (CNA 3) on April 8, 2021, at 8:20 AM, CNA 3 stated it was difficult to assist Resident 69 as the resident still could feed herself, she would only assist if the resident allowed her. CNA 3 stated Resident 69 never ate hot cereals at breakfast and that might not be her preferences. CNA 3 stated Resident 69 liked sweet foods like dessert or shakes and did not eat soup at lunch. CNA 3 stated she never mentioned Resident 69's intake or food preferences to the Director of dietary services (DDS) or RD. During a review of Resident 69's Weights and Vitals Summary reports, the report indicated the following weights: 116 lbs. on 4/16/2020 116 lbs. on 5/14/2020 116 lbs. on 6/8/2020 113.2 lbs. on 7/8/2020 116 lbs. on 8/7/2020 113.6 lbs. on 9/7/2020 117 lbs. on 10/5/2020 113 lbs. on 11/11/2020 112 lbs. on 12/7/2020 111 lbs. on 1/6/2021 111 lbs. on 2/4/2021 110 lbs. on 3/8/2021 103 lbs. on 4/5/2021 Based on the weight history, Resident 69 had a severe weight loss of 7lbs (6.4%) from March to April 2021 and a gradual weight loss of 13 lbs. (11.2%) over a year period from April 2020 to April 2021. A review of Resident 69's Nutrition and Dietary Services Progress Notes and Nutrition Assessment, the assessment indicated the last entry of the Registered Dietician's (RD) assessment of Resident 69's nutrition status was April 30, 2020. There were no other assessments or progress notes from the RD or Interdisciplinary Team ([IDT] group of different disciplines working together towards a common goal for a resident) regarding Resident 69's weight or nutrition status since the annual assessment on April 30, 2020, before the resident experienced significant weight loss on April 5, 2021. The assessment indicated resident had an 11 lbs. (8%) insidious weight loss, but there was not a weight goal range for the resident indicated. During a concurrent record review and interview with the RD on April 7, 2021 at 2:10 PM, the RD confirmed she did not assess resident since last year April and stated her last assessment for Resident 69 was April 30, 2020. She stated she would inform the IDT which residents should be reviewed during the weight variance meeting and the criteria was 5 lbs., or 5% weight change in a month, 7.5% in 3 month and 10% in 6 months. She also stated she reviewed weight trends over the 6-month timeframe to determine residents with gradual weight changes. The RD stated she reviewed Resident 69's gradual weight loss a year ago but did not review Resident 69's nutrition status again as there was not a big change in weight trends in the last 6 months. The RD stated that she agreed if she would have reviewed Resident 69's weights in a 12-month time span instead of 6 months, she would see there was a gradual weight loss trend and intervened sooner. She further stated there would be a potential that April 2021's significant weight loss might be avoided if the facility had intervened sooner. During an interview with Registered Nurse 7 (RN 7) on April 7, 2021 at 2:51 PM, RN 7 stated she knew Resident 69 triggered for significant weight loss in April 2021, but the IDT had not met to review Resident 69's significant weight loss as of yet. RN 7 stated she did not know Resident 69 experienced gradual weight loss prior to this significant weight change as she relied on the RD to provide her a list of residents to be reviewed by the weight variance IDT. During an interview with Licensed Vocational Nurse 4 (LVN 4) on April 7, 2021 at 2:56 PM, LVN 4 stated Resident 69 did not eat fortified soup at lunch. RN 7 stated she agreed if the fortified cereal and fortified soup were not eaten, it would not be effective and nutrition interventions should have been re-evaluated. RN 7 also stated if the IDT had intervened earlier and reviewed the gradual weight loss sooner, they might be able to prevent Resident 69's significant weight loss to occur on April 2021. During an interview with the RD on April 8, 2021 at 8:47 AM, the RD stated she would have re-evaluated the interventions if nurses told her about Resident 69 not eating the fortified cereal or fortified soup during meals. 2. During a review of Resident 75's Admission Record, the Admission Record indicated Resident 75 was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 75's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 75's order summary report, the report indicated Resident 75 was on a regular diet with mechanical soft texture. The report indicated Resident 75 also had an enteral tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth) order of Fibersource HN 1.2 (tube feeding formula brand), 250 milliliter ([ml] volume measurement) three times a day to provide 750 ml and 900 kilocalories ([kcal] calorie measurement) starting on October 8, 2020. During a review of Resident 75's Weights and Vitals Summary Report, the report indicated the following weights: 164 lbs. on 8/7/2020 146 lbs. on 9/11/2020 136 lbs. on 10/5/2020 135 lbs. on 11/11/2020 135 lbs. on 12/7/2020 131 lbs. on 1/6/2021 129 lbs. on 2/4/2021 130 lbs. on 3/8/2021 126 lbs. on 4/5/2021 Based on the weight history, Resident 75 had a severe weight loss of 35 lbs., 21.3% weight loss in 6 months from August 2020 to February 2021, and a severe weight loss of 16 lbs., 11.0% in 6 months from September 2020 to March 2021. During a review of Resident 75's Nutrition and Dietary Services Progress Notes and Nutrition Assessment, the last assessment entry from the RD of Resident 75's nutrition status was January 28, 2021. There were no other assessments from the RD for February or March 2021 to address Resident 75's severe weight loss. During a concurrent record review and interview with the RD on April 8, 2021 at 8:18 AM, RD stated she did not assess Resident 75 after January 28, 2021. She stated Resident 75 was on her list that triggered for significant weight loss for 6 months in March 2021, but she missed the assessment. The RD also stated residents who were on tube feedings should have been assessed on a monthly basis and stated that she missed both February and March tube feeding assessments for Resident 75 due to time constraints. The RD stated Resident 75's usual body weight was between 145-160 lbs. according to the comprehensive nutrition assessment on September 10, 2020. During a review of Resident 75's Weight Variance Meeting records with RN 7 and the DDS on April 8, 2021, at 10:11AM, the records indicated the IDT, which was comprised of the social services director, director of dining services (DDS), registered nurse, and activity's director, reviewed Resident 75's significant weight change on February 11, 2021. The review indicated Resident 75 had a total of a 35 lbs. (21%) weight loss from August 2020 (164 lbs.) to February 2021 (129 lbs). Interventions included regular mechanical soft diet with bolus feeding of Fibersource HN 1.2 250 ml to provide 750 ml and 900 kcal. On March 8, 2021, the IDT reviewed Resident 75's significant weight loss 16 lbs. (11.0%) from September 2020 (146 lbs.) to March 2021 (130 lbs.) and interventions remained the same, Fibersource HN 1.2 250 ml to provide 750 ml and 900 kcal. During concurrent interviews with RN 7 and the DDS on April 8, 2021, at 10:13 AM regarding Resident 75's nutrition intervention remained the same despite resident had a significant 11% weight loss in 6 months, RN 7 stated they did not make changes to the current interventions as the resident was already started on bolus feeding to supplement her diet and the RD did not have any recommendations for Resident 75's significant weight change. Both RN 7 and the DDS confirmed they did not know the RD had not assessed Resident 75 since January 28, 2021. RN 7 and the DDS stated they thought Resident 75's significant weight change was assessed by the RD and there were no recommendations to change the interventions. Both RN 7 and the DDS stated they agreed that if they had known the RD did not assess this significant weight loss, they would have requested a RD consult to re-evaluate the resident's nutrition interventions. During a concurrent record review of the facility's situation/ background/assessment/recommendation (SBAR) and change of condition ([COC] tool to inform the doctor of resident's change of condition) dated February 9, 2021 and concurrent interview with RN 7 on April 8, 2021 at 10:20 AM, RN 7 verified Resident 75's primary doctor and responsible party were notified of resident's significant weight change. RN 7 stated the note indicated the MD was notified with an order of RD consult, the order was carried out, we will continue to monitor closely. RN 5 verified the telephone order status on the electronic charting system and stated she did not see the RD consult ordered on or after February 9, 2020 even though it was written on the SBAR note. RN 7 stated the consult notification to the RD might have been verbal instead of a written notification. During a telephone interview with the RD on April 8, 2021, at 11:22 AM regarding whether she received the consult ordered for Resident 75 that was written on SBAR on February 9, 2021, the RD stated that she did not receive the RD consult order for Resident 75 and she was not informed verbally about the consult. c. During a review of Resident 95's Admission Record, the Admission Record indicated Resident 95 was admitted to the facility on [DATE], and last readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 95's MDS, dated [DATE], indicated Resident 95 had no cognitive impairment. A review of Resident 95's History and Physical (H/P) examination dated February 30, 2020, the H/P indicated Resident 95 had the capacity to understand and make decisions. During a review of Resident 95's Order Summary report, the report indicated Resident 95 was on a consistent carbohydrate diet ([CCHO] diet with consistent amount of carbohydrate each meal to help with blood sugar control) and an order of high protein nourishment two times a day on December 31, 2020 for wound healing support and significant weight loss. During a review of Resident 95's Weights and Vitals Summary Report, the report indicated the following weights: 104.2 lbs. on 9/7/2020 104 lbs. on 10/5/2020 104 lbs. on 11/11/2020 104 lbs. on 12/7/2020 96 lbs. on 12/30/2020 96 lbs. on 1/6/2021 96 lbs. on 2/4/2021 97 lbs. on 3/8/2021 96 lbs. on 4/5/2021 Based on the weight history, Resident 95 had a severe weight loss of 8 lbs., 7.7 % in 3 months from November 2020 to February 2021. During an interview with Resident 95 on April 8, 2021 at 8:14 AM, Resident 95 stated she was not aware she had lost weight. Resident 95 stated she would like her weight goal to be at least 100 lbs., but she had not discussed this with the RD or nurses before. During a review of Resident 95's Nutrition and Dietary Services Progress Notes and Nutrition assessment with the facility RD on April 8, 2021, at 9:10AM, the assessment records indicated there were no assessments from the RD in February 2021 to address Resident 95's severe weight loss in 3 months. The last entry from the RD in the computer system was dated January 11, 2021. An interview with the RD on April 8, 2021, at 9:11 AM, she stated she missed Resident 95's 3-month severe weight loss assessment that was triggered from November 2020 to February 2021. The RD stated the IDT weight variance committee reviewed Resident 95's weight change as the resident was on the list that she provided to the IDT for a weight variance meeting. During a review of Resident 95's weight variance assessment meeting report dated February 11, 2021 with RN 7 and DDS on April 8, 2921 at 10:19 AM, the report indicated Resident 95 had lost 8 lbs. (8%) in 3 months. There were no target weight range or desirable weight goal reviewed in the weight variance meeting and there were no changes to the nutrition intervention. During concurrent interviews with RN 7 and the DDS on April 8, 2021 at 10:20AM, both RN 7 and the DDS stated they did not review Resident 95's desired weight goal and the nutrition interventions was not changed as the resident remained stable at 96 to 97 lbs. The DDS stated they would review the weight goal for residents who wished to be on a planned weight loss goal, but they did not obtain weight goal ranges for those who were on a weight gain plan. RN 7 stated she agreed that if they had discussed with Resident 95 her desired goal weight, they could have changed the nutrition interventions to promote weight gain. During a review of the facility's policy and procedure (P/P) titled, Weight Assessment and Intervention, revised September 2008, the policy and procedure indicated assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the resident's target weight range. The P/P also indicated individualized care plan shall address, to the extent possible, goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment.

Based on observation, interview, and record review, the facility failed to ensure all nursing staff were trained in the care, services and treatment for [REDACTED]. Resident 1, who had spastic movements ([DIAGNOSES REDACTED] is a muscle control disorder that is characterized by tight or stiff muscles and an inability to control those muscles) related to [DIAGNOSES REDACTED]. The staff failed to provide care and services to ensure the resident was monitored for [MEDICAL CONDITION] and spastic movements; had padded side rails and preventive measures put in place to ensure Resident 1 was placed in an area to prevent harm and injuries during spastic movements. Residents 2 and 3, who had a [DIAGNOSES REDACTED]. Resident 4, who had a [DIAGNOSES REDACTED]. care. These deficient practices resulted in Resident 1 sustaining a fracture (broken bone) to the right middle finger after being placed in hazardous areas during spastic movements and had the potential to result in falls, injuries and death to Residents 2, 3 and 4 who had [DIAGNOSES REDACTED]. A pattern of the facility's system failure to ensure staff were trained and provided the necessary care and services and supervision for residents who had [DIAGNOSES REDACTED]. On 1/8/2020 at 5:35 p.m., an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance or requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) was declared for the facility's non-compliance to adhere to its policies, physicians' orders and residents care plans and ensure staff were properly trained to provide care to residents with [DIAGNOSES REDACTED]. safety. On 1/8/2020 at 8:05 p.m., the facility's ADM provided a Plan of Action (POA) for correction of the non-compliance, which included the following: 1.The residents' physicians' orders for padded side rails would be carried out effective 1/8/2020. 2. The medical director was contacted on 1/8/2020 to determine the need for lab test for [MEDICAL CONDITION] medications. 3. All residents diagnosed with [REDACTED]. 4. Resident 1's physician ordered a STAT (immediately) [MEDICATION NAME] ((levetiracetam) an anti-epileptic/ anticonvulsant medication) level on 1/8/2020. 5.The pharmacist consultant was contacted on 1/8/2020 for a Medication Regimen Review (MRR). 6.The DON updated care plans for residents at risk for fall/injury related to ataxia (abnormal, uncoordinated body movements). 7.The DON started providing in-services to licensed and unlicensed nurses on 1/8/2020 on how to care for residents with [MEDICAL CONDITION] disorder. In-services training would be completed by 1/9/2020. 8. Residents diagnosed with [REDACTED]. 9. The Interdisciplinary Team ((IDT) coordinated group of experts from several different fields who work together toward a common business goal) will review residents with [MEDICAL CONDITION] [DIAGNOSES REDACTED]. 10. The DON would conduct a daily audit for residents diagnosed with [REDACTED]. On 1/9/2020 at 7:05 p.m., during a concurrent observation, interview and record review, the ADM was notified the IJ was lifted while onsite, after the team verified the POA was followed and implemented. Findings: a. A review of Resident 1's records indicated the following: An Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A physician order [REDACTED]. A physician's orders [REDACTED]. Administration Record [REDACTED] A care plan dated 7/27/19 indicated Resident 1 had [MEDICAL CONDITION] activity related to [MEDICAL CONDITION]. The staff's interventions included to not to leave the resident alone during a [MEDICAL CONDITION] activity, [MEDICAL CONDITION] precaution, to monitor [MEDICAL CONDITION] activity, changes in behavior and report to the physician. The care plan did not indicate any [MEDICAL CONDITION] precautions interventions. A history and physical (H/P) report, dated 11/4/19 indicated Resident 1 had the capacity to understand and make decisions. A Minimum Data Set (MDS), an assessment and care screening tool, dated 11/1/19 indicated Resident 1 usually understood and was understood by others. The MDS indicated Resident 1 required a one-person physical assist with bed mobility, moving from one location of the facility to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 1 required a two-person physical assist transferring to and from bed, chair, wheelchair and standing position. Resident 1's MDS indicated the resident used a wheelchair for mobility. A MAR for the month of 1/2020 indicated Resident 1 was receiving: 0.5 milligram ((mg)unit of measurement) [MEDICATION NAME] (anticonvulsant) two times daily, 500 mg [MEDICATION NAME] two times daily, and was monitored for and had no anti-convulsant side effects such as drowsiness and ataxia every shift. An Unusual Occurrence Report dated 1/4/2020 indicated on 1/3/2020 at approximately 4:30 p.m., Certified Nursing Assistant 1 (CNA 1) noticed Resident 1's right middle fingernail bed was discolored and notified Licensed Vocational Nurse 1 (LVN 1). This report indicated Resident 1's physician ordered a STAT (immediate) X-ray. According to this report, the X-ray result indicated Resident 1 had an acute distal phalanx fracture (broken bone of the hand, closest to the fingertip). The facility's conclusion indicated the staff members had witnessed Resident 1 hitting hard objects (not easily penetrated objects) such as bedside rails and windowsills during the spastic episodes. An x-ray result, dated 1/2/2020 and timed 10:46 a.m. indicated Resident 1 had a right middle finger fracture (broken bone). A nursing progress note, dated 1/6/2020 and timed at 12:19 p.m., indicated Resident 1 had a splint (strip of rigid material used for supporting and immobilizing a broken bone) in place and Resident 1 was exhibiting tremors and ataxia in both hands. On 1/8/2020 at 9:57 a.m., during a concurrent interview and review of Resident 1's [MEDICAL CONDITION] care plan, dated 7/24/19, the DON stated the care plan did not include the use of padded side rails or how the staff should care for Resident 1 before a [MEDICAL CONDITION] (as an intervention) and the staff had not been trained on the care of [MEDICAL CONDITION] residents. The DON stated residents diagnosed with [REDACTED]. According to the DON, padded side rails prevented injury in case a resident hit the side rail. On 1/8/2020 at 11:21 a.m., during a concurrent observation and interview, LVN 1 stated Resident 1 had a history of [REDACTED]. LVN 1 stated Resident 1 was supposed to have padded side rails to prevent injuries from [MEDICAL CONDITION] and ataxia. LVN 1 stated she had not received any in-service on how to care for residents diagnosed with [REDACTED]. b. A review of Resident 2's records indicated the following: An Admission Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. An H/P dated 8/8/19 indicated Resident 2 had the capacity to understand and make decisions. A physician's orders [REDACTED]. A Change of Condition (COC) form, dated 9/29/19 and timed at 3:16 a.m. indicated on 9/29/19 at 1:15 a.m., a CNA notified a Registered Nurse (RN) Resident 2 was observed in bed, with his eyes rolling up and the resident's head and left hand making a rhythmic jerking movement. The COC form indicated Resident 2 had an oxygen saturation level of 93 percent ((%) unit of measurement) (normal reference range (NRR) is 98-100 %) and was administered 5 liters of supplemental oxygen (02) and 911 (emergency response) was called. According to the COC, Resident 2's [MEDICAL CONDITION] activity continued until the paramedics arrived and transported the resident to a GACH. A care plan dated 9/30/19 titled, [MEDICAL CONDITION] Activity Related to [MEDICAL CONDITION]. The staff's interventions indicated not to leave Resident 2 alone during a [MEDICAL CONDITION] activity; monitor Resident 2 for [MEDICAL CONDITION] activity and document the location of the [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity, duration, level of consciousness, any incontinence (inability to control bowel/bladder), sleeping and/or dazed post-ictal state after the [MEDICAL CONDITION]. The care plan also indicated to turn Resident 2 on the side with his head hyper-extended to prevent aspiration (fluid into the lungs). An MDS, dated [DATE] indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required a one-person physical assist with bed mobility, moving from one location of the facility to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 2 required a two-person physical assist for transferring from and to the bed, chair, wheelchair and standing position. Resident 2's MDS indicated the resident used a wheelchair for mobility. A physician's orders [REDACTED]. A MAR for the month of December from 12/1/19 to 12/31/19 indicated Resident 2 was receiving 750 mg of [MEDICATION NAME] and 150 mg [MEDICATION NAME]. The MAR indicated [REDACTED]. On 1/8/2020 at 2:17 p.m., during a concurrent interview and review of Resident 2's COC form, dated 11/12/19 and timed at 11:15 p.m., the DON stated on 11/12/19 at 5:35 p.m., a CNA reported to an RN that Resident 2 was shaking. The DON stated the RN called 911 (emergency services) and Resident 2 was transferred to a GACH. According to the DON, Resident 2 had another [MEDICAL CONDITION] episode on 11/29/19. The DON stated each time Resident 2 had a [MEDICAL CONDITION] activity, the paramedics had to be called to stop Resident 2 from having [MEDICAL CONDITION] with an unknown drug given. The DON stated the [MEDICAL CONDITION] episode on 11/12/19 lasted for approximately twenty-five (25) minutes and the paramedics had to administer two or three doses of the unknown medication before Resident 2's [MEDICAL CONDITION] stopped. The DON stated Resident 2 did not have any bedside rails because it was an unnecessary device and did not stop a [MEDICAL CONDITION]. On 1/8/2020 at 4 p.m., during a concurrent observation and interview, Resident 2 was in bed without side rails. LVN 1 stated Resident 2 had a history of [REDACTED]. LVN 1 stated since Resident 2 had episodes of [MEDICAL CONDITION], the resident should have padded bedside rails to prevent injuries related to [MEDICAL CONDITION] activity. c. A review of Resident 3's records indicated the following: An Admission Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A care plan dated 11/7/15 indicated Resident 3 was at risk for episodes of [MEDICAL CONDITION]. The staff's interventions indicated to provide Resident 3 with a safe environment, not to leave Resident 3 alone during a [MEDICAL CONDITION] episode, protect Resident 3 from injury, document the type of [MEDICAL CONDITION] activity, duration, level of consciousness, any incontinence (involuntary urination/bowel movements) and after a [MEDICAL CONDITION] episode. An H/P dated 3/13/19 indicated Resident 3 did not have the capacity to understand and make decisions. An MDS dated [DATE] indicated Resident 3 did not have the ability to understand and be understood by others and cognition (thought process) was severely impaired. The MDS indicated Resident 3 required a two-person physical assist with bed mobility and transferring. The MDS indicated Resident 3 required a one-person physical assist moving from one location to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 3 used a wheelchair for mobility. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A COC form dated 11/27/19 and timed at 3:05 p.m., indicated on 11/27/19 at an unknown time, a caregiver notified an unnamed staff of Resident 3 having a strong [MEDICAL CONDITION]. The COC indicated Resident 3's eyes rolled back and Resident 3's entire body was shaking for two minutes. According to this COC, Resident 3 was administered 1.5 mg [MEDICATION NAME] IM (antianxiety ) or post [MEDICAL CONDITION]. A MAR for the month of 1/2020 indicated Resident 3 was receiving 300 mg [MEDICATION NAME] two times daily;1500 mg [MEDICATION NAME] two times daily; and [MEDICATION NAME] 10 mg in the morning on Monday, Wednesday and Friday. On 1/8/2020 at 2:25 p.m., during a concurrent interview and a review of Resident 3's [MEDICAL CONDITION] care plan and a COC form, dated 12/30/19 and timed at 2:30 p.m., the DON stated Resident 3 had two episodes of [MEDICAL CONDITION] activity on 12/30/19 at 2:30 p.m., for fifteen (15) seconds and at 2:38 p.m., for five (5) seconds. The DON stated the COC did not indicate the type of [MEDICAL CONDITION], level of consciousness, if any incontinence and after [MEDICAL CONDITION] activity as indicated in Resident 3's plan of care. The DON stated Resident 3 had side rails that were not padded so the pads could not fall off. According to the DON, when Resident 3 starts seizing, the caregiver would leave the resident unattended to go inform the nurse, so the nurse could observe the [MEDICAL CONDITION] activity and document appropriately. d. A review of Resident 4's records indicated the following: An Admission Face sheet indicated Resident 4 was admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. An H/P dated 9/11/19 indicated Resident 4 had a fluctuating capacity to understand and make decisions. An MDS dated [DATE] indicated Resident 4 was able to understand and be understood by others. The MDS indicated Resident 4 required a one-person physical assist with bed mobility, transferring, walking, dressing, toilet use and personal hygiene. A physician order [REDACTED]. A COC form dated 12/28/18 and timed at 7:20 p.m., indicated on 12/28/19 at an unknown time, Resident 4 was found unconscious (not awake and responsive of surroundings) and unresponsive. The COC form indicated Resident 4 was transferred to a GACH. A MAR for the month of 12/2019 indicated Resident 4 was receiving 200 mg of [MEDICATION NAME] two times daily and 5 ml [MEDICATION NAME] Acid three times daily for convulsion. A care plan dated 1/25/19 indicated Resident 4 had history of [MEDICAL CONDITION] disorder. The staff's interventions included not to leave Resident 4 alone during a [MEDICAL CONDITION], protect Resident 4 from injury, if out of bed, help the resident to the floor and to use padded side rails if ordered to reduce the risk of injury and administer [MEDICAL CONDITION] medications as ordered. On 1/8/2020 at 11:49 a.m., during a concurrent observation and interview, CNA 2 stated Resident 4's bed was always elevated and did not have side rails. CNA 2 stated Resident 4 had frequent [MEDICAL CONDITION] and no in-service had been provided on the care of residents diagnosed with [REDACTED]. CNA 2 stated residents not having padded side rails could result in falls and injuries. On 1/8/2020 at 11:18 a.m., during an interview, CNA 3 stated she had never cared for a resident diagnosed with [REDACTED]. CNA 3 who was assigned to care for both Residents 1 and 2 was not aware the residents had [MEDICAL CONDITION] disorders. CNA 3 stated there has not been any in-service training provided on how to care for residents with [MEDICAL CONDITION]. A review of an online article, by NCBI Bookshelf /National Library of Medicine titled, [MEDICAL CONDITION] precautions indicated how to manage a patient during a [MEDICAL CONDITION] included the following: 1. Stay with the patient and call for help 2. Keep other people out of the way 3. Loosen the patient's clothing 4. Clear objects away from the patient 5. Place the patient on the left side to maintain a patent airway 6. Padded side rails may help prevent falls out of bed 7. Time the patient [MEDICAL CONDITION] activity 8. Do not place anything in the patient's mouth 9. Call 911 if necessary On 1/8/2020 at 5:22 a.m., during a concurrent review of the facility's in-service binder and interview, the DON stated the staff had not been in-serviced on the care of residents diagnosed with [REDACTED]. The DON stated the Director of Staff Development (DSD) was out on leave. A review of the facility's policy and procedure titled, Staff Development Program, with a revised date of 12/2009, indicated the purpose of the staff development program was to plan and organize a system of training so that each employee could develop their abilities, as well as limitations in providing care for residents. This policy indicated training was meant to teach employees of specific facility's policies and procedures. A review of the facility's policy and procedure titled, [MEDICAL CONDITION] and [MEDICAL CONDITION] with a revised date of 4/2013, indicated individuals with [MEDICAL CONDITION] or [MEDICAL CONDITION] activity will be identified and managed appropriately. According to this policy, the staff would carefully describe signs and symptoms including residents' current level of consciousness, cognitive ability, speech, physical function, abnormal motor activity, tremors, overall physical condition and comparison of the resident's current status to his or her usual level of cognition and physical function. The policy indicated the staff should not just document a resident had a [MEDICAL CONDITION].

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a change in a resident's condition for one of 14 residents (77), who had [DIAGNOSES REDACTED]. 1. Report to Physician 1 of Resident 77's below the therapeutic level of [MEDICATION NAME] Acid (medication to control and prevent [MEDICAL CONDITION] activity) level of 30.2 micrograms per milliliter ((mcg/ml) (therapeutic level range is between 50-100 mcg/ml). 2. Notify Medical Director when Physician 1 did not call back the facility in response to the notification about Resident 77's abnormal [MEDICATION NAME] Acid (medication to control and prevent [MEDICAL CONDITION] activity) of 30.2 micrograms per milliliter ((mcg/ml) therapeutic levels range between 50-100 mcg/ml). 3. Notify Physician 1 of Resident 77's two [MEDICAL CONDITION] episodes that occurred on the same day. The last event lasted 15 minutes. These deficient practices resulted in a delay in providing timely care, and treatment to Resident 77 who had two [MEDICAL CONDITION] episodes on the same day; one that lasted for one minute, and another [MEDICATION NAME] for more than 15 minutes. Resident 77 was transferred to a general acute care hospital (GACH), where Resident 77 was diagnosed with [REDACTED]. On 1/24/20, at 5:38 p.m., due to identified deficient practices, the Administrator (ADM), and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy (IJ) situation and provided with written IJ template. On (MONTH) 25, 2020 at 4:15 p.m., after receipt of acceptable plan of action (POA) and verification of POA implementation, the IJ was lifted in the presence of the ADM and the DON. Findings: On 1/23/20 at 7:42 a.m., Resident 77 was observed lying in bed, positioned on his side, and having a [MEDICAL CONDITION]. Resident 77 was receiving oxygen through a face mask and was unresponsive. RN 3 was standing at the resident's bedside and looking at the resident. A review of Resident 77's Admission Records indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 77's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 12/5/19, indicated Resident 77 had severely impaired cognitive skills for daily decision making and was dependent on staff for activities of daily living (such as bed mobility, transfer, dressing, eating, toilet use and personal hygiene). A review of Resident 77's Physician order [REDACTED]. A review of Resident 77's care plan for [MEDICAL CONDITION], dated 10/28/17 indicated interventions that included to monitor the resident for [MEDICAL CONDITION] activity and report to the physician if [MEDICAL CONDITION] activity occurs. A review of Resident 77's for [MEDICAL CONDITION] Activity dated 1/21/20, indicated interventions to obtain and monitor laboratory and diagnostic work as ordered, report results to the physician, and follow up as indicated. A review of Resident 77's laboratory results indicated the following levels of [MEDICATION NAME] Acid blood levels: 1. On 7/29/19, the [MEDICATION NAME] Acid blood level was 69.6 mcg/ml. 2. On 1/15/20, the [MEDICATION NAME] Acid blood level result was flagged in yellow, indicating an abnormal level of 30.2 mcg/ml. [MEDICATION NAME] Acid therapeutic level range is between 50-100 mcg/ml. A review of Resident 77's clinical record indicated there was no documented evidence Physician 1 was notified of abnormal [MEDICATION NAME] Acid level laboratory report. A review of a handwritten note on the laboratory test results dated 1/15/20, indicated Resident 77's abnormal [MEDICATION NAME] Acid test report was faxed to Physician 1's office on 1/15/20, and that Resident 77 was on [MEDICATION NAME] Acid 500 mg twice a day. On 1/23/20 at 12: 27 p.m., during a review of Resident 77's clinical record and concurrent interview, Registered Nurse 3 (RN 3) acknowledged there was no documentation in the clinical record that Physician 1 was notified of the abnormal [MEDICATION NAME] Acid level laboratory result. RN 3 stated Resident 77's [MEDICATION NAME] Acid level is low and the medication dose needs to increase, the resident is on [MEDICATION NAME] Acid for [MEDICAL CONDITION], and low level of this medication will result in a [MEDICAL CONDITION]. A review of the Incident Form (paramedics' report) dated 1/23/20, indicated the paramedics were dispatched to the facility on [DATE] at 7:33 a.m. and arrived at Resident 77's bedside at 7:44 a.m. Resident 77 was having a [MEDICAL CONDITION] and staff stated the resident was last seen normal at 5:00 a.m. The incident form indicated the paramedics administered Midazolam (medication to stop [MEDICAL CONDITION] activity) 5.0 mg intramuscularly ((IM) into the muscle) to prevent Resident 77 from having [MEDICAL CONDITION]. The report indicated that on the same day at 7:56 a.m., the paramedics transferred Resident 77 to a general acute care hospital (GACH). A review of Emergency Department (ED) Nursing notes dated 1/23/20 at 10:12 p.m., indicated the facility's RN 1 informed ED Resident 77 has had tremors, but tremors have not lasted long. The ED notes on the same day at 12:05 p.m. indicated Resident 77 transferred to the telemetry unit (monitor critically injured patients who need constant attention and monitoring) for closer observations. A review of the GACH records for Resident 77, indicated the laboratory reports dated 1/23/20 at 8:10 a.m., revealed the [MEDICATION NAME] Acid level was less than ten mcg/ml. A review of Resident 77's History and Physical form from GACH, dated 1/23/20 at 3:57 p.m., indicated the resident's lips were dry, with dry blood, had lactic acidosis (occurs when cells make lactic acid from blood sugar faster than it can be broken down), and febrile [MEDICAL CONDITION]ly secondary to subtherapeutic (below normal range) level of [MEDICATION NAME] Acid. The GACH's Preliminary Report notes dated 1/23/20 at 9:58 a.m., indicated the following: 1. Upon arrival, the resident had [MEDICAL CONDITION], shaking intermittently with episodes of [MEDICAL CONDITION] exacerbation (worsen), and more pronounced shaking on the right side. 2. Rectal (is taken by putting the thermometer at the end of the bowel) temperature was at 38.7 degrees Celsius ((C) reference range of 37.6 C or less), heart rate of 107 beats per minute (reference 60 to 100 beats per minute). 3. The resident was administered [MEDICATION NAME] (to treat [MEDICAL CONDITION] disorder) 2.0 mg intravenously ((IV) into a vein) at 10:07 a.m. and to continue 1 mg IV push, PRN for [MEDICAL CONDITION]. 4. The resident had elevated (raised) lactic acid (raised with strenuous exercise or other conditions such as [MEDICAL CONDITION] and severe infections), which may be secondary to [MEDICAL CONDITION] or possible [MEDICAL CONDITION] (severe infection). 5. The resident was administered IV fluids and broad-spectrum antibiotics (medication to treat infections). A review of Medication Administration Record [REDACTED]. On 1/23/20 at 12:27 a.m., during an interview RN 3 stated the resident (Resident 77) has been having [MEDICAL CONDITION] today since 7:30 a.m. RN 3 stated on the same day at 6:25 a.m., the licensed vocational nurse (LVN 6), who worked 11 p.m., to 7 a.m. shift, informed her about Resident 77 having [MEDICAL CONDITION] earlier that day. RN 3 stated licensed nurses was supposed to notify Physician 1 or Medical Director and document any resident's change of condition (C[NAME]). RN 3 stated I did not inform the doctor Resident 77 had a [MEDICAL CONDITION]. RN 3 stated a [MEDICAL CONDITION] activity was a C[NAME], and the resident could suffer a [MEDICAL CONDITION], and die from poor blood circulation and lack of oxygen. On 1/23/20 at 4:21 p.m., during an interview and review of Resident 77's laboratory test report for [MEDICATION NAME] Acid level dated 1/15/20, RN 5 verified her handwriting and initials. On the report was handwritten note Faxed 1/15/20. RN 5 stated the residents' laboratory test results usually faxed to the physicians. RN 5 said she should have contacted and reported to Physician 1 the abnormal [MEDICATION NAME] Acid results dated 1/15/20 to enable Physician 1 to make necessary adjustments to Resident 77's medications. RN 5 stated, We do not store fax confirmation receipts. It is the practice here. RN 5 stated, In case I cannot get a hold of the physician, I will endorse information to incoming shift. During an interview on 1/24/20 at 4:50 p.m., the Director of Nurses (DON) stated the facility must immediately report the abnormal laboratory results to the physician. The DON stated it was the practice of the facility to fax all laboratory reports, including reports with critical results. DON stated, We cannot wait for the fax when there is a critical report. The DON stated medical records department files fax confirmation receipts. The DON stated the licensed nurses must communicate the C[NAME] to the physician and document it in the nurse's notes. A review of the facility's policy titled First Aid revised 7/2014, indicated that regardless of nature or severity, any resident's injury/situation shall be reported to the attending physician and family, documented in the resident's medical record, and follow the facility policy for emergency physician's care. A review of the facility's policy titled Change in a Resident's Condition or Status revised 5/2017, indicated the following: 1. The facility shall promptly notify the attending physician and the resident's representative of changes in the resident's medical condition or status. 2. The significant change of condition is a considerable decline in the resident's status that will not resolve itself without intervention and impacts more than one area of the resident's health status. A review of the facility's policy titled Laboratory and Diagnostic Test Results-Clinical Protocol revised 11/2018, indicated: 1. A nurse will determine the test was done to monitor a drug level. 2. Nursing staff will identify situations that warrant immediate physician notification and convey the abnormal result to a physician regardless of any other factors. 3. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message or another person acting as the physician's agent example office staff. 4. Facility staff should document information about when, how and to whom information was provided and the response. 5. Direct voice communication is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review. 6. A physician should respond within one hour regarding a laboratory test result requiring immediate notification. 7. The nursing staff should contact the Medical Director for assistance if the attending or covering physician does not respond to the immediate notification within an hour. 8. Physicians or nurses with concerns about how test results were handled or reported should notify the DON and/or Medical Director and concerns should be prevented timely, clinically appropriate management of current results or clinical situation.

Based on observation, interview, and record review, the facility failed to implement its abuse policy to protect two of 21 sampled residents (Residents 1 and 2) from being financially abused by the facility's Social Service Designee (SSD) and the Business Office Manager (BOM). The facility failed by not keeping track and safe guarding the residents who had bank cards and ensuring Residents 1 and 2 were not coerced (persuade (an unwilling person) to do something by using force or threats) into giving money to the facility staff (Cross referenced to F606). These deficient practices resulted in Resident 1 being coerced by the BOM to sign a release of money on [DATE] to pay a share of cost ((SOC) amount resident pays the facility) and coerced by the SSD on [DATE] to go to the bank and withdraw $6000.00. Resident 2 was coerced by the SSD to give him his wallet for safe keeping and took $200.00 from the residents' wallet. A pattern of the facility's system failure to adhere to its policies and ensure residents were free from financial abuse, which included the facility's failure to have a system in place to account for resident's personal properties and safe guard residents from financial abuse. On [DATE] at 4 p.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 declared for financial abuse. The facility's administrator (ADM) was notified of the immediacy and seriousness of the residents' health and safety being threatened. On [DATE] at 4:44 p.m., the ADM submitted an acceptable Plan of Action (POA) for the correction of the IJ. The POA included the following: 1. The Social Worker and Business Officer Manager were suspended pending further investigation and terminated on [DATE]. 2. The facility will return Resident 1's $6000.00 and any other funds fraudulently (obtained, done by, or involving deception, especially criminal deception) removed from Resident 1's account by the Social Services Director as determined by the facility and the financial institution of Resident 1. 3. Resident 2 stated that he gave his wallet containing $200.00 cash to Social Services Director. The facility will reimburse Resident 2 of the $200.00 cash on [DATE]. 4. The Administrator reported the abuse to the local Police department, Ombudsman Program and California Department of Public Health (CDPH) after Department of Public Health (DPH) was onsite investigating the theft and a Report of Suspected Dependent Adult/Elder Abuse (form 341) report will be filed on [DATE]. 5. All staff will be in-serviced on resident abuse by [DATE]. 6. The facility conducted interviews of residents with Patient Trust Funds to ensure that all funds have been managed accordingly and there is no missing money. 7. If the facility determines funds are missing, the facility will refund the missing funds to the resident. 8. All Automated Teller Machine (ATM)/Credit Cards given to facility to safeguard per the resident's request will be kept in a locked cabinet. 9. All items will be listed in a log. Residents will be given a receipt for all items safeguarded by facility. 10. The Administrator or Designee will audit the log/locked cabinet on a monthly basis for accuracy. 11. The facility will ensure that all residents are discharged to a safe environment. 12. IDT team will be in-serviced on facility policy regarding resident's discharge. 13. The facility will conduct a review of all residents discharged during the past 6 months to ensure that residents were discharged to a safe environment. On [DATE] at 4:47 p.m., during an interview, the ADM and the Director of Nursing (DON) were notified by the surveyor that the IJ was lifted, after the team verified that the POA was followed and implemented as listed above. Findings: a. A review of Resident 1's records indicated the following: An Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. The Face Sheet indicated Resident 1 was self-responsible (able to make one's own decisions). A Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated [DATE], indicated Resident 1's cognitive skills (ability to reason and think) for daily decision-making was severely impaired. The MDS indicated Resident 1 had no problems making himself understood or understanding. The MDS indicated Resident 1 required extensive assistance of a two-person physical assist for transfer and dressing and an extensive assist of a one-person physical assist for toilet use and personal hygiene. According to the MDS, Resident 1 had impairment of one side of the lower extremities (right side). A physician's progress note, dated [DATE] and timed at 12:18 a.m., indicated Resident 1 was alert and oriented to self, had history of falling, and muscle weakness. An initial psychological consultation (diagnostic procedure that involves the assessment of the present state of mind and how it affects his or her behavior and function), dated [DATE] indicated Resident 1 was alert, but disoriented to date and place. The consultation indicated that Resident 1 had neurocognitive (study of the neural processes and structures involved in cognition (thought process)) dysfunctions such as verbal and visual learning memory. The assessment indicated Resident 1 had significant cognitive deficits, poor insight, judgement, related to the [DIAGNOSES REDACTED]. The psychologist (someone who studies the mind and behavior) recommended re-orientation due to Resident 1's level of confusion and disorientation. A care plan titled, Resident has Impaired Cognitive Function/Impaired thought Processes, dated [DATE] with a target date of [DATE], indicated Resident 1's goal was cope with cognitive decline and maintain safety. The staff's interventions included to monitor/document/report to physician any changes in cognitive function such as ability to make decisions, recall, difficulty understanding others, level of confusion, and mental status. A review of the Nurses Notes, dated [DATE] and timed at 5:30 p.m., indicated Resident 1 was discharged to the independent living facility ((IL) for seniors who are able to live on their own) with discharge instructions. A facility's document titled, Authorization Agreement for Direct Payment (Credit Card), dated [DATE] indicated Resident 1 gave authorization to the skilled nursing facility (SNF) to withdraw $33, 953.00. On [DATE] at 3:15 p.m., during an interview, the Bank's Compliance Officer (BCO) stated Resident 1 was a victim of financial abuse by the SNF's SSD. The BCO stated on [DATE] Resident 1's bank card was blocked due to unauthorized usage and on the same day, the SSD called the bank impersonating Resident 1 and was requesting to have Resident 1's bank card unblocked. The BCO stated and provided proof of several transactions that were made utilizing Resident 1's bank card transactions as follows: On [DATE] for $1,005.00 On [DATE] for $1,972.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] two for $2,000 equaling $4000 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] for $2,000.00 On [DATE] an Automated Teller Machine (ATM) withdrawal for $303. On [DATE] an ATM withdrawal of $503.00, and a purchase at a discount department store for $508.19. On [DATE], Resident 1 was discharged from the facility and transferred to IL. On [DATE] an unsuccessful transaction was attempted at an out of state airport (Texas) for $103.00 On [DATE] a withdrawal for $6000.00 cash at the financial institution. On [DATE] two unsuccessful ATM transactions were attempted for $500 and $300. On [DATE] at 9:10 a.m., during a concurrent interview and review of the bank's audio recording, dated [DATE], a male caller identified himself as Resident 1 and provided first and last name, date of birth, but failed to provide the password of Resident 1's account twice. On [DATE] at 11:25 a.m., during an interview, in the presence of the Director of Nursing (DON) and the BOM, the SSD stated Resident 1 had intermittent confusion. The SSD stated he took Resident 1 to the bank on [DATE] to withdraw $6000.00 cash to pay for Resident 1's first and last month rent at an unlicensed IL. The SSD stated he was aware that it was not allowed to take residents to the bank after they were discharged , but he got involved with Resident 1. The SSD stated on [DATE] he did place a telephone call to the bank and stated he was Resident 1. The SSD stated he was aware what he did was wrong because he used to work as a bank teller in the past and impersonating (pretending to be another person) a person is unlawful. During the concurrent interview, the DON stated she was aware the SSD was assisting Resident 1 using his ATM at the bank on [DATE], but was not aware the SSD was not introducing himself and stating to be Resident 1. The BOM stated Resident 1 owed $36,000 for one year of the unpaid SOC. The BOM stated she was withdrawing $2000.00 daily starting from [DATE] through [DATE] to cover Resident 1's SOC utilizing the ATM with withdrawals. The BOM stated that she had no documentation that was provided to Resident 1 regarding owing SOC since ,[DATE]. The BOM stated she did not believe what she did was wrong because she wanted the facility to get paid. The BOM denied giving Resident 1 a notice to pay of vacate (leave) the facility, in regard to being late on SOC or owing SOC. A review of the SSD's written and signed declaration, dated [DATE] and timed at 12:30 p.m., indicated on [DATE] he called the bank stating he was Resident 1 and inquired about why the ATM being blocked. The declaration indicated the SSD and the unlicensed Independent Living Manager (ILM) took Resident 1 to the bank to withdraw $6000.00 on [DATE]. On [DATE] at 12:59 p.m., during an interview, the SSD and BOM stated the facility has never had a system in place to identify the residents in the facility, who kept their ATM cards in their possession. The BOM and SSD stated after reviewing the facility's daily census dated [DATE], they identified 18 residents who kept their ATM cards in their possession. The SSD and BOM stated there was no way to identify if any of the 18 residents identified had financial abuse since the facility did not have a system in place to safe guard residents from financial abuse. The SSD stated Resident 1 was the only resident he had assisted with bank transactions. The SSD stated what he did of taking Resident 1 to the bank and impersonating him was wrong, but he was trying to help Resident 1 and because he needed 24 hours nursing care. On [DATE] at 1:18 p.m., during an interview, the DON stated the SSD's job entailed following up with the residents' only to return belongings such as clothing once they were discharged from the facility, but not to accompany the resident to the bank or use the resident's ATM cards. A review of the written declaration, dated [DATE] and timed at 4:30 p.m., indicated the Social Services Assistant (SSA) stated on ,[DATE], she found a box on top of the office cabinet containing wallets, driver's License cards, social security cards, cell phones, wallets and watches, and was told by the SSD that those items belonged to discharged , expired, and other facility's residents. The SSA stated on [DATE], Resident 2 asked about the wallet he had given to SSD containing $200.00 and the declaration stated that the SSA found Resident 2's wallet and driver license inside the box containing other resident belongings. The SSA declaration indicated that on [DATE], upon going through the SSD's desk, she found Resident 1's ATM card. On [DATE] at 2:05 p.m., during an interview, the Bank Compliance Officer (BCO) stated the facility was made aware on [DATE] regarding the SSD's misuse of Resident 1's funds. On [DATE] at 3:20 p.m., during an interview, the ADM stated both the SSD and BOM were on [DATE] suspended pending investigation. The ADM stated during the investigation, the SSD stated he was told by the ILM to call the bank as if he was Resident 1 and inform the bank he needed his ATM card unblock to pay for rent. The ADM stated what the SSD did was considered fraud (wrongful or criminal deception intended to result in financial or personal gain) and stated upon further investigation of the SSD's employee file, she found that the SSD was not truthful on his application regarding his Bachelor's degree in Social Services. The ADM stated on [DATE] the DON saw the SSD coming to the facility to drop off Resident 1's sealed bank statement containing the new ATM card that was ordered by the SSD. On [DATE] at 7 p.m., during a concurrent observation and interview, Resident 1 observed at the IL facility wheeling himself to his room with difficulty in maneuvering the wheelchair. Resident 1 stated he did not remember who the SSD or BOM were at the facility and did not remember authorizing any bank transactions because he did not have money. Resident 1 stated that he did not remember going to the bank on [DATE] to withdraw money or to any ATM (machine that dispenses cash) machine. Resident 1 stated not remembering when the last time he ate and/or took his medications. On [DATE] at 5:58 p.m., during an interview, the physician assistant (PA) stated he had assessed Resident 1 on ,[DATE] and it was determined Resident 1 had no mental capacity to make decisions. The PA stated Resident 1 was not appropriate for a discharge to an Independent Living due to his Dementia. b. A review of Resident 2's records indicated the following: An Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. An MDS, dated [DATE] indicated Resident 2's cognition was intact (ability to reason and think) for daily decision-making and had no memory problems. The MDS indicated Resident 2 was able to make himself understood and understand. The MDS indicated Resident 2 was totally dependent of a one-person physical assist for dressing, eating, turning, and toileting. On [DATE] at 5 p.m., during an observation and interview in resident's room, Resident 2 stated a week prior the SSD told him that it would be safer if he kept his wallet. Resident 2 stated he was later notified by the SSD his wallet with the $200.00 had disappeared. Resident 2 stated that a few days after that the SSD informed him he had found his wallet, but Resident 2 stated that it was not his wallet. A review of the SSD employee application dated [DATE] indicated an unverified Bachelor degree of Social Services from an accredited state college. A review of the Assurance Identification (ID) background report provided by the facility and dated [DATE], matching the social security and date of birth of the SSD, indicated a criminal conviction of lewd acts (a crime that is of a sexual nature), filed on [DATE] with an active warrant for his arrest as of [DATE]. The background report indicated a first conviction of a misdemeanor for disorderly conduct was filed on [DATE] with a guilty plea. On ,[DATE] /19 at 1:50 p.m., during a telephone interview, the ADM stated she was not aware the SSD was hired after the facility's background check came back with negative results about the SSD. The ADM stated that the previous DON hired the SSD and she was no longer working in the facility. A review of the facility's policy titled, Resident Trust Account Policy and Procedures, dated [DATE] indicated that generally accepted accounting principles meant that the facility employs proper bookkeeping techniques. The policy indicated that the booking keeping should include information on when the transactions occurred, what they are, and maintain an ongoing balance for every resident. Share of cost was deducted on the 5th working day. A review of the facility's revised ,[DATE] policy titled, Abuse Prevention Program, indicated that the residents had the right to be free from abuse, neglect, misappropriation of property and exploitation. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED].

Based on observation, interview and record review, the facility failed to adhere to its policy regarding abuse prevention to ensure not to hire any personnel with criminal (relating to, involving, or being a crime) background to ensure two of 20 sampled residents (Residents 1 and 2), to ensure the Social Services Director (SSD) was licensed and met the qualifications to render services at the nursing home. The SSD was hired after the facility received the criminal background results indicating an active warrant (a legal or government official authorizing the police or some other body to make an arrest, search premises, or carry out some other action relating to the administration of justice) for his arrest. (cross referenced to F602). This deficient practice resulted in the SSD coercing (obtain something by using force or threat) Resident 1 to withdraw money from the bank to pay rent and misusing his funds and ensuring Resident 2 that he would safe keep his wallet and later informing Resident 2 the wallet was lost. Resident 1 had a monetary loss of $42,291.00 and Resident 2 had a monetary loss of $200.00. Findings: a.A review of Resident 1's records indicated the following: An Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. The Face Sheet indicated Resident 1 was self-responsible. A Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 6/8/19, indicated Resident 1's cognitive skills (ability to reason and think) for daily decision-making was severely impaired. The MDS indicated Resident 1 had no problems making himself understood or understanding. A physician's progress note, dated 8/1/19 and timed at 12:18 a.m., indicated Resident 1 was alert and oriented to self, had history of falling, and muscle weakness. A review of the unsigned Physician's telephone orders, dated 8/29/19 and timed at 10:06 a.m., indicated to discharge Resident 1 to an ((unlicensed) facility not certified by the State) Independent Living facility ((IL) for seniors who are able to live on their own in an apartment or house, but who want the conveniences of living within a community that provides services and amenities such as housekeeping, social activities, dining, transportation, and security). On 9/18/19 at 7 p.m., during a concurrent observation and interview at Resident 1's unlicensed IL, Resident 1 was observed wheeling himself to his room with difficulty in maneuvering the wheelchair. Resident 1 stated he did not remember who the Social Services Designee (SSD) or Business Office Manager (BOM) from the facility were and did not remember authorizing any bank transactions because he did not have money. Resident 1 stated that he did not remembered going to the bank on 9/9/19 to withdraw money or to any automated teller machine ((ATM) machine that dispenses cash) to get money. Resident 1 admitted to not remembering when the last time he ate and/or took his medications. b. A review of Resident 2's records indicated the following: An Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. An MDS, dated [DATE] indicated Resident 2's cognition was intact (ability to reason and think) for daily decision-making and had no memory problems. The MDS indicated Resident 2 was able to make himself understood and understand. The MDS indicated Resident 2 was totally dependent of a one-person physical assist for dressing, eating, turning, and toileting. A review of the SSD's employee personnel file indicated the SSD was hired on 10/18/18 as the Director of Social Services. In the SSD's employee file, there was a certificate for social work consultant, dated 6/16/10. A review of the SSD's employee application, dated 10/18/18, indicated an unverified Bachelor degree in Social Services from an accredited state college, as required to have when working for a facility with more than 120 beds. A review of the Assurance Identification (ID) background report provided by the facility and dated 10/24/18 (six days after the SSD was hired), indicated a criminal conviction of lewd acts (a crime that is of a sexual nature), filed on 5/30/18 with an active warrant for his arrest as of 6/5/18. The background report also indicated the SSD had a first conviction (to be found guilty) of a misdemeanor (criminal act) for disorderly conduct filed on 12/8/09 with a guilty plea. On 9/13/19 at 11:25 a.m., during an interview in the presence of the Director of nursing (DON) and the business office manager (BOM), the SSD stated Resident 1 had intermittent confusion. The SSD stated he took Resident 1 to the bank on 9/9/19 after the resident was discharged from the facility (8/29/19) and living at the unlicensed IL to withdraw $6000.00 cash to pay for his first and last month rent at the IL facility. The SSD stated he was aware that it was not allowed to take residents to the bank after being discharge from the facility, but he got very involved with Resident 1. The SSD stated on he placed a telephone call to the Resident 1's bank after the resident was discharged and stated that he was Resident 1. The SSD stated that he was aware what he did was wrong because he used to work as a bank teller in the past and impersonating (pretending to be) a person was unlawful. During the concurrent interview, the DON stated that she was aware that the SSD was assisting Resident 1 using his ATM at the bank on 9/9/19 but was not aware that the SSD was introducing himself to the bank as Resident 1. The BOM stated Resident 1 owed $36,000.00 for one year of the unpaid Share of Cost ((SOC) payment for housing based on resident's income). The BOM stated she was withdrawing $2000.00 daily at the facility using Resident 1's ATM starting 7/29/19 through 8/19/19 to cover Resident 1's SOC. The BOM stated she had no documentation Resident 1 owed SOC since 9/2018. The BOM stated that she did not believe what she did was wrong because she wanted the facility to get paid. The BOM denied giving Resident 1 a notice to pay or vacate (leave) regarding the overdue SOC. A review of the SSD's written and signed declaration (written statement), dated 9/13/19 and timed at 12:30 p.m., indicated on 9/5/19 he called the bank stating he was Resident 1 and inquired about Resident 1's ATM card being blocked. The declaration indicated the SSD and the Independent Living Manager (ILM) took Resident 1 to the bank after the resident was discharged from the facility to withdraw $6000.00 on 9/9/19. On 9/18/19 at 3:20 p.m., during an interview, the new facility's Administrator (ADM) stated the SSD was investigated for financial fraud against Residents 1 and 2 and was suspended on 9/16/19. The ADM stated that during their internal investigation, the SSD lied about obtaining funds for Resident 1 and on his employment application regarding having a bachelor's degree of Social Work. The ADM stated the SSD was one class short of obtaining his bachelor's degree and only obtained a certification of social services which did not qualified him to provide services to the nursing home. In a concurrent interview, the DON stated a box containing resident's wallets, credit cards, a black purse, and ATM cards were discovered in the SSD's office. On 9/18/19 at 3:56 p.m., during an interview, the DON stated residents' personal items should had been logged in on the log sheet and placed in a secure location (administrator office). On 9/18/19 at 4:17 p.m., during a concurrent observation and interview, the Social Services Assistant (SSA) stated the SSD kept the box of the residents' personal items on an unlocked cabinet inside of the social services office. The SSA stated Resident 1's ATM card was found in the top drawer of the SSD's desk. The facility had no system in place to identify residents who had ATM cards and were at risk. On 9/18/19 at 4:19 p.m., an observation of three unidentified resident wallets containing personal identification cards, a black cloth purse, and Resident 1's ATM card inside a decorative storage box located on top of a tall cabinet. The facility provided a document to indicate SSD was suspended on 9/16/19 and terminated on 9/19/19 for violating the facility's handbook for committing fraudulent (obtained, done by, or involving deception (act of causing one to believe information that is not true) especially criminal deception) activities and for calling Resident 1's bank impersonating (someone tries to look and sound like another person as much as possible) the resident. A review of the facility's job description for a Social Services Director, indicated assumes administrative authority, responsibility, and accountability to provide medically-related social services which assists residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. The SSD qualification requirement indicated a Bachelor of Arts Degree in Social Work or Human services field. Essential job functions included making referrals and obtain services from outside entities, assist residents with financial and legal matters, assist with discharge planning, and demonstrate honesty and integrity at all times in the care and use of resident and facility property. A review of the facility's policy titled, Abuse Prevention Program indicated as part of the resident abuse prevention the administration will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation (the action of making use of and benefiting from the source), misappropriation by a court of law.

Based on interview and record review, the facility failed to follow its policy to provide adequate care and assistant devices to prevent accidents for one of two sampled residents (Resident 1). Resident 1, who had [MEDICAL CONDITION] (a condition that causes bones to become weak and brittle) with risk for fractures (broken bones) feet were no properly placed on a shower chair and was allowed to drag the floor while being pushed in a shower chair (crossed referenced to F656). This deficient practice resulted in Resident 1's right foot being caught between the bottom frame of the shower chair and the floor. Resident 1 complained of pain and sustained an acute (sudden) non-displaced (broken bone that snapped into two or more parts and were lined up) lateral malleolar (bone on the outside of the ankle joint) fracture requiring an orthopedic consult (a physician who specialized in the care and treatment of [REDACTED]. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 7/23/16, indicated the resident had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 1 required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS indicated Resident 1 was totally dependent on staff for bathing and/or showers of transferring in and out of the tub and/or shower. According to the MDS, Resident 1 required staff assistance for moving between locations in the room and the adjacent corridors and Resident 1 had impairment on one side of the upper extremity (shoulder, elbow, wrist, hand) and the lower extremity (hip, knee, ankle, foot). The MDS indicated Resident 1 used a wheelchair for mobility (the ability to move). A review of a Physical Therapy ((PT), a health care provider trained in diagnosing physical abnormalities, restoring and maintaining physical function and mobility, and promoting physical activity and proper function) Initial Evaluation, dated 6/1/16, indicated Resident 1 required assistance with wheelchair management and mobility due to right [MEDICAL CONDITION] (weakness to right side of the body). The PT's evaluation indicated that Resident 1 had impaired safety awareness and was non-ambulatory (not able to walk). The PT's evaluation indicated Resident 1's range of motion ((ROM), the measurement of movement around a specific joint or body part) of the right ankle was impaired and the resident's right lower extremity (hip, knee, and ankle) had impaired strength. A review of a Nursing Progress note, dated 10/12/16 and timed at 1:41 p.m., indicated the resident's right foot and ankle was swollen with purplish discoloration at the right inner ankle and the resident complained of pain level of 10 out of 10 (10 being the worst pain possible and 0 being no pain at all). The progress note indicated the physician was notified and the order was obtained for an x-ray of the right foot. The progress note also indicated that a nurse reported that while pushing Resident 1 back to the room in a shower chair on 10/12/16, the resident's right foot slipped out of the footrest and was caught between the footrest and the floor. A review of Resident 1's x-ray of right ankle, dated 10/12/16, indicated the resident had an acute (sudden) non-displaced (broken bone that snapped into two or more parts and were lined up) lateral malleolar (bone on the outside of the ankle joint) fracture (broken). A review of the physician's orders [REDACTED]. foot. On 10/24/16 at 8:20 a.m., during an interview, Resident 1 was asked about the incident on that occurred 10/12/16, the resident stated Certified Nursing Assistant 1 (CNA 1) placed her in a wheelchair and did not put her feet up off the floor, because the CNA was in a hurry. Resident 1 stated while she was in the wheelchair, her right foot was sliding on the floor and started hurting. On 10/24/16 at 10:05 a.m., during an interview, CNA 1 stated she was assigned to take care of Resident 1 on 10/12/16. CNA 1 stated she was pushing Resident 1 in a shower chair that did not have proper footrests and the resident's feet were resting on the bottom frame of the shower chair. CNA 1 stated when she was pushing the resident in the shower chair, the resident's right foot slipped off the bottom frame of the shower chair and was caught angled down sideways between the bottom frame of the shower chair and the floor. CNA 1 stated Resident 1 stated, Ouch. CNA 1 stated she stopped pushing the shower chair and placed Resident 1's right foot back on the bottom frame of the shower chair, but Resident 1 complained of right foot pain and there was a pink discoloration on the top portion of the resident's right foot. CNA 1 stated Resident 1's right foot had the tendency to slip off the bottom frame of the shower chair. CNA 1 stated a shower chair with a proper footrest should be used for Resident 1 if available. On 10/24/16 at 10:35 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated a shower chair with a proper footrest should have been used for Resident 1 to keep the resident's feet off the floor and to prevent foot injury. On 6/7/17 at 1:30 p.m., during an interview, Director of Nursing 2 (DON 2) stated Resident 1 had right sided weakness and [MEDICAL CONDITION]. DON 2 stated a shower chair with a proper footrest should have been used for Resident 1 so that the resident's feet would not drag on the floor, which was the cause for pain and the fracture. According to the facility's policy and procedure titled, Safety and Supervision of Residents, revised in (MONTH) 2007, indicated the facility was responsible for making the environment as free from accident hazards as possible and resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The policy indicated staff should use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident and the MDS. The policy also indicated the interdisciplinary care team ((IDT), healthcare providers from different disciplines that work collaboratively as a team toward a common goal for the resident) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident, and the care team shall target interventions to reduce the potential for accidents.

Based on interview and record review, the facility failed to follow its policy to develop a care plan to address individualized resident's [DIAGNOSES REDACTED]. Resident 1's plan of care did not include objectives and care measures to identify the [DIAGNOSES REDACTED]. This deficient practice resulted in Resident 1 not receiving specific care to prevent injuries and fractures. Resident 1's right foot was not properly position on a footrest while in a shower chair and became caught between the bottom frame of the shower chair and the floor. Resident 1 sustained an acute (sudden) non-displaced (broken bone that snapped into two or more parts and were lined up) lateral malleolar (bone on the outside of the ankle joint) fracture. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] and last re-admitted on [DATE] with the following Diagnoses: [REDACTED]. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 7/23/16, indicated the resident had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS indicated Resident 1 was totally dependent on staff for bathing and transferring in and out of tub or shower. According to the MDS, Resident 1 required staff assistance for moving between locations in her room and adjacent corridor and had impairment on one side of the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). The MDS indicated Resident 1 used a wheelchair for mobility (the ability to move). A review of Resident 1's Physical Therapy ((PT), a health care provider trained in diagnosing physical abnormalities, restoring and maintaining physical function and mobility, and promoting physical activity and proper function) Initial Evaluation, dated 6/1/16, indicated the resident required assistance with wheelchair management and mobility due to right [MEDICAL CONDITION] (weakness to right side of the body). The PT's evaluation indicated that Resident 1 had impaired safety awareness and was non-ambulatory (not able to walk). The evaluation indicated Resident 1's range of motion ((ROM), the measurement of movement around a specific joint or body part) of the right ankle was impaired and the resident's right lower extremity (hip, knee, and ankle) had impaired strength. A review of Resident 1's progress notes, dated 10/12/16 at 1:41 p.m., indicated the resident's right foot and ankle was swollen with purplish discoloration at the right inner ankle and the resident complained of pain level of 10 out of 10 (10 being the worst pain possible and 0 being no pain at all). The progress note indicated the physician was notified and the order was obtained for an x-ray of the right foot. The progress note indicated that a nurse reported that while pushing Resident 1 back to her room in a shower chair, the resident's right foot slipped onto the floor and was caught between the shower frame and the floor. A review of Resident 1's x-ray result of the right ankle, dated 10/12/16, indicated the resident had an acute (sudden) non-displaced (broken bone that snapped into two or more parts and were lined up) lateral malleolar (bone on the outside of the ankle joint) fracture (broken). A review of Resident 1's Physician Order, dated 10/12/16 and timed at 6:28 p.m., indicated to apply a splint (a device used to support and immobilize a broken bone) and to provide non-weight bearing (no weight can be placed on the affected injured site for proper recovery) to the right foot. On 6/12/17 at 4:25 p.m., during a review of Resident 1's care plans and a concurrent interview, the record indicated there was no plan of care developed or implemented of how to provide nursing care to prevent fractures and injuries for Resident 1's [DIAGNOSES REDACTED]. According to the facility's policy and procedure titled, Care Plans, Comprehensive Person- Centered, dated 2001, with a revision date of (MONTH) (YEAR), indicated a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The policy indicated assessments of residents were ongoing and care plans were revised as information about the residents and the resident's conditions changed.

Based on interview and record review, the facility failed to follow its policy regarding fall incidents and a resident's plan of care to provide the necessary assistance and supervision to prevent the falls for one of two sampled residents (Resident 1). Resident 1 had a [DIAGNOSES REDACTED]. This deficient practice resulted in Resident 1 having two falls on the same day and sustaining an acute (sudden) fracture (broken bone) of the left femoral head (head of the leg bone that fits in the hipbone), which required a transfer to a general acute care hospital (GACH) and undergoing a [MEDICAL CONDITION] arthroplasty of the left hip (a surgical procedure that replaced the head of a damaged leg bone with an implant designed to stabilized the leg bone and restore hip function). Resident 1 was admitted into the GACH for four days. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 8/31/16, indicated the resident's cognition (ability to reason and think) was intact. According to the MDS, Resident 1 was not steady, used a wheelchair for mobility and required staff supervision for getting around in the facility. A review of Resident 1's care plan, initiated 12/4/15, indicated the resident was at risk for fall related to the [DIAGNOSES REDACTED]. A review of another care plan, initiated 3/4/16, indicated Resident 1 had self-care deficits for activities of daily living ((ADL), basic self-care tasks on daily basis such as eating and walking) and the resident required assistance with locomotion on and off the unit. The staff's intervention indicated that the staff would provide assistance and cues for the resident with moving around the facility. A review of Resident 1's physician progress notes [REDACTED]. A review of Resident 1's Nurses Progress Note, dated 10/10/16 and timed at 7:30 p.m., indicated the resident had a fall incident. The note indicated Resident 1 was behind his wheelchair and was ambulating in the hallway and he told Certified Nurse Assistant 1 (CNA 1) that he fell in the dining room. The note indicated Licensed Vocational Nurse 1 (LVN 1) heard a bang and she found the resident in a sitting position behind a nightstand in his room. The resident complained of slight pain on bluish discolored left knee and was unable to bend the knee. According to the nurse's note, a PA (physician assistant) was notified with an order for [REDACTED].>A review of another nurse's note, dated 10/10/16 and timed at 23:05 (11:05 p.m.) indicated the results of Resident 1's left knee x-rays were negative with no fracture or dislocations. A review of a Nurses Progress Note, with a topic of Fall Incident, dated 10/11/16 and timed at 15:15 (3:15 p.m.) indicated Resident 1 complained of pain to the left knee and was medicated with extra strength (ES) Tylenol (for mild pain). A review of a Nurse's Progress Note, dated 10/12/16 and timed at 19:20 (7:20 p.m.), indicated Resident 1 complained of left hip pain. According to the nurse's note, the PA was notified with new orders noted and carried out. A review of Resident 1's x-ray results of the left hip, dated 10/13/16, indicated the resident had an acute [MEDICAL CONDITION] femoral head (left hip area). A review of a physician's orders [REDACTED]. A review of a Nurse's note, dated 10/14/16 and timed at 4:50 p.m., indicated Resident 1 was transferred to the GACH's emergency room for a left femoral head fracture. A review of the GACH's hospital Admission Record indicated Resident 1 was admitted to the hospital on [DATE] and discharged on [DATE], four days later, from the hospital with a [DIAGNOSES REDACTED]. A review of the GACH's record, dated 10/14/16 and titled, History and Physical (H/P) indicated Resident 1 was brought in by ambulance with complaints of left femur (leg bone) fracture. The H/P indicated the facility's staff reported that three days prior Resident 1 yelled from the cafeteria (sic) and the resident was found down on the floor. The H/P indicated Resident 1 recalled that he fell and he was weak already on baseline. A record review of a report of an x-ray of the left femur and pelvis (hip), dated 10/14/16, indicated Resident 1 had an intertrochanteric [MEDICAL CONDITION] femur. A record review of an operative report, dated 10/16/16, indicated Resident 1 had a [MEDICAL CONDITION] arthroplasty of the left hip (a surgical procedure that replaced the head of a damaged leg bone with an implant designed to stabilized the leg bone and restore hip function). On 6/6/17 at 8:25 a.m., during an interview, Resident 1 was asked about the incident on 10/10/16, the resident stated on that evening, after dinner he had slipped and fell and his left hip hit the floor. Resident 1 stated when he fell ; he had left hip pain of 7 on a pain scale 10 being the worse (0 being no pain and 10 being the worst pain possible). Resident 1 stated he had another fall the same evening in his room, which he landed in a sitting position next to his roommate's nightstand. At 11:40 a.m., on 6/6/17, during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she was assigned to take care of Resident 1 on the night of the unwitnessed fall incident on 10/10/16. LVN 1 stated after dinner between the hour from 8 p.m. to 9 p.m., Certified Nurse Assistant 1 (CNA 1) reported to her that Resident 1 had a fall in the dining room. LVN 1 stated there was not a staff assigned to supervise the residents in the dining room at that time because the dining room was closed by then. LVN 1 stated after the fall, Resident 1 walked behind his wheelchair by himself from the dining room back to his room. LVN 1 stated Resident 1 had another unwitnessed fall in his room the same evening. LVN 1 stated when she heard a noise, she saw Resident 1 in a sitting position on the floor in the resident's room. LVN 1 stated she did not investigate how Resident 1 fell in the dining room, as per policy. On 6/7/17 at 11:10 a.m., during an interview, Director of Nursing 2 (DON 2) stated after dinner there were no staff assigned to monitor the dining room on 10/10/16. DON 2 stated when Resident 1 had an unwitnessed fall in the dining room; the staff should have assisted all the residents back to their rooms after dinner, including Resident 1 to prevent another fall. DON 2 stated the staff should have investigated circumstances of the fall in the dining room by finding out how the fall occurred and what part of the resident's body hit the floor and provided that information to the physician so the physician could determine the appropriate orders. According to the facility's policy and procedure titled, Safety and Supervision of Residents, revised (MONTH) 2007, indicated the facility strives to make the environment as free from accident hazards as possible. The resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. According to the facility's policy and procedure titled, Accidents and Incidents- Investigating and Reporting, revised (MONTH) 2012, the facility was responsible for including in the investigation, the circumstances surrounding the accident or incident and the injured person's account of the accident or incident.

Based on interview and record review, the facility failed to follow a resident's care plan, physician's orders, and its policy to provide the necessary care and services for the prevention of weight loss for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. These deficient practices resulted in Resident 1 losing 38.2 pounds ((lbs.) 22 percent (%) of the resident's body weight) in six months (December 4, (YEAR)-June 1, (YEAR)) and resulted in Resident 1 being transferred to the general acute care hospital (GACH) and diagnosed with [REDACTED]. Resident 1 required an extensive evaluation of care and treatment at the GACH. Findings: A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was initially admitted to the facility on (MONTH) 25, 2014 and was last readmitted on (MONTH) 14, (YEAR). Resident 1's [DIAGNOSES REDACTED]. enough healthy red blood cells). A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated (MONTH) 21, (YEAR), indicated a Brief Interview for Mental Status (BIMS) score of 13 (13-15 no impairment), which indicated that Resident 1 did not have problems with memory and cognition (thought process). The MDS indicated Resident 1 required supervision and setup assistance from the staff when eating and extensive physical assistance of a one person with bed mobility. According to the MDS, Resident 1 was not on a physician prescribed weight loss regimen and had a weight loss of five % or more in the last month or 10 % or more in the last six months. A review of Resident 1's Physician Order Summary Report, from (MONTH) 1 to (MONTH) 10, (YEAR), indicated the following: 1. (MONTH) 9, (YEAR), an order for [REDACTED].>2. (MONTH) 17, (YEAR), an order for [REDACTED]. 3. (MONTH) 30, (YEAR), an order for [REDACTED].>4. (MONTH) 1, (YEAR), an order for [REDACTED]. A review of Resident 1's Weights and Vital Summary form, indicated the resident weighed the following: December 4, (YEAR) 169.2 lbs. January 1, (YEAR), 167.7 lbs. February 5, (YEAR), 162 lbs. March 14, (YEAR), 143.8 lbs. April 1, (YEAR), 145.1 lbs. May 1, (YEAR), 151.2 lbs. May 26, (YEAR), 131 lbs. June 1, (YEAR), 131 lbs. A review of the Certified Nursing Assistants (CNAs) documentation form indicated the following: 1. (MONTH) 1-7 and 15-31, (YEAR), Resident 1 had one meal intake between 0% and 25%, 16 meal intakes between 26% and 50% and four meal intakes with no documentation of the percentage. During the occasions where Resident 1's meal intake was 50% or less, the resident was not offered a meal substitute on seven occasions. There were 31 occasions where Resident 1 was independent in eating and did not receive any supervision from staff and four occasions with no documentation of staff support provided during meals. 2. (MONTH) 1-30, (YEAR), Resident 1 had eight occasions of meal intake between 0% and 25%, 14 occasions of meal intake between 26 percent and 50 percent, one occasion when the resident refused to eat, and 11 occasions with no documentation of meal intake indicated. During the occasions where Resident 1's meal intake was 50 % or less, the resident was not offered a meal substitute on 10 occasions. There were 44 occasions where Resident 1 was independent in eating and did not receive any supervision from staff and 11 occasions with no documentation of staff's support provided during meals. 3. (MONTH) 1-31, (YEAR), Resident 1 had two occasions of meal intake between 0% and 25%, 37 occasions of meal intake between 26 % and 50 %, two occasions where the resident refused to eat, and 19 occasions with no documentation of meal intake indicated. During the occasions where Resident 1's meal intake was 50 % or less, the resident was not offered a meal substitute on 20 occasions. There were 27 occasions where Resident 1 was independent in eating and did not receive any supervision from staff and 19 occasions with no documentation of staff support provided during meals. 4. (MONTH) 1-4, (YEAR), Resident 1 had five occasions of meal intake between 0 and 25%, four occasions of meal intake between 26 % and 50 % and three occasions with no documentation of meal intake indicated. There was one occasion where Resident 1 received supervision and setup help with eating and three occasions with no documentation of staff support provided during meals. A review of Resident 1's Care Plan, indicated the following: 1. (MONTH) 15, (YEAR), Resident 1 had an Activities of Daily Living (ADLs) self-care deficit and needed assistance with eating. There was no documentation of eating interventions noted on the care plan. 2. (MONTH) 15, (YEAR), Resident 1 had [MEDICAL CONDITION] and would remain free from further complications of the disease within 90 days. The staff's interventions included monitoring the resident during meals and encouraging adequate nutrition and hydration. 3. (MONTH) 21, (YEAR), Resident 1 had an alteration in nutrition, ate less than 75 percent of most meals, and had the potential for dehydration (a deficit of total body water) and weight changes. The care plan indicated Resident 1 would consume at least 75 percent of most meals and maintain adequate nutrition and hydration in the next 90 days. The staff's interventions included offering meal substitutes, monitoring the resident's weight, and monitoring the resident's labs. 4. (MONTH) 11, (YEAR), Resident 1 had a weight loss of 24.9 pounds in 180 days and 22.6 pounds in 90 days due to poor food intake. The care plan indicated the resident's weight would be stabilized within 30 days. Staff interventions included monitoring the resident's weight loss weekly, offering meal substitutes and assisting the resident with meals as needed. 5. (MONTH) 4, (YEAR), Resident 1 had an alteration in nutrition due to a decreased ability to eat independently and [MEDICAL CONDITION] and had lost 11 pounds in one month and 22.9 pounds in six months. The care plan indicated Resident 1 would maintain adequate nutrition and hydration within 30 days. The staff's interventions included weekly weights for four weeks, assisting and feeding the resident as necessary and adaptive feeding equipment to assist the resident while eating. A review of Resident 1's laboratory results, dated (MONTH) 16, (YEAR), indicated the following: Resident 1's Blood Urea Nitrogen ((BUN) a test used to assess the function of the kidneys and level of hydration) was elevated at 43 (Normal Reference Range (NRR) = 7-25) and the [MEDICATION NAME] level (protein levels; to assess the severity of malnutrition) was low at 3 (NRR= 3.5-5.7). A review of Resident 1's laboratory results, dated (MONTH) 15, (YEAR), indicated the following: Resident 1's BUN was elevated at 37 (NRR= 7-25), the [MEDICATION NAME] was low at 3.3 (NRR=3.5-5.7). A review of Resident 1's Dietary Progress (RD) Notes, indicated the following: 1. (MONTH) 10, (YEAR), Resident 1 ate 50-75 percent of meals and had a good intake. The note indicated Resident 1 had a significant weight loss of 22 pounds in three months and an undesirable Body Mass Index ((BMI) a measure of body fat based on height and weight) of 19 (NRR 18.5-25). The RD's note indicated the resident would continue to be monitored and did not indicate any RD's recommendations. 2. (MONTH) 31, (YEAR), Resident 1 had poor food intake of about 10-20 percent and had a significant weight loss of 6 pounds in one month. The RD note indicated the resident refused to eat vegetables and meat and was only eating ice cream, protein shakes and soup. According to the note, Resident 1's BMI was 16.8 and a pureed diet was offered, but refused by the resident. The note indicated there were no new recommendations by the RD for the resident and the resident would continue to be monitored. 3. Medical Records (MR 1) was unable to locate any additional notes or assessments from the RD for the time period of (MONTH) 1, (YEAR) to (MONTH) 10, (YEAR). A review of Resident 1's Occupational Therapy Discharge Summary, dated (MONTH) 2, (YEAR) indicated Resident 1 required set up assistance with eating. The summary indicated with consistent staff follow through, the resident had a good prognosis to maintain his current level of functioning. A review of Resident 1's Nurse's Note, dated (MONTH) 4, (YEAR) and timed 4:12 p.m., indicated Resident 1 had a weight loss of 22.9 pounds in 6 months and 11 pounds in one month. The note indicated Resident 1 had a decreased ability to eat independently and had tremors when holding a fork or cup. According to the note, Resident 1 would benefit from weighted utensils. The note indicated the physician was made aware and an order for [REDACTED].>A review of GACH's Progress Notes indicated the following: 1. Resident 1 was admitted to the GACH in critical condition on (MONTH) 4, (YEAR), and the resident's [DIAGNOSES REDACTED]. 2. Resident 1 had a low blood pressure of 84/53 (NRR=120/80) and appeared emaciated (very thin and bony usually caused by losing too much weight). Resident 1 was unable to speak and follow commands, had dry mucous membranes and difficulty chewing due to broken teeth. 3. Resident 1's [MEDICATION NAME] level was 2.8 (NRR 3.3-4.8) and BUN was elevated at 45 (NRR 5-25). On (MONTH) 10, (YEAR), at 11:53 a.m., during a concurrent interview and record review, RD 1 (RD 2 was no longer employed at the facility) stated Resident 1 weighed 169.2 lbs., on (MONTH) 4, (YEAR) and weighed 131 lbs., on (MONTH) 1, (YEAR). RD 1 stated Resident 1 had a significant weight loss of 38 lbs., which was 22 % of his body weight in six months. According to RD 1, while reviewing the clinical record, Resident 1's low [MEDICATION NAME] levels indicated the resident was not receiving enough protein. RD 1 stated when Resident 1 initially started losing weight on (MONTH) 5, (YEAR), to prevent Resident 1 from losing any additional weight, she would have recommended a high protein nourishment (HPN), an appetite stimulant and a speech therapist evaluation at that time. The RD 1 was unable to locate any RD 2 (who was the RD for the facility at that time) recommendations or physician's orders for HPN, an appetite stimulant or speech evaluation from (MONTH) 5, (YEAR) to (MONTH) 29, (YEAR). RD 1 stated although Resident 1 had a poor meal intake during the months of (MONTH) and (MONTH) (YEAR), the staff should have offered meal substitutes, but did not do so. According to RD 1, it was important to offer meal substitutes when the resident refused meals or had a poor intake because it could possibly increase the resident's meal intake. At 1:22 p.m., on (MONTH) 10, (YEAR), during an interview, CNA 1 stated Resident 1 was very sick and did not eat much of his food. According to CNA 1, if a resident did not eat enough food or refused to eat, a meal substitute should always be offered to the resident. On (MONTH) 10, (YEAR), at 6:20 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated the CNA Log documentation, dated March-May (YEAR), indicated Resident 1 had a higher meal intake on the days when he was fully assisted with eating meals. The DON was unable to locate an order for [REDACTED]. On (MONTH) 14, (YEAR) at 1:20 p.m., during a telephone interview, Resident 1's family member (FM 1) stated Resident 1 had tremors and was unable to feed himself. FM 1 stated Resident 1 needed assistance from the facility's staff with eating, but was not being assisted during meals. According to FM 1, Resident 1's meal tray would be left on the bedside table and the resident would be unable to feed himself, resulting in the resident losing weight. A review of the facility's policy and procedure titled, Impaired Nutrition/Unplanned Weight Loss Clinical Protocol, with a revision date of (MONTH) 2012, indicated strategies to increase a resident's intake of meals included providing between meal snacks and nutritional supplementation. The policy indicated residents with impaired nutrition would be closely monitored and residents with functional impairments would receive assistance with eating. According to the policy, the resident's care plan would be evaluated to ensure interventions are being implemented and effective. A review of the facility's policy and procedure titled, Assistance with Meals, with a revision date of (MONTH) 2010, indicated residents would receive assistance with meals in a manner that met the individual needs of the resident. A review of the facility's policy and procedure titled, Weight Assessment and Interventions, with a revision date of (MONTH) 2012, indicated nursing would immediately notify the dietician, in writing, of any residents with a verified weight loss of 5% or more since the last weight assessment. The policy indicated the dietician would respond within 24 hours of written notification. According to the policy, weight loss of 10 percent in six months was considered significant and a weight loss of greater than 10 percent in six months was considered severe. The policy indicated negative weight loss trends would be evaluated by the treatment team.

Based on interview and record review, the facility failed to ensure that the physician's order for [MEDICAL TREATMENT] (a treatment to purify the blood when the kidneys are not functioning) was implemented as prescribed for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1, who had an order to receive [MEDICAL TREATMENT] treatment three times a week, missing [MEDICAL TREATMENT] treatments, which resulted in Resident 1 being transferred to a general acute care hospital (GACH) via 911 emergency. Resident 1 was identified with abnormal laboratory results, due to not receiving [MEDICAL TREATMENT] treatments, that lead to the potentially lethal abnormal heart rhythms that required an emergency evaluation and treatments. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was admitted to facility on 4/9/18 with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H/P), dated 4/11/18, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's physician order summary report, dated 5/1/18, indicated an order, dated on 4/9/18, for [MEDICAL TREATMENT] treatments on Tuesday, Thursday, and Saturday (T/TH/Sat) at 9:30 a.m. A review of an Admission Assessment, dated 4/9/18, indicated Resident 1 had a [DIAGNOSES REDACTED]. A review of Resident 1's Nurses [MEDICAL TREATMENT] Documentation Record, dated 4/10/18 and untimed, indicated a handwritten documentation of no [MEDICAL TREATMENT] today resident refused to sign. A review of Resident 1's care plan titled, [MEDICAL TREATMENT], initiated on 4/10/18, indicated the resident needed [MEDICAL TREATMENT]. The facility's staff intervention included to notify the physician for any significant change in the resident's condition before and after [MEDICAL TREATMENT] treatment. On 5/1/18 at 9:30 a.m., during a telephone interview, the Administrator at the [MEDICAL TREATMENT] center stated Resident 1 never received [MEDICAL TREATMENT] because the resident did not sign forms to receive the [MEDICAL TREATMENT] treatments. On 5/1/18 at 11:15 a.m., during review of Resident 1's physician order, dated 4/9/18, and a concurrent interview, the Director of Nursing (DON) stated the resident had a physician's order for [MEDICAL TREATMENT] treatment scheduled for Tuesday, Thursday, and Saturday at 9:30 a.m. The DON stated Resident 1 did not received the [MEDICAL TREATMENT] treatments on 4/10/18 (Tuesday) and 4/12/18 (Thursday) because the resident refused to sign forms to receive [MEDICAL TREATMENT] treatments. A review of a nursing progress note, dated 4/11/18 and timed at 10:30 a.m., as a late entry for 4/10/18, and a concurrent interview, the DON stated Resident 1 refused to sign the consent forms to receive [MEDICAL TREATMENT] care on 4/10/18. The DON stated the physician was not notified that Resident 1 refused [MEDICAL TREATMENT] on 4/10/18 and 4/12/18, and should have been notified. The DON stated when Resident 1 missed [MEDICAL TREATMENT] treatments then there was potential for a change of condition related to the kidneys such as, [MEDICAL CONDITION], which can affect the heart's function. The DON stated when Resident 1 missed her [MEDICAL TREATMENT] treatment she was not evaluated by the Nephrologist (a physician who specialized in the care of kidneys and diseases of the kidneys). The DON stated there was no care plan to address Resident 1's refusal for [MEDICAL TREATMENT] and it was a new identified problem and a care plan should have been initiated. On 6/26/18 at 2:07 p.m., during a telephone interview, the Assistant Director of Nursing (ADON) stated when Resident 1 refused [MEDICAL TREATMENT] then an interdisciplinary team ((IDT), a group of health care providers who discuss the residents' care concerns) meeting should have been done to address Resident 1's refusal for [MEDICAL TREATMENT]. A review of progress note, dated 4/13/18 and timed at 4:03 p.m., indicated Resident 1 refused to go for [MEDICAL TREATMENT] treatment and a call was made to the physician and the physician ordered to transfer the resident to a general acute care hospital (GACH). A review of Resident 1's GACH Admission Record indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Emergency Department (ED) note, dated 4/13/18, indicated the resident had a potassium level of 7.1 (Normal Reference Range (NRR)=3.5 - 5.1 millimoles per liter (mmol/L)) and an electrocardiogram ((EKG), a reading of the electrical activity of the heart) indicated peak T- waves (an abnormal change in the electrical heart waveform due to potassium levels that could lead to a lethal heart rhythm). The ED note indicated Resident 1 was administered calcium [MEDICATION NAME] (a medication used to prevent cardiac effects of high levels of potassium in the blood by lowering the potassium levels), and insulin and [MEDICATION NAME] 50% (medications used in combination to shift potassium into the cells to lower potassium levels in the blood). According to the ED note, Resident 1 was started on [MEDICAL TREATMENT] on 4/14/18 at 3:45 a.m. The ED note indicated Resident 1 was transferred to the GACH for immediate (STAT) [MEDICAL TREATMENT] treatment due to missed [MEDICAL TREATMENT] treatments for one week.

Based on observation, interview, and record review, the facility's staff failed to follow its policy regarding monitoring and maintaining alarms in functional use; and applying Wander Guards (a tracking system placed on the wrist or ankle that activates door alarms if the resident moves outside a specific area) as prescribed by the physician and the resident's plan of care. The facility's staff failed to implement safety measures to ensure adequate supervision and alarm doors were functional to prevent elopement for three of four sampled residents (Residents 1, 2, and 3). 1. Resident 1, a newly admitted resident, who had a history of [REDACTED]. Resident 1 traveled over 30 miles and was found at an Assisted Living facility ((ASL) lower level of care). 2. Resident 2, who had a high risk for elopement, did not have a Wander Guard on as per the physician's orders [REDACTED]. 3. Resident 3, who had a high risk for elopement and had a Wander Guard wrist band, but had access to the facility's unlocked and unalarmed maintenance door, which was observed to lead to the outside parking lot and the main street. These deficient practices of not following the physician's orders [REDACTED]. Resident 1, who had [MEDICAL CONDITION] and required assistance of staff in care, left the facility unsupervised and was missing for over 10 hours of unknown whereabouts, until the ASL called the skilled nursing facility (SNF) facility. A system of the facility to follow its policy and the physician's orders [REDACTED]. The systems failed and resulted in an immediate threat to the health and safety for Residents 1, 2, and 3, who had high elopement risks. On (MONTH) 12, (YEAR) at 5 p.m., an Immediate Jeopardy (IJ) was declared and the facility's Administrator and Director of Nursing (DON) were verbally notified. The facility submitted an acceptable Plan of Action (POA) on (MONTH) 12, (YEAR). The IJ was lifted on (MONTH) 13, (YEAR) at 8:15 a.m., and the Administrator was informed, after the team confirmed through observation and interviews that the facility's POA was implemented as follows: 1. A Wander Guard was placed on Resident 2's lower leg by the staff. 2. Activation of the emergency door alarms for the dining room door, the door between rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS]. 3. Battery replaced for maintenance door and alarm working. 4. CNAs staff member will be placed at the maintenance patio door for 24-hour monitoring with completion of a log every 15 minutes. 5. Maintenance Assistant assigned to check emergency exit alarms on the weekends. 6. CNAs will monitored the emergency exit alarms daily and log in every emergency exit alarm door daily. 7. The staff members will be assigned to monitor the front door 24-hours a day/seven days a week with completion of a log every 15 minutes. 8. In-service provided to all licensed staff on when to initiate a change of condition and elopement assessments. Findings: a. A review of Resident 1's Admission Record Face Sheet, indicated the resident was admitted to the facility on (MONTH) 28, (YEAR). Resident 1's [DIAGNOSES REDACTED]. The record indicated Resident 1 was conserved (a person appointed by a judge to make legal decisions on behalf of another). A review of Resident 1's Minimum Data Set (MDS), a care-screening and assessment tool, dated (MONTH) 4, (YEAR), indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 (13-15 = interviewable). The MDS indicated the resident used a wheelchair for mobility and required staff supervision with a one-person physical assist with locomotion on and off of the unit. A review of Resident 1's March, (MONTH) (YEAR) Nurse Progress Notes, indicated the following: 1. On (MONTH) 30, (YEAR) at 10:30 p.m., Resident 1 had delusions and hallucinations and was to be visually checked every hour. 2. On (MONTH) 31, (YEAR) at 9:34 p.m., Resident 1 was hallucinating and talking to himself about an evil angel, Lucifer, and killing five people. A review of Resident 1's (MONTH) (YEAR) Nurse Progress Notes indicated the following: 1. On (MONTH) 3, (YEAR) at 4:33 p.m., Resident 1 was hallucinating and notified the facility's staff that he was talking to a staff member from his previous ASL facility in his head. The resident stated the staff member told him it was okay for him to leave and go to that facility. 2. On (MONTH) 3, (YEAR) at 7:46 p.m., the resident notified the facility's staff that he was talking to the Lord and was going to be discharged from the facility. 3. On (MONTH) 9, (YEAR) at 10:46 p.m., Resident 4 entered the facility and notified staff that a resident was observed leaving the facility unattended. The facility's staff were unable to locate Resident 1 within the facility and surrounding area and the law enforcement was notified. 4. On (MONTH) 10, (YEAR) at 8:26 a.m., the facility received a call from Resident 1's previous ASL facility at 8 a.m., with notification that Resident 1 was currently at their facility. The ASL called back at 9:20 a.m., the same day and indicated that Resident 1 left their facility for an unknown destination. A review of the facility's Daily Perimeter Door Alarm Log on (MONTH) 12, (YEAR), indicated the facility had a total of ten (10) perimeter doors with alarms. The log indicated the following: 1. The facility's main entrance door was checked and passed testing in the morning of (MONTH) 20, (YEAR) and (MONTH) 10, (YEAR). There was no night checks indicated. 2. The door between rooms [ROOM NUMBERS] was checked and passed testing on the morning of (MONTH) 26, (YEAR) and (MONTH) 11, (YEAR). There was no night checks indicated. 3. The door by room [ROOM NUMBER] was checked and passed testing on the morning of (MONTH) 29, (YEAR) and (MONTH) 12, (YEAR). There was no night checks documented. 4. The door inside the Rehabilitation (Rehab) Room was checked and passed testing on the morning of (MONTH) 30, (YEAR). There was no night check indicated. 5. The door by the Rehab loading dock was checked and passed testing on the morning of (MONTH) 2, (YEAR). There was no night check indicated. 6. The door by the kitchen loading dock was checked and passed testing on the morning of (MONTH) 3, (YEAR). There was no night checks indicated. 7. The door inside the dining room was checked and passed testing on the morning of (MONTH) 4, (YEAR). There was no night checks indicated. 8. The door by the maintenance patio was checked and passed testing on the morning of (MONTH) 5, (YEAR). There was no night checks indicated. 9. The door between rooms [ROOM NUMBERS] was checked and passed testing on the morning of (MONTH) 6, (YEAR). There was no night checks indicated. 10. The door between rooms [ROOM NUMBERS] was checked and passed testing on the morning of (MONTH) 9, (YEAR). There was no night checks indicated. On (MONTH) 12, (YEAR) at 8:50 a.m., during an interview, the Assistant Director of Nursing (ADON) stated the facility's front entrance door was locked every night at 8 p.m. The ADON stated once the front door was locked, it could only be opened from the inside of the facility. The ADON stated once the door was locked and closed, it would only alarm if the resident had a Wander Guard and Resident 1 did not have a Wander Guard. On (MONTH) 12, (YEAR) at 9:20 a.m., during an interview, the Administrator (ADM) stated other than the facility's front entrance door, other exit doors had emergency exits and would alarm if opened. The ADM stated there was not anyone assigned at night to watch the front exit doors to ensure residents did not leave out unsupervised. On (MONTH) 12, (YEAR) at 9:30 a.m., during an observation and concurrent interview, the ADM checked the facility's emergency doors and attempted to open them. The ADM stated that an alarm should sound once the door was opened. However, an alarm did not sound upon the ADM opening four of the ten emergency exit doors: the door inside the dining room, the maintenance patio door, the door between rooms [ROOM NUMBERS], and the door between rooms [ROOM NUMBERS]. The ADM stated the alarms for the doors were turned off and was not sure how long they had been off. The ADM stated the facility's emergency exit doors and alarms were checked by maintenance daily. On (MONTH) 12, (YEAR) at 10 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 eloped from the facility through the front door at night. The DON stated Resident 4 observed Resident 1 leaving from of the facility's front entrance and later notified the staff. The DON stated Resident 1 did not have an order to go out on pass and the staff should supervise and watch for residents going near the front exit door at night. On (MONTH) 12, (YEAR) at 10:30 a.m., during an interview, the Maintenance Director (MTD) stated the maintenance patio door was a high traffic door and the alarm was never turned on, even at night. The MTD stated the maintenance patio lead to the facility's parking lot and outside to the streets. The MTD stated all emergency exit doors were checked by the maintenance staff for functionality every morning, except on weekends, and that the alarms should be turned on and working for the resident's safety. On (MONTH) 12, (YEAR) at 10:40 a.m., during an observation and concurrent interview, the Maintenance Worker (MW) stated that the emergency exit alarms were not checked that day (April 12, (YEAR)) and were last checked and working on (MONTH) 11, (YEAR) at 6:10 a.m. The MW stated the exit doors and alarms should be checked daily. The MW attempted to use the key to turn on the maintenance door alarm and could not get the alarm to work. The MW stated the battery needed to be changed. The MW removed the old battery and there was a dried, hard white and brown substance covering the battery pack and the MW stated the brownish/white substance was acid. The MW was asked when the door alarm battery was last changed, but he did not know. On (MONTH) 12, (YEAR) at 10:59 a.m., during an interview, Resident 4 stated on (MONTH) 9, (YEAR), approximately 9 p.m., while going out of the facility's front entrance door to smoke, Resident 1 asked Resident 4, You can just open the door and go out? Resident 4 stated, I told him that I can, as I opened the door and went out. Resident 4 stated a few minutes later, Resident 1 was seen walking down the street toward the main street and the train station. Resident 4 stated he rang the bell approximately 20 to 30 minutes later to go back inside the facility and he then notified the facility's staff that a resident (Resident 1) was seen leaving the facility. On (MONTH) 12, (YEAR) at 11:45 a.m., during an interview and concurrent record review, the MTD stated the MW was supposed to check all the facility's exit doors and alarms each day, but the alarm log indicated the MW checked only one of the facility's door and alarm each day. On (MONTH) 12, (YEAR) at 12:06 p.m., during a telephone interview, Registered Nurse 1 (RN 1) stated after 8 p.m., residents were not supposed to go out of the front entrance to smoke and should use the smoking patio instead. RN 1 stated the residents needed frequent monitoring to keep them safe and prevent them from leaving out the front exit at night. RN 1 stated there were too many residents at the facility and staff could not watch everyone. On (MONTH) 12, (YEAR) at 3:10 p.m., during a telephone interview, the ASL staff stated Resident 1 arrived to their location on (MONTH) 9, (YEAR) between the hours of 11 p.m. and 12 a.m. the next morning. The ASL staff stated Resident 1 was confused and thought that he still resided at their facility. The ASL staff stated they notified the facility that Resident 1 was there, but the resident left before the facility arrived to pick him up. On (MONTH) 12, (YEAR) at 4:20 p.m., during an observation and concurrent interview, the DON was observed opening the maintenance patio door and an alarm did not sound. The DON stated the door was supposed to be locked and an alarm was supposed to sound once the door was opened. The DON was unsure if the door had a Wander Guard system and attempted to walk through the door with a Wander Guard in hand. An alarm did not sound. The DON stated there was no Wander Guard alarm on the door and verified that the door lead to the outside parking lot. The DON was unable to locate a facility's policy on the emergency exits or for the door alarms. On (MONTH) 12, (YEAR) at 6:51 p.m., during a telephone interview, Resident 1's family member (FM 1) stated the resident arrived at their house on (MONTH) 10, (YEAR) between the hours of 11 a.m. and 1 p.m. FM 1 stated the facility's DON and ADM arrived to transport the resident back to the facility, but the resident refused to return and was left at FM 1's house. FM 1 sated the resident often left the previous ASL for several days at a time and the ASL would call looking for the resident. FM 1 stated, I am not in a position to care for the resident (Resident 1) physically or mentally. I would rather he be in a locked facility for his own safety. b. A review of Resident 2's Admission Record Face Sheet indicated the resident was admitted to the facility on (MONTH) 11, (YEAR). Resident 2's [DIAGNOSES REDACTED]. According to the Face Sheet, Resident 2 was conserved. A review of Resident 2's MDS, dated (MONTH) 4, (YEAR), indicated the resident had a BIMS score of 15. The MDS indicated Resident 2 used a wheelchair for mobility and was independent with locomotion on and off of the unit. A review of Resident 2's physician's orders [REDACTED].>A review of Resident 2's physician's orders [REDACTED]. According to the physician's orders [REDACTED]. A review of Resident 2's care plan titled, At Risk for Injury, dated (MONTH) 9, (YEAR), indicated the resident had previous attempts of trying to leave the facility unattended and was at risk for injury. The staff's interventions included monitoring the resident's Wander Guard placement and functioning every shift and maintaining the Wander Guard at all times. A review of Resident 2's Elopement Risk Evaluation, dated (MONTH) 15, (YEAR), indicated the resident had a score of 10 and was at risk for elopement and wandering. The evaluation indicated the Interdisciplinary Team ((IDT) a group of disciplines working together toward a common goal of a resident) recommended continued use of the Wander Guard due to Resident 2's history of leaving the facility to go and buy cigarettes. On (MONTH) 12, (YEAR) at 11:15 a.m., during an observation and concurrent interview, Resident 2 was observed without a Wander Guard on the outdoor smoking patio. Licensed Vocational Nurse 1 (LVN 1), in the presence of Certified Nursing Assistant 1 (CNA 1), was unable to locate Resident 2's Wander Guard. LVN 1 stated Resident 1 was supposed to have a Wander Guard, because the resident was an elopement risk and needed a Wander Guard for safety. On (MONTH) 12, (YEAR) at 11:20 a.m., during an interview, Resident 2 was unable to recall the last time a Wander Guard was placed on his arms or legs. c. A review of Resident 3's Admission Record Face Sheet indicated the resident was admitted to the facility on (MONTH) 7, (YEAR). Resident 3's [DIAGNOSES REDACTED]. According to the Face Sheet, Resident 3 was self-responsible (able to make all the decisions). A review of Resident 3's MDS indicated the resident had a BIMS score of 5 (0-7 = severe impairment), which indicated that Resident 3 had severe problems with memory and cognition (thought process). The MDS indicated Resident 3 used a walker for mobility and required staff's supervision with a one-person physical assist with locomotion on and off of the unit. A review of Resident 3's physician's orders [REDACTED]. According to the physician's orders [REDACTED]. A review of Resident 3's Nurse's Progress Note, dated (MONTH) 9, (YEAR), and timed at 11:47 a.m., indicated the resident was found exiting the facility's emergency doors. A review of Resident 3's care plan titled, At Risk for Elopement/Wandering, dated (MONTH) 9, (YEAR), indicated the resident wandered aimlessly and had previous attempts of trying to leave the facility unattended. The staff's interventions included applying a Wander Guard to Resident 3 at all times. A review of Resident 3's Elopement Risk Evaluation, dated (MONTH) 8, (YEAR), indicated the resident had a score of seven and was not at risk for elopement and wandering. The Medical Records staff were unable to locate any other Elopement Risk Evaluations for Resident 3. A review of the facility's undated policy titled, Wander Guard System, indicated nurses would assess residents for wandering, exit seeking and elopement behaviors on admission, quarterly, annually and as needed. Licensed nurses were to check placement and function of the Wander Guard every shift.

Based on interview and record review, the facility failed to follow its policy by not accurately assessing the risk for falls and implementing fall prevention interventions for two of three sampled residents (Resident 1 and Resident 2). Resident 1, who had generalized muscle weakness and difficulty walking, was not accurately assessed for fall risk. Resident 2, who had difficulty walking and was at risk for elopement (leaving without consent), was not accurately assessed for fall risk, had multiple falls and no new interventions were implemented to prevent further falls. These deficient practices had the potential to result in serious injury to Resident 2 and resulted in Resident 1 falling and sustaining a subdural hematoma (bleeding inside the brain caused by severe head trauma), nasal fractures (broken bones), incisor (teeth) fractures and having to be transferred to general acute care hospital (GACH 1) for further evaluation. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on (MONTH) 21, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated (MONTH) 18, (YEAR), indicated a brief interview for mental status (BIMS) score of 5 (0-7 severe impairment), which indicated that Resident 1 had problems with memory and cognition (thought process). The MDS indicated Resident 1's vision was moderately impaired, the resident used a wheelchair and required extensive staff assistance with locomotion on and off of the unit. A review of Resident 1's Care Plan, dated (MONTH) 22, (YEAR), indicated the resident had poor static (lack of movement) sitting and required occupational therapy ((OT) the use of assessment and intervention to develop, recover, or maintain the meaningful activities in daily life) three times a week for four weeks. A review of Resident 1's Fall Risk Assessments (a score of 10 of greater indicated the resident was at high risk for falls) indicated the resident was not at risk for falls. The assessments indicated the following: 1. The (MONTH) 22, (YEAR) Admission Assessment indicated Resident 1 had a score of 7. The form indicated the resident was alert and did not have a drop in blood pressure when going from lying to standing, there was no blood pressure documented on the form. 2. The (MONTH) 12, (YEAR) Post Fall Assessment indicated Resident 1 had a score of 6. The form indicated the resident was alert, had no falls in the past three months and did not have a drop in blood pressure when going from lying to standing, the blood pressure was documented as 140/100 (NRR 120/80) for both standing and lying. 3. The (MONTH) 17, (YEAR) Readmission Assessment indicated Resident 1 had a score of 9. The form indicated the resident was alert, did not have any fractures and did not have a drop in blood pressure when going from lying to standing, there was no standing blood pressure documented on the form. A review of Resident 1's Change of Condition (C[NAME]) form, dated (MONTH) 12, (YEAR), and timed at 4:11 p.m., indicated Resident 1 had a fall while in the activity room on the same day. The form indicated Resident 1 was leaning forward while seated in the wheelchair and fell on to her face. The note indicated after the fall, the resident had upper lip swelling and was bleeding from the nose and face. 911 was called and the resident was transferred to general acute care hospital (GACH 1) for further evaluation and treatment. A review of GACH 2's Progress Notes indicated Resident 1 was initially diagnosed with [REDACTED]. The note indicated Resident 1 was transferred to GACH 2's emergency roiagnom on (MONTH) 12, (YEAR) for further treatment and evaluation. The note indicated GACH 2 diagnosed Resident 1 with a right subdural hematoma, a left subdural hematoma, bilateral nasal bone fractures, central incisor fractures and lateral incisor fractures. The resident was transferred to the Intensive Care Unit ((ICU) specialty unit in the hospital for critically ill patients). A review of GACH 2's Patient Transfer and Referral Record, dated (MONTH) 16, (YEAR), indicated Resident 1 was being discharged from GACH 2 and transferred back to the facility. The form indicated the resident continued to have facial swelling and ecchymosis (skin discoloration resulting from bleeding underneath). A review of Resident 1's Re-admission Assessment, dated (MONTH) 16, (YEAR), indicated the resident was readmitted to the facility on (MONTH) 16, (YEAR) at 8:15 p.m. The assessment indicated Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Physical Therapy (PT) evaluation, dated (MONTH) 21, (YEAR), indicated after falling and being hospitalized , Resident 1 experienced a decline in functional mobility. On (MONTH) 6, (YEAR) at 10:48 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated when seated in the wheelchair, Resident 1 frequently leaned forward and tried to pick stuff up off of the floor. CNA 1 stated that Resident 1 was not at risk for falls and was unsure if the resident had any previous falls. On (MONTH) 6, (YEAR) at 12:47 p.m., during an interview, the Activity Director (AD) stated Resident 1 fell in the activity room during bingo. The AD stated Resident 1 was sitting in a wheelchair near the table and when she looked up, the resident was on the floor. The AD stated the resident needed frequent redirecting because Resident 1 was sometimes confused, knew how to unlock the wheelchair and could self-propel the wheelchair. On (MONTH) 6, (YEAR) at 1 p.m., during an interview, Activity Assistant 1 (AA 1) stated Resident 1 frequently needed to be reminded by staff not to lean forward and attempt to pick up stuff off of the floor while seated in the wheelchair. On (MONTH) 2, (YEAR) at 2:40 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 was attempting to lean forward while in the wheelchair and fell on her face. The DON was unsure if Resident 1 had any previous incidents of leaning forward while seated in the wheelchair. On (MONTH) 2, (YEAR) at 3 p.m., during an interview, the DON stated the activity staff should have notified the nursing staff about Resident 1's behavior of leaning forward while seated in the wheelchair so that a care plan could be created and a chair alarm implemented to prevent falls. On (MONTH) 9, (YEAR) at 10:34 a.m., during a concurrent telephone interview and record review, the DON stated Resident 1's Fall Risk Assessments were completed inaccurately. The DON stated if the Fall Risk Assessments were completed correctly, Resident 1 would have been considered a fall risk upon admission. The DON stated if a resident was considered at high risk for falls, a fall care plan would be initiated and interventions would be implemented to prevent falls. The DON was unable to locate a fall risk care plan or any fall prevention interventions implemented for Resident 1 prior to the residents fall on (MONTH) 12, (YEAR). A review of Resident 2's Admission Record indicated the resident was admitted to the facility on (MONTH) 18, (YEAR). Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated (MONTH) 4, (YEAR), indicated the resident had a BIMS score of 14 (13-15 no impairment), and had no memory problems. The MDS indicated Resident 2 was not steady when walking and required staff supervision for locomotion on and off of the unit. A review of Resident 2's physician's orders [REDACTED]. 1. A wander guard (a tracking system placed on the wrist or ankle that alarms if the resident moves outside a defined area) for elopement prevention was ordered on (MONTH) 8, (YEAR). 2. A tab alarm was ordered on (MONTH) 6, (YEAR) for Resident 2's bed was ordered on (MONTH) 6, (YEAR). 3. A self-release belt for Resident 2's wheelchair was ordered on (MONTH) 6, (YEAR). A review of Resident 2's Fall Risk Assessments (a score of 10 of greater indicated the resident was at high risk for falls) indicated the following: 1. The (MONTH) 19, (YEAR) Admission Assessment indicated Resident 2 had a score of 4. The form indicated the resident had no falls in the past three months, had normal gait and balance, and did not have a drop in blood pressure when going from lying to standing, there was no blood pressure documented on the form. 2. The (MONTH) 28, (YEAR) Post Fall Assessment indicated Resident 2 had a score of 13. The form indicated the resident did not have any falls in the past three months. A review of Resident 2's Physical Therapy Evaluation, dated (MONTH) 21, (YEAR), indicated the resident was being evaluated for a decline in functional mobility and had problems with balancing when walking. The evaluation indicated Resident 2 reported having a previous fall prior to arriving at the facility. A review of Resident 2's Care Plan, dated (MONTH) 27, (YEAR), indicated the resident was at risk for falls. The care plan indicated Resident 2 had falls on the following dates: (MONTH) 28, 2019, (MONTH) 10, (YEAR), (MONTH) 17, (YEAR), (MONTH) 4, (YEAR) and (MONTH) 5, (YEAR). The care plan indicted the resident would have reduced risk of falls in the next 90 days and the staff's interventions included maintaining a safe environment. A review of Resident 2's Care Plan, dated (MONTH) 29, (YEAR), indicated the resident was receiving anticoagulant (medication used to thin the blood and prevent blood clots) medication and was at risk for bleeding. The staff's interventions included informing Resident 2's physician of all falls and keeping the resident's environment safe and hazard free. A review of Resident 2's Care Plan, dated (MONTH) 4, (YEAR), indicated the resident was at risk for elopement and wandering and the resident would be kept safe, would not leave the facility unattended and would have any injuries in the next 90 days. The staff's interventions included hourly monitoring of Resident 2's whereabouts and keeping a hazard free environment. On (MONTH) 6, (YEAR) at 10:57 a.m., during an interview, CNA 2 stated Resident 2 did not have any recent or previous falls and was not at risk for falls. CNA 2 stated if a resident was at risk for falls, staff would provide frequent monitoring to the residents and lower beds. CNA 2 stated it was important to know if a resident had any previous falls or was at risk for falls to help ensure they don't fall again. On (MONTH) 9, (YEAR) at 10:34 a.m., during a concurrent telephone interview and record review, the DON stated Resident 2's Fall Risk Assessments were completed inaccurately. The DON stated Resident 2 had a total of five falls on the following dates and in the following locations: (MONTH) 28, (YEAR) in front of facility, (MONTH) 10, (YEAR) on smoking patio, (MONTH) 17, (YEAR) on smoking patio, (MONTH) 4, (YEAR) on smoking patio and (MONTH) 5, (YEAR) in the activity room. The DON stated Resident 2 would fall after attempting to stand up from the wheelchair. The DON was unable to locate any fall prevention interventions implemented for Resident 2 after any of the five falls. The DON stated to prevent future falls, new fall prevention interventions should have been implemented each time the resident fell . On (MONTH) 9, (YEAR) at 10:34 a.m., during a telephone interview and concurrent record review, the DON stated on (MONTH) 6, (YEAR), a tab alarm was ordered for Resident 2's wheelchair and bed. The DON stated Resident 2 did not have any falls after the tab alarm was implemented. A review of the facility's policy and procedure titled, Falls-Clinical Protocol, revised (MONTH) 2012, indicated the facility staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address the risk of serious consequences associated with falling. The policy indicated staff would try various interventions until the incidence of falling stopped or was reduced. A review of the facility's policy and procedure titled, Assessing Falls and Their Causes, revised (MONTH) 2010, indicated after a resident falls, staff would document appropriate interventions taken to prevent future falls in the resident's medical record. A review of the facility's policy and procedure titled, Safety and Supervision of Residents, revised (MONTH) (YEAR), indicated resident safety, supervision and assistance provided to prevent accidents were facility wide priorities. The policy indicated the facility would use an individualized, resident-centered approach to identify environmental hazards, resident risk factors, and the type and frequency of resident supervision required. According to the policy, the facility would adjust individual resident interventions accordingly.

Based on interview and record review, the facility failed to follow its policy and the resident's plan of care for one of three sampled residents (Resident 1). Resident 1, who had [MEDICAL CONDITION] (a condition that causes bones to become weak and brittle), was being transferred by a one-person physical assist with a Hoyer Lift (a lifting machine used for transferring) instead of a two-person physical assist, as per the facility's policy and the resident's plan of care. This deficient practice resulted in Resident 1 falling from the Hoyer Lift and sustaining a lacerated liver (a tear in the liver usually caused by abdominal trauma), multiple right rib fractures (broken bones), a right ulna fracture (a broken bone in the arm), a right humerus fracture (a broken bone in the arm), a right tibia fracture (a broken bone in the leg), a right femur fracture (a broken bone in the leg) and a left tibia fracture. Resident 1 required a transfer to a general acute care hospital (GACH) for further treatment, evaluation and was hospitalized for [REDACTED]. Findings: A review of Resident 1's Admission Record, indicated the resident was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated October 4, 2017, indicated a Brief Interview for Mental Status (BIMS) score of 15 (13-15 no impairment), which indicated that Resident 1 did not have problems with memory and cognition (thought process). The MDS indicated Resident 1 was totally dependent on the facility's staff with a two person physical assist in transferring. A review of Resident 1's Care Plan, indicated the resident was at risk for falls and would have reduced risk of falls in the next 90 days. The interventions included transferring the resident using a Hoyer lift and a two-person assist. A review of Resident 1's Care Plan, indicated the resident had a self-care deficit, required total assistance with activities of daily living (ADLs) and would have minimized risk for falls or injury in the next 90 days. The interventions included safe resident handling by transferring the resident with a Hoyer lift with two person assist. A review of October 2017's Certified Nursing Assistance (CNA) Documentation, indicated Resident 1 was being transferred using one person assist on the following dates: October 8, 9, 11, 15, 16, and October 19, 2017. A review of November 2017's CNA Documentation, indicated Resident 1 was being transferred using one person assist on the following dates: November 2, 3, 6, 14, and November 19, 2017. A review of Resident 1's Change of Condition form, dated November 21, 2017, indicated the resident had a fall from the Hoyer Lift and was observed on the floor, laying on her back. The resident's right arm was swollen, bleeding and had a hematoma (a blood filled are under the skin). The resident was transferred via ambulance a GACH for further evaluation. A review of the GACH's Emergency Department (ED) Documentation, indicated Resident 1 arrived November 20, 2017 after a fall from a Hoyer Lift. The resident reported falling forward from the Hoyer Lift, landing on her knees and then falling on to the right side. The resident reported 8/10 pain in the right arm and leg pain with a blood pressure (BP) of 199/91 (normal reference range (NRR) =120/80). Resident 1 had to be given [MEDICATION NAME] (a strong narcotic pain medication) and [MEDICATION NAME] (a strong narcotic pain medication) and was diagnosed with [REDACTED]. substances to help the body cope with trauma, stress or threatening conditions) that can be caused by trauma), hemoperitoneum (blood in the abdominal area), retroperitoneal hematoma (blood in the abdominal area), and [MEDICAL CONDITION] (low levels of red blood cells in the body). The resident was admitted and transferred to the intensive care unit for additional care and monitoring. A review of the GACH's Nurse Practitioner (NP) Discharge Summary, indicated Resident 1 received a blood transfusion after the resident's hemoglobin ( a part of the blood that transports oxygen and iron to the body) dropped to 6.7 (NRR= 11.5-15.0). A review of Resident 1's Readmission documentation to the facility, dated November 29, 2017, indicated the resident was readmitted to the facility on [DATE], with an immobilizer (a strip of material used to support and immobilize a broken bone) on both legs and a cast on the right arm. On November 28, 2017 at 9:14 a.m., during an interview, CNA 1 stated for a resident's safety and to prevent accidents, Hoyer lift transfers required a two person physical assist. CNA 1 stated on the day of the incident (November 20, 2017) she was assisting CNA 2 with transferring Resident 1. Once the resident was attached to the Hoyer lift, CNA 1 reported leaving CNA 2 inside the resident's room and went to the hallway to prepare the resident's chair. While in the hallway, CNA 1 stated she heard CNA 2 yell that the resident was falling and when she re-entered the room, Resident 1 had already fallen on the floor. On November 28, 2017 at 10:15 a.m., during and interview, the Director of Staff Development (DSD) indicated CNA 1 and CNA 2 were present at the Hoyer Lift In-service that took place on November 20, 2017 at 6:30 a.m , (the incident occurred November 20, 2017 at approximately 11:30 a.m.) The DSD stated during the in-service, the CNAs were instructed on the proper use of the Hoyer lift and to always use two person physical assist when using the Hoyer lift. The DSD stated the CNAs performed a successful return demonstration on properly using the Hoyer Lift. On November 28, 2017 at 11:20 a.m., during an interview, CNA 2 stated on the day of the incident, CNA 1 was supposed to help with the Hoyer lift transfer by standing behind Resident 1 while they maneuvered the Hoyer lift to the resident's wheelchair. CNA 2 stated that CNA 1 left the room and stood by the room door while CNA 2 moved Resident 1, who was attached to the Hoyer Lift in a sling. CNA 2 stated while moving the resident alone, the Hoyer lift machine malfunctioned and Resident 1 fell on to the floor. On December 5, 2017 at 8:25 a.m., during a concurrent observation and interview, Resident 1 was observed in the bed with a cast on the right arm, and immobilizers on both legs. The resident stated that she had just returned to the facility after being in the ICU for 9 days after falling from the Hoyer Lift. The resident stated that there was supposed to be two people transferring her but on the day of the fall, only one CNA was transferring her. Resident 1's eyes watered as she stated the incident made her feel terrible and resulted in having additional body pain. The resident stated she feared using the Hoyer Lift again and had chosen not get up in her chair or out of the room since she had returned from the GACH. Before the fall, Resident 1 stated she would frequently get up in her wheelchair to go to activities and to meditate. On December 5, 2017 at 8:52 a.m., during an interview, CNA 3 stated before the fall, Resident 1 was very happy, but since returning from the GACH the resident was more quiet, appeared sad, and sometimes seemed like she was going to cry. On February 7, 2018 at 4:10 p.m., during a concurrent telephone interview and record review, the Director of Nursing (DON) stated Resident 1 required a two person physical assist with all transfers. Upon review of the resident's November 2017 CNA Documentation, the DON stated there were five instances where a one person physical assist was used to transfer the resident. The DON stated using a one person physical assist with the Hoyer lift transfers could result in accidents. A review of the facility's policy and procedure, titled Using a Mechanical Lifting Machine, revised July 2017 indicated at least two nursing assistants were required to safely move a resident with a mechanical lift. A review of the Innvacare Hoyer Lift User manual indicated a two assist was recommended when using the Hoyer Lift for transfers.

Based on interview and record review, the facility failed to follow the resident's plan of care and its policy related to residents with wandering behavior (moving or walking while confused or otherwise cognitively impaired, often seen in resident's with dementia), for one of three sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. This deficient practice of Resident 1 not being supervised resulted in Resident 1 wandering into Residents 2 and 3's room and attempting to strike Resident 2 with a broom and a fork. During the altercation, Resident 1 fell and sustained a left shoulder fracture (broken bone), a pneumothorax (the presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung), multiple left rib fractures, two cervical spine fractures (broken bones in the neck) and resulted in a transfer to two general acute care hospitals (GACH 1 and 2) for further evaluation. Findings: A review of Resident 1's Admission Face Sheet Record, indicated Resident 1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated February 4, 2017, indicated a brief interview for mental status (BIMS) score of 3 (0-7 severe impairment), which indicated that Resident 1 had problems with memory and cognition (thought process). According to the MDS, Resident 1 exhibited wandering behaviors and disorganized thinking (altered thought process characterized by thoughts that come and go rapidly, inability to concentrate on one thought for very long, being easily distracted and inability to connect thoughts into logical sequences). Resident 1 required limited staff assistance with walking and transferring. A review of Resident 1's Fall Risk Assessment, dated December 8, 2016, indicated the resident had a score of 14. According to the Assessment, a score of 10 or greater indicated the resident was at high risk for falls. A review of Resident 1's Nurse Progress Note, dated December 19, 2016, indicated Resident 1 was found in another resident's (Resident 2) room, holding a trash can and attempting to strike a resident with it. Resident 1 became combative (aggressive to fight) towards staff and attempted to stab a nurse with the pointed handle of a comb. The staff was unable to control the resident and 911 was called. A review of Resident 1's Care Plan, dated December 21, 2016, indicated the resident was physically aggressive, with the goal of the resident would not harm himself or others in next 90 days. The staff's interventions included anticipating the resident's care needs and providing them before the resident became overly stressed and intervening to protect the rights and safety of others. A review of Resident 1's Elopement Risk Evaluation, dated December 22, 2016, indicated the resident had a score of 12 and was at risk for elopement and wandering. A review of Resident 1's Care Plan, dated December 22, 2016, indicated the resident was at risk for elopement and wandering related to forgetfulness and the resident would remain safe in the next 90 days. The staff's interventions included monitoring the resident's whereabouts, redirecting the resident to the correct room, providing a safe and secure surrounding and educating the resident about respecting the privacy of other residents. A review of Resident 1's Nurse Progress Note, dated January 6, 2017, and timed at 9:52 p.m., indicated the resident was very agitated, grabbed a chair and attempted to throw it at the staff. A review of Social Service (SS) Progress Note, dated January 15, 2017, and timed at 6:01 p.m., indicated Resident 1 have been wandering into other resident's rooms. According to the SS note, the Social Services Director (SSD) counseled the resident and showed the resident where his room was located. A review of the SS Progress Note, dated February 5, 2017, and timed at 11:43 a.m., indicated the resident continued to wander into other resident's rooms. A review of a nurse's note, dated February 19, 2017 and timed at 19:40 (7:40 p.m.), indicated Resident 1 was in a resident's room hitting Resident 2 and Resident 1 was found on the floor. Once assisted up Resident 1 became combative while holding a broom and a fork. The facility's investigation report, dated February 20, 2017, indicated Resident 1 was in other residents' (Residents 2 and 3) room and attempting to hit Resident 2 with a broom and a fork. The residents tried to take the fork and broom from Resident 1, which resulted in Resident 1 falling and hitting his head on the bed. A review of Resident 1's Nursing Home to Hospital Transfer Form, dated February 19, 2017 and timed 8:20 p.m., indicated the resident was being transferred to GACH 1 for evaluation after a fall. After attempting to hit another resident with a broom and fork, Resident 1 was found lying on the floor. The resident was observed to have a bleeding laceration (deep cut) to the left side of the head. A review of GACH 1's emergency room (ER) Documentation, dated February 19, 2017, indicated the resident complained of left arm and left side chest pain on arrival to the GACH's emergency room . Resident 1 had decreased left side breath sounds and left chest wall crepitus (a crackling feel to the touch, caused by air under the skin) with tenderness. Resident 1 was diagnosed with [REDACTED]. The resident had to be immediately transferred to a higher level of care to GACH 2 for further care and treatment. A review of GACH 1's Procedure Report, dated February 20, 2017 and timed 12 a.m., indicated Resident 1 had a chest tube (a tube inserted through the chest wall to help drain air, blood, or fluid from the space surrounding the lungs) inserted. On October 17, 2017 at 10:13 a.m., during an interview, Resident 3 stated Resident 1 was confused and would frequently come into their room (Residents 2 and 3) to look out the window. The staff would have to be called to remove Resident 1 from the room. On the day of the incident (February 19, 2017), Resident 3 stated that Resident 1 entered the room on three separate occasions before returning a fourth time and attacking Resident 2 with a broom and a fork. Resident 3 stated that the call light was pushed for assistance with removing Resident 1 from the room, but was not answered for approximately 40 minutes. Resident 3 stated once the staff responded to the call light, Resident 1 had already fallen and was on the ground near the foot of Resident 3's bed. A review of Resident 3's Admission Record, indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS), a care screening and assessment tool, dated September 19, 2017, indicated a brief interview for mental status (BIMS) score of 15 (13-15 no impairment), which indicated that Resident 3 did not have any problems with memory or cognition (thought process). A review of Resident 3's History and Physical form, dated September 13, 2017, indicated the resident had the capacity to understand and make decisions. On October 17, 2017 at 10:20 a.m., during an interview, Resident 2 stated he was sleeping when Resident 1 came into the room and attacked him with a fork and broom. Resident 2 stated he grabbed the broom and attempted to pull it away but the broom broke and Resident 1 fell backwards onto the floor near Resident 3's footboard. Resident 2 stated Resident 1 had blood on his face and attempted to get up from the floor. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated a brief interview for mental status (BIMS) score of 9 (8-12 mild impairment), which indicated that Resident 1 had mild problems with memory and cognition (thought process). A review of Resident 2's History and Physical form, dated August 10, 2017, indicated the resident had the capacity to understand and make decisions. On October 17, 2017 at 12:48 p.m., during an interview, the Assistant Director of Nursing (ADON) stated Resident 1 had sun downing syndrome (a symptom of dementia in which activity increases and confusion and agitation worsen in the evening and at night) and would go into other resident's rooms primarily at night. The ADON stated that interventions for resident's with wandering behaviors included applying a wander guard band (a tracking system using a wrist or ankle band that automatically locks doors or alarms if the resident moves outside a defined area), monitoring the resident's whereabouts and 1:1 monitoring for residents who wandered frequently. The ADON stated that Resident 1 did not have 1:1 monitoring. On December 21, 2017 at 4:08 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was very confused and would enter other resident's rooms. CNA 1 stated that the resident would be redirected back to his room, but would eventually leave and go back into the other rooms. CNA 1 stated Resident 1 needed 1:1 monitoring because the resident would frequently enter other resident's rooms, which was unsafe to other residents and Resident 1. On December 21, 2017 at 4:34 p.m., during an interview, Registered Nurse 1 (RN 1) stated the whereabouts for all residents in the facility were checked every two hours. RN 1 stated to keep residents safe, the whereabouts of residents with wandering behaviors should be checked every hour. RN 1 stated that due to staff being so busy and having many residents on their assignments, it was impossible to check on a resident's whereabouts every hour. At 4:50 p.m., on December 21, 2017, during a concurrent interview and record review, the ADON stated the whereabouts for residents on monitoring were to be documented on the Medication Administration Record (MAR), in the nurse progress notes or on the wander guard checklist. The ADON and RN 1 were unable to locate any documentation in Resident 1's chart for the monitoring of Resident 1's location. On December 21, 2017 at 4:58 p.m., during an interview, the Medical Records employee (MR 1), stated Resident 1 did not have a wander guard. MR 1 stated that the wander guard was only used for residents at risk for elopement and Resident 1 was not at risk for elopement, only for wandering. MR 1 stated the wander guard was shown on Resident 1's care plan due to nursing using the care plan template for wandering /elopement, which automatically included wander guard as an intervention. MR 1 was unable to locate any documentation for the monitoring of Resident 1's whereabouts anywhere in the resident's medical record, as per the resident's plan of care. A review of the facility's policy and procedure, titled Unsafe Resident Wandering, revised on November 2010 indicated nursing staff would document circumstances related to unsafe behavior such as wandering and would implement a detailed monitoring plan for residents who were at high risk of elopement or other unsafe behavior.

Based on observation, interview, and record review, the facility failed to follow its policy, the resident's plan of care to provide the necessary care and services for the prevention of the development of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), the physicians orders for the offloading of pressure and to accurately assess the stage of a pressure ulcer for two of two sampled residents (Residents 1 and 2) who were admitted without a pressure ulcer. a. Resident 1, who was at risk for the development of a pressure sore, developed a left foot Stage IV pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia (a type of tissue beneath the skin that attaches, stabilizes, encloses, and separates muscles), muscle, tendon, ligament, cartilage or bone in the ulcer) and later developed a left heel pressure ulcer. b. Resident 2, who was at risk for a pressure sore development, developed a sacrococcyx (the base of the spine near the tailbone) Stage IV pressure ulcer and later developed a left heel pressure ulcer with multiple lower extremity blisters. These deficient practices resulted in the residents developing pressure ulcers, possibly delayed healing of the pressure ulcers and put the residents at risk for infection. Findings: a. A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was initially admitted to the facility on [DATE], and was 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 July 13, 2017, indicated a brief interview for mental status (BIMS) score of 5 (0-7 severe impairment), which indicated that Resident 1 had problems with memory and cognition (thought process). The MDS indicated Resident 1 was totally dependent on one staff for physical assistance in bed mobility, personal hygiene, and toilet use. The MDS indicated Resident 1's range of motion was impaired at the bilateral (involving both sides) upper and lower extremities and had a [DIAGNOSES REDACTED]. According to the MDS, Resident 1 was at risk of developing pressure sores and had one current unhealed and unstageable pressure sore (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 (soft, moist dead tissue; usually white, yellow, green or tan in color) or eschar (dead tissue, usually brown or black in color)). A review of Resident 1's Nurse's Admission Record, dated March 18, 2013, indicated there was no documentation Resident 1 had any pressure sores upon admission. A review of Resident 1's Care Plan, dated October 14, 2015, indicated the resident was at risk for skin breakdown and skin impairment and would be minimized in the next 90 days. The interventions included turning and repositioning the resident at least every two hours and as needed. A review of Resident 1's Physician Orders, dated February 10, 2017, indicated the residents heels were to be offloaded (process in which pressure on the extremity is reduced) using a pillow. A review of Resident 1's Change of Condition (C(NAME)) record, dated March 27, 2017 indicated redness was noted to the resident's left medial foot, left medial first metatarsal (toe), left medial ankle, left plantar (sole of the foot) foot, left lateral ankle, right heel, right lateral foot, right fifth toe, and right first toe. A review of Resident 1's Care Plan, dated March 27, 2017, indicated that the resident had a pressure ulcer to the left plantar foot and the ulcer would exhibit signs of healing, decreased size and improved appearance in the next three months. The interventions included to float the resident's heels when in bed, to perform wound care as ordered by the medical doctor, to assist the resident as needed with repositioning and to minimize pressure over bony prominences (areas of the body with limited amount of fat tissue over the bone and are at the greatest risk for developing pressure sores). A review of Resident 1's left plantar foot Weekly Pressure Ulcer Record, dated March 27, 2017, indicated the resident had a Stage I pressure ulcer (intact skin with a localized area of non-blanchable (redness that does not briefly lighten when touched) [DIAGNOSES REDACTED] (redness)) to the left plantar foot at two different sites and the left medial heel. A review of Resident 1's left plantar foot Weekly Pressure Ulcer Record, dated July 25, 2017, indicated the resident had a suspected deep tissue injury that measured 1.6 centimeters (cm) in length, 1 cm in width and 0.4 cm in depth. The wound bed was described as 20 percent (%) slough, 60% necrotic (dead tissue, usually brown or black in color) and 20% granulation tissues (healing tissue, usually red or pink in color). The pressure reliving interventions included offloading the resident's heels with a pillow. The record indicated that a suspected deep tissue injury was a purple or maroon localized area of discolored intact skin or a blood filled blister. A review of Resident 1's left plantar foot Weekly Pressure Ulcer Records indicated the following: 1. On August 18, 2017, Resident 1 had a Stage III pressure ulcer that measured 1.1 centimeters (cm) in length, 1.4 cm in width, and 0.3 cm in depth. The wound bed was described as 20% yellow tissue and 80% granulation tissues. The record indicated that when in bed, the resident's bilateral lower extremities would be offloaded with pillows. 2. On August 29, 2017, Resident 1 had a suspected deep tissue injury that measured 1 cm in length, 0.7 cm in width and 0.2 cm in depth. The wound bed was described as 20% slough and 80% granulation tissues. 3. On September 5, 2017, Resident 1 had a suspected deep tissue injury that measured 1.8 cm in length, 1.5 cm in width and 0.2 cm in depth. The wound bed was described as 50% slough and 50% granulation tissues. 4. On September 12, 2017, Resident 1 had a Stage III pressure ulcer that measured 1.8 centimeters (cm) in length, 1.5 cm in width, and 0.1 cm in depth. 5. On September 27, 2017, Resident 1 had a Stage IV pressure ulcer that measured 2.2 cm in length, 2.5 cm in width and 0.4 cm in depth. The wound bed was described as 50% slough and 50% granulation tissues. The record indicated Resident 1 was on a low air loss (LAL) mattress for wound management. 6. On October 5, 2017, Resident 1 had a Stage IV pressure ulcer that measured 2.9 cm in length, 2.1 cm in width, and 0.4 cm in depth. The wound bed was described as 50% slough and 50% granulation tissues. A review of Resident 1's left medial heel Weekly Pressure Ulcer Record indicated the following: 1. On July 18, 2017, the resident had a suspected deep tissue injury that measured 1 cm in length, 1 cm in width and the depth was unable to be determined. The wound bed was described as 100% eschar (dead tissue, usually tan, brown or black in color). The record indicated that an unstageable wound was a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. 2. On July 25, 2017, indicated the resident had a suspected deep tissue injury that measured 1.2 cm in length, 0.8 cm in width and the depth was unable to be determined. The wound bed was described as 100% eschar. A review of Resident 1's Nursing Home to Hospital Transfer Form, dated September 13, 2017, and timed at 5:18 p.m., indicated the resident was transferred to a General Acute Care Hospital 1 (GACH 1), there was no documentation of pressure ulcers noted under the skin/wound care section. A review of GACH 1's Patient Notes, dated September 14, 2017, and timed at 3:13 p.m., indicated on admission, the resident had a left plantar foot Stage IV pressure ulcer, a right buttock Stage II pressure ulcer, and deep tissue injuries to the bilateral heels. A review of Resident 1's Admission/Readmission Data Collection form, dated September 25, 2017 and timed at 1:50 p.m., indicated the resident was readmitted to the facility from GACH 1. The resident had a stage IV pressure ulcer to the left plantar foot and left medial heel discoloration. A review of Resident 1's Physician Orders, dated September 26, 2017, indicated the resident's left plantar foot was to be cleansed with Dakin's solution (a solution used to kill germs and prevent their growth), patted dry, santyl (an ointment that breaks down damaged tissue in a wound and helps healthy tissue grow) applied and covered with foam dressing (a sterile pad or compress applied to a wound to promote healing and protect the wound from further harm) every shift for 14 days. On October 3, 2017 at 9:40 a.m., during an interview, Licensed Vocational Nurse (LVN 1) stated Resident 1 had a Stage IV pressure ulcer on the left foot. The resident was to be turned and repositioned every two hours and have the heels offloaded with pillows. LVN 1 stated that the resident was contracted (a permanent shortening of a muscle or joint), could not move, and did not have a low air loss mattress (a mattress that is used in the treatment and management of pressure ulcers that inflates using air and reduces the amount of bodily pressure placed on the mattress surface, (LAL)). LVN 1 stated it was okay for the resident not to have a low air loss mattress as long as the resident's heels were being offloaded. LVN 1 stated Resident 1 had a Stage IV pressure ulcer prior to being transferred to GACH 1 on September 13, 2017. On October 3, 2017 at 10:10 a.m., during a concurrent observation and interview in the presence of Certified Nursing Assistant (CNA 1), Resident 1 was observed in bed and turned on the left side. A pillow was between the resident's knees. The resident's left foot was observed on top of the white bed sheet and in direct contact with the top of the mattress. No pillow was observed underneath the resident's feet to offload. There were multiple tan and brown spots on the sheet and a dried ring containing reddish-brown substance observed around the resident's left foot. CNA 1 stated the resident's feet should be up. A reddish-brown dried substance was noted to the resident's left foot. CNA 1 was unable to locate any wound dressing on Resident 1's left foot or anywhere in or around the resident's bed, as prescribed by the physician. On October 3, 2017 at 10:15 a.m., during a concurrent observation and interview in the presence of CNA 1, LVN 1 and LVN 3, LVN 1 stated that Resident 1's wound could get worse because the dressing was removed and not intact. LVN 1 stated that the CNA may have removed the resident's dressing during repositioning, but was unable to locate any wound dressing anywhere in or near the resident's bed. Resident 1 was not on a LAL mattress. On October 3, 2017 at 10:20 a.m., during an interview, CNA 2 stated that Resident 1 had sores on her foot and was turned and repositioned every two hours. CNA 2 stated it was okay for Resident 1's feet to be lying on the bed. CNA 2 denied removing the resident's wound dressing. On October 3, 2017 at 10:29 a.m., during a concurrent observation and interview in the presence of CNA 1, LVN 1 stated Resident 1's left foot wound measured 2.5 cm in length, 2.5 cm in width and 0.5 cm in depth. The wound was a stage IV, had exposed bone and was 50% slough and 50% granulation tissue. The LVN placed a pillow underneath the resident's heels and stated that the facility no longer used foot protectors and that it was better to offload the heels using a pillow (placing a pillow underneath the heels to reduce the amount of pressure, prevent and manage pressure sores and to protect them from the mattress surface). On October 3, 2017 at 11:40 a.m., during an interview, LVN 2 stated all residents with a Stage IV pressure ulcer would have a LAL mattress. LVN 2 stated the residents with wounds on the heel or foot need to be turned every two hours and have the heels offloaded to prevent the ulcer from getting worse. On October 3, 2017 at 11:55 a.m., during an interview, the Director of Nursing (DON) stated that residents with a Stage IV pressure ulcer get a low air loss mattress. On October 3, 2017 at 4:30 p.m., during a concurrent observation and interview, Resident 1's heels and feet were observed on top of the mattress and not offloaded. One pillow was placed below the resident's knees, but there was no pillow noted beneath the resident's heels. CNA 4 stated that the resident's heels and feet were on top of the bed and were supposed to be up on a pillow. On December 5, 2017 at 4:40 p.m., during a telephone interview, the DON stated Resident 1's pressure ulcers developed at the facility. On December 7, 2017 at 10:15 a.m., during a telephone interview, LVN 2 stated a suspected deep tissue injury was a blood filled blister or purple discoloration with intact skin. An open wound or a wound with 100% eschar was not a suspected deep tissue injury. b. A review of Resident 2's Face Sheet (admission record) indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's Admission/Readmission Data Collection form, dated May 10, 2016 indicated there was no documentation that Resident 2 had any pressure sores upon admission. A review of Resident 2's Minimum Data Set (MDS), a care screening and assessment tool, dated July 31, 2017, indicated the resident had severely impaired cognitive (thought process) skills and problems with short and long-term memory. The MDS indicated Resident 2 was totally dependent on one staff for physical assistance in bed mobility, personal hygiene, and toilet use. The MDS indicated Resident 2's range of motion was impaired at the bilateral lower and on one side of the upper extremities. The MDS indicated Resident 2 was at risk to develop pressure sores and had one current Stage IV pressure sore (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). A review of Resident 2's coccyx (a small bone at the base of the spine) Weekly Pressure Ulcer Record, dated July 13, 2016, indicated the resident had a Stage II pressure sore that measured 2 cm in length, and 0.3 cm in width. The wound bed was described as superficial and preventative measures included turning the resident every two hours. A review of Resident 2's Care Plan, dated August 1, 2016, indicated the resident was at risk for skin breakdown and impairment that would be minimized in the next 90 days. The interventions included turning and repositioning the resident at least every two hours and as needed. A review of Resident 2's Care Plan, dated August 23, 2017 indicated that the resident had stage IV pressure ulcer to the sacrococcyx and the ulcer would exhibit signs of healing, decreased size and improved appearance in the next 14 days. The interventions included assisting the resident as needed with repositioning and to relieve pressure. A review of Resident 2's Situation, Background, Assessment, Recommendation or Change of Condition ((SBAR/C(NAME)) forms that are used to communicate a resident's condition and health status with other healthcare practitioners) records indicated that the resident developed a right thigh blister on September 1, 2017, a left heel blood filled blister on September 7, 2017 and a right lateral thigh blister on September 21, 2017. A review of Resident 2's Care Plan, dated September 7, 2017, indicated the resident had a pressure ulcer to the left heel and the ulcer would exhibit signs of healing, decreased size and improved appearance in the next 90 days. The interventions included floating the resident's heels when in bed and minimizing pressure over boney prominences. A review of Resident 2's SNF Wound Care Progress Notes, dated August 29, 2017, indicated the resident had a sacro-coccyx pressure wound that measured 3.8 cm in length, 2 cm in width and 0.3 cm in depth. The wound bed was described as 15% slough and 85% granulation tissues. The resident was noted to be contracted (a permanent shortening of a muscle or joint) and was nonverbal. The plan included offloading of pressure every two hours. A review of Resident 2's SNF (Skilled Nursing Facility) Wound Care Progress Notes, dated August 29, 2017, indicated the resident had a sacro-coccyx pressure wound that measured 4.2 cm in length, 2 cm in width and 0.3 cm in depth. The wound bed was described as 15% slough and 85% granulation tissues. The plan included offloading of pressure every two hours. A review of Resident 2's SNF Wound Care Progress Note, dated October 3, 2017, indicated the resident had a sacro-coccyx pressure wound that measured 4.3 cm in length, 2.3 cm in width and 0.2 cm in depth. A wound to the Left heel and left 3rd toe were noted. On October 3, 2017 at 9:40 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 2 had a Stage IV pressure ulcer on the sacrococcyx and the residents should not be on the same side of the pressure ulcer, because it could get worse and not heal from the continued pressure. LVN 1 stated Resident 2 was to be turned on the right and left side only, not on the back (due to the wound). On October 3, 2017 at 11 a.m., during an observation, Resident 2 was observed positioned on her back in the bed. On October 3, 2017 at 11:18 a.m., during a concurrent observation and interview in the presence of CNA 3 and LVN 4, LVN 4 stated the CNA assigned to the resident was currently on break and that any CNA could assist the resident. LVN 4 and CNA 3 were unsure of where Resident 2's wounds were located. The resident's left foot was wrapped in gauze and on top of the mattress, no pillow was noted under the resident's heels to offload. CNA 3 stated it was okay for Resident 2 to be positioned on the back and that the residents are turned every two hours. On October 3, 2017 at 11:40 a.m., during an interview, LVN 2 stated residents with pressure ulcers on the sacrococcyx were to be turned side to side only and not on their back. LVN 2 stated a resident should not be turned on the side of the body that has a pressure ulcer and the treatment nurses and/or charge nurses notify the CNA on how to turn and reposition the residents. On December 5, 2017 at 4:40 p.m., during a telephone interview, the DON stated the pressure ulcers for Resident 2 developed at the facility. A review of facility's policy and procedure, titled Pressure Ulcer/Skin Breakdown-Clinical Protocol revised October 2010, indicated the physician would authorize orders pertinent to wound treatments including pressure reduction surfaces. The policy indicated that the nurse would assess and document a full assessment of the resident's pressure sore including location and stage and when new wounds developed or when wounds were not healing, the physician was to help staff review and modify the resident's care plan. A review of facility's policy and procedure, titled Support Surface Guidelines revised October 2010, indicated that any resident who was at risk for developing a pressure ulcer should be placed on a pressure reducing device when lying in bed. The policy indicated that the use of appropriate support surfaces with interventions such as turning and repositioning could reduce pressure ulcer development by 50%. A review of facility's policy and procedure, titled Repositioning, revised May 2013 indicated positioning the resident on an existing pressure ulcer was to be avoided and may impede healing. The policy indicated for residents with a Stage I pressure ulcer or higher, repositioning every two hours was inadequate.

Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal abusive behavior by Resident 2 for five of five sampled residents (Residents 1, 3, 4, 6, and 7). Residents 1, 3, 4, 6, and 7 were not protected from Resident 2's ongoing verbal abuse and threatening behavior. The facility failed to assess, monitor, and develop a plan to address and prevent Resident 2's ongoing verbal abuse, after Residents 1, 3, 4, 6 and 7 complained about Resident 2's abusive behavior towards them. This deficient practice resulted in Residents 1, 3, 4, 6, and 7 being verbally abused and resulted in the residents feeling unsafe and fearful; which resulted in emotional distress, mental anguish, and psychological trauma. On July 24, 2017, at 4:15 p.m., an Immediate Jeopardy (IJ) was declared and the facility's Administrator, Assistant Administrator, Director of Nursing, and Assistant Director of Nursing were notified of the immediacy. The facility submitted a plan of action (POA) on July 24, 2017, however failed to follow the plan. The POA included Resident 2's physician ordering a discharge to a lower level of care, an Interdisciplinary Team (IDT) meeting with the resident, and an in-service for staff to discuss pain management and monitoring. The IJ was lifted on July 26, 2017, at 1:50 p.m., and the Administrator was informed after the team confirmed that the facility's POA was implemented as follows: 1. Resident 2 was placed on 1:1 with daily visual monitoring while the resident was in the facility. 2. An IDT meeting was held to discuss Resident 2's verbal abusiveness; the smell and possible use of marijuana, compliance with the out on pass order, and the option of an alternative placement. 3. Resident 1, Resident 2's roommate, was moved to a different room. 4. The DON and Administrator met with Resident 2 to discuss the need for Resident 2 to cease the verbal abusiveness toward residents, staff, and visitors. 5. Resident 2's Medical Doctor (MD 1) met with the resident and ordered a lower level of care for discharge plans. 6. An in-service was conducted with staff for adequate monitoring of pain control for Resident 2. Findings: a. A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated July 7, 2017, indicated Resident 1's cognition was intact. The MDS indicated Resident 1 was totally dependent on the staff for mobility, dressing, eating, and hygiene. According to the MDS, Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 8-15 indicated interviewable). A review of Resident 1's Social Services (SS) Note, dated July 2, 2017, and timed at 4:50 p.m., indicated Resident 2 (Resident 1's roommate) had Resident 1's friend kicked out of the room while he was visiting with Resident 1. A review of Resident 1's SS Note, dated July 2, 2017, and timed at 5:46 p.m., indicated Resident 1 expressed concern to the Social Services Director (SSD) regarding Resident 2 not wanting religious visitors in their room. A review of Resident 1's SS Note, dated July 16, 2017, and timed at 3:18 p.m., indicated a Certified Nursing Assistant 1 (CNA 1) heard Resident 2 tell Resident 1, You can't get out of that bed? You just want this da-n preacher to come here. You're dying! You're dying! You're dying! You're dying! A review of Resident 1's SS Note, dated July 16, 2017, and timed at 3:41 p.m., indicated Resident 1 confirmed the remarks made by Resident 2. The note indicated Resident 1 appeared to be in a sad mood and looked at Licensed Vocational Nurse 1 (LVN 1) and stated, Am I really rotting in bed? Resident 1 declined a room change and stated, I've been in this room for [AGE] years and am pretty comfortable here. A review of Resident 1's physician progress notes [REDACTED]. On July 24, 2017 at 9:05 a.m., during an interview, Resident 1, who was a quadriplegic, stated Resident 2 told her that nobody was going to help her and she was going to lie in the bed until she was dead. On July 24, 2017 at 9:42 a.m., during a telephone interview, CNA 1 stated she heard Resident 2 tell Resident 1, You talk to the preacher and you are rotting away. You're dying. You're dying. CNA 1 stated Resident 1 got upset because Resident 2 told her visitor to Get the he-l out of here. On July 24, 2017 at 9:58 a.m., during a telephone interview, LVN 1 stated while speaking to Resident 1 about the incident with Resident 2, Resident 1 appeared sad and asked her, Am I really rotting? On July 24, 2017 at 1:20 p.m., during an interview, Resident 1 stated, If I had a visitor, my roommate (Resident 2) would tell them to get out of the room. One was a pastor and the other was my best friend. They would leave because of her. I was really upset and I felt bad. b. On July 24, 2017 at 8:52 a.m., during the facility's initial tour, Resident 2 was observed in the bed. The resident had a sleep mask covering both eyes and when approached asked, What time is it? After being told the time was 8:52 a.m., Resident 2 responded, Oh Fu-K No! Come back later, 1 p.m. would be a good time to come back. A review of Resident 2's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's history and physical (H/P), dated September 30, 2016, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition was intact with a BIMS score of 15. The MDS indicated the resident had verbal behavioral symptoms directed toward others on a daily basis and rejected evaluation or care needed to achieve goals for health and well-being on a daily basis. According to the MDS, Resident 2 required supervision for locomotion on the unit and extensive to limited assistance from one staff member for mobility and transferring. Resident 2 received anti-anxiety and anti-depressant medication seven days a week and hypnotic medication six days a week. A review of Resident 2's Progress Notes indicated the resident had several incidences of profanity, verbal abuse, and aggressive behaviors directed toward residents, staff, and visitors, dating back to October 2014. A review of Resident 2's care plan titled, Resident Has a Behavioral Problem, initiated June 21, 2015, without an updated date for review. There was only a target date of 7/31/17. The care plan indicated Resident 2 had a physical and verbal aggressive behavior problem manifested by flicking cigarettes at staff, intentionally banging her motorized wheelchair into the facility's property, being verbally and physically abusive to other residents, and making derogatory comments directed toward staff. The goal was for Resident 2 to have less than one episode per week of verbal or physical aggression directed toward residents and staff. A review of Resident 2's SS Assessment, dated August 3, 2016, and timed at 12:54 p.m., indicated Resident 2 had a history of [REDACTED]. The note indicated Resident 2 always declined psychological and psychiatric services for evaluation. A review of Resident 2's Initial Psychiatric Evaluation note, dated October 4, 2016, indicated the resident was argumentative with the MD and stated, Fu-k you, get away from me! You're a son of a bit-h! A review of Resident 2's Nurses Progress Note, dated March 19, 2017, and timed at 6:04 p.m., indicated Resident 2 was screaming in the hallway while following a Registered Nurse 1 (RN 1) and called RN 1 abusive and inappropriate names. A review of Resident 2's SS Assessment, dated May 4, 2017, and timed at 10:11 a.m., indicated after offering to assist Resident 2, the resident became upset and started using profanity towards the SSD. Resident 2 stated the SSD was useless. A review of Resident 2's Nurses Progress Note, dated June 11, 2017, and timed at 2:28 p.m., indicated Resident 2 was verbally abusive toward two CNAs calling them fat and stupid in the ear shot of other residents. A review of Resident 2's SS Note, dated June 15, 2017, and timed 3:15 p.m., indicated Resident 2 approached the SSD and yelled, Don't you ever get the Ombudsman involved again. She is a piece of Sh-t! A review of Resident 2's SS Note, dated June 26, 2017, and timed 2:23 p.m., indicated Resident 2 became upset that Resident 1 had a religious visitor. Resident 2 raised her voice and told the SSD she did not want any religious visitors in her room without her permission. A review of Resident 2's SS Note, dated July 2, 2017, and timed 4:47 p.m., indicated Resident 2 kicked Resident 1's visitor out of the room while he was visiting with Resident 1. The note indicated Resident 2 did not want a man in her room while she was sleeping. A review of Resident 2's Nurses Progress Note, dated July 9, 2017, and timed at 10:07 p.m., indicated Resident 2 asked if Resident 1 had any visitors and then stated, Fu-k, I have to stay in bed tomorrow so no one comes in. A review of Resident 2's Nurses Progress Note, dated July 14, 2017, and timed at 4:39 p.m., indicated while Resident 2 was speaking to LVN 2 in the hallway, the resident stated another employee was a Di-k and a muffin top eater. After LVN 2 told Resident 2 she was not being nice, the resident stated, I don't give a fu-k, it's true. In the ear shot of other residents. A review of Resident 2's Nurses Progress Note, dated July 16, 2017, and timed at 2:10 p.m., indicated Resident 2 stated she had the right over the entire room and wanted Resident 1 out of the room when Resident 1's friends or pastor came to visit. A review of Resident 2's SS Note, dated July 16, 2017, and timed 2:54 p.m., indicated during a meeting with the SSD and LVN 1, Resident 2 was adamant she had the right to kick anyone out of the room, even if it was the roommate's visitor. The SSD was later informed that Resident 2 was overheard by CNA 1 telling Resident 1, You can't get out of that bed? You just want this Da-n preacher to come here. You're rotting away. You're dying. You're dying. You're dying! A review of Resident 2's Situation Background Assessment and Recommendation (SBAR) / Change of Condition (C(NAME)) Note, dated July 16, 2017, and timed at 3 p.m., indicated Resident 2 verbally abused Resident 1. A review of Resident 2's SS Note, dated July 16, 2017, and timed at 3:41 p.m., indicated Resident 1 confirmed the remarks made by Resident 2. The note indicated Resident 1 appeared to be in a sad mood and looked at LVN 1 and stated Am I really rotting in bed? The Resident declined a room change and stated I've been in this room for [AGE] years and am pretty comfortable here. On July 24, 2017 at 9:58 a.m., during a telephone interview, LVN 1 stated Resident 2 was verbally abusive to other residents and staff. LVN 1 was tearful and stated the resident (Resident 2) Harassed me all day for two days, in the earshot of other residents. On July 24, 2017 at 1:25 p.m., during a telephone interview, the ADON stated, When the resident (Resident 2), has an outburst we let her vent and yell after that she becomes calm. If not, we send her to the social worker. We try to keep the other residents out of the resident's (Resident 2) way for the most part. On July 24, 2017 at 4:31 p.m., during an interview, Resident 2 stated, I don't get along with patients here except two. The rest of them are A-S HOL-S and idiots. They are jealous because my MS is not as bad, as theirs, and I can get up and move. On July 25, 2017 at 9:39 a.m., during a telephone interview, MD 1 stated Resident 2 was independent, impolite, and verbally abusive to him and others. On July 25, 2017 at 9:58 a.m., during an interview, Resident 2 stated, If they disrupt me sleeping, I have the right to kick other people's visitors out of the room. The visitation policy only applies to family. On July 26, 2017 at 4 p.m., during an interview, Resident 2 stated she told Resident 1 she was going to die. c. On July 24, 2017 at 8:58 a.m., during the facility's initial tour, Resident 3, who was a roommate to both Residents 1 and 2, was observed in the hallway outside of the room. CNA 2 was assisting Resident 3 into a seated walker. A review of Resident 3's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident's cognition was intact with a BIMS score of 15. On July 24, 2017 at 10:50 a.m., during an interview, CNA 2 stated Resident 2 would yell bad words if Resident 3 was in the bathroom when Resident 2 needed to use it. On July 24, 2017 at 11:05 a.m., during an interview translated by CNA 2, Resident 3 tearfully stated the resident (Resident 2) talks bad to me and makes me cry. I wish it was her who changed rooms instead of my other roommate (Resident 1) so I can feel safer, I don't feel safe. d. A review of Resident 4's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident's cognition was intact with a BIMS score of 15. A review of Resident 4's H/P, dated August 10, 2016, indicated the resident had the capacity to understand and make decisions. On July 24, 2017 at 1:53 p.m., during an interview, Resident 4 stated, The resident (Resident 2) attacked me at the train station (while they were out on pass). She kept slamming the gate on me and laughing. She calls me names, tells everyone that I'm gay and says my mother sucks my CO-K. I've notified the old and the new Administrator, the DON, and social services, but they blow me off and nothing was done. I had a restraining order filed against her (Resident 2). She has been horrible to me and has made my life HE-L. Sometimes I don't feel safe here. e. A review of Resident 6's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Resident 6's [DIAGNOSES REDACTED]. A review of Resident 6's MDS, dated [DATE], indicated the resident's cognition was intact with a BIMS score of 15. A review of Resident 6's H/P, dated February 8, 2017, indicated the resident had the capacity to understand and make decisions. On July 24, 2017 at 4:55 p.m., during an interview, Resident 6 stated the resident (Resident 2) Makes a vomit sound each time I pass by. She says really nasty things to me. This has been going on since 2013. I notified social services and the past Administrator. I would cry and was scared to come out of my room for a long time. It's intimidating. f. A review of Resident 7's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 7's [DIAGNOSES REDACTED]. A review of Resident 7's MDS, dated [DATE], indicated the resident's cognition was intact with a BIMS score of 15. A review of Resident 7's H/P, dated June 14, 2017, indicated the resident had the capacity to understand and make decisions. On July 24, 2017 5:45 p.m., during an interview, Resident 7 stated the resident (Resident 2) Bullied me for four months. She would say terrible things to me. I had [MEDICAL CONDITION] on my nose and she would say Pinocchio, looks like somebody stomped on your nose. She (Resident 2) would whisper into my ear too bad you can't use your arms because I'm a quadriplegic. I have seen her do the same to other residents here. She is very rude, even to her own nurse. g. A review of Resident 5's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's MDS, dated [DATE], indicated Resident 5's cognition was intact with a BIMS score of 15. A review of Resident 5's H/P, dated July 12, 2017, indicated the resident had the capacity to understand and make decisions. On July 24, 2017 at 12:15 p.m., during an interview, Resident 5 stated he was the facility's resident's council president. Resident 5 stated Resident 2 could be heard from the facility hallway cursing and yelling at four to five different facilities' staff. Resident 5 stated Resident 2's cursing could be heard by a lot of the residents and it had been going on for over a year. A review of the facility's policy and procedures titled, Abuse Prevention Program, with a revision date of August 2006, indicated the facility was committed to protecting its residents from abuse by anyone, including other residents. The policy indicated the facility's abuse prevention program provided policies and procedures that govern, as a minimum the implementation of changes to prevent future occurrences of abuse. A review of the facility's policy and procedures titled, Resident to Resident Altercations, with a revision date of December 2007, indicated the facility's staff would monitor residents for aggressive/inappropriate behavior towards other residents, visitors, or staff. The staff would review the events, including interventions to prevent additional incidents and make any necessary changes in the care plan approaches. Staff would also document in the resident's clinical record, all interventions and their effectiveness.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 2) received the necessary supervision and adequate monitoring to prevent accidents and hazards. Resident 2, who was wheelchair bound had a history of [REDACTED]. areas unsupervised; and operating her motorized power wheel chair at high speeds throughout the facility (See F 329 for further information). These deficient practices had the potential to result in serious injury to Resident 2, and other residents, staff and visitors; and posed a fire hazard to residents who resided in the facility due to Resident 2 smoking unsupervised and in undesignated areas. On July 24, 2017, at 4:15 p.m., an Immediate Jeopardy (IJ) was declared and the facility's Administrator, Assistant Administrator, Director of Nursing and Assistant Director of Nursing were notified of the immediacy. The facility submitted a plan of action (POA) on July 24, 2017, however failed to follow the plan. The IJ was lifted on July 26, 2017, at 1:50 p.m., after it was confirmed the facility's POA was implemented, the Administrator was informed. Findings: a. A review of Resident 2's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's History and Physical (H/P), dated September 30, 2016, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Sheet (MDS), a standardized assessment and care-screening tool, dated May 4, 2017, indicated Resident 2's cognition was intact. The MDS indicated Resident 2 required supervision for locomotion on the unit and extensive to limited assistance from one staff member with mobility and transfers. The MDS indicated Resident 2 used a wheelchair for mobility. Resident 2 received anti-anxiety and antidepressant medication seven days a week and hypnotic medication six days a week. A review of Resident 2's care plan, with an initiation date of July 22, 2015, without an update indicated the resident would leave the facility late at night and early in the morning. A review of Resident 2's physician's telephone order, dated September 29, 2016, and timed at 8:33 p.m., indicated Resident 2 to go out on pass (OOP). A review of Resident 2's Nurses Progress Note, dated June 22, 2017, and timed at 11:12 a.m., indicated on June 21, 2017, Resident 2 did not sign the out on pass book and returned to the facility at 9 p.m. On July 24, 2017 at 1:25 p.m., during an interview, the Assistant Director of Nursing (ADON) stated, The resident (Resident 2) should sign out, but half of the time she doesn't. We don't know where she goes, but she comes back to the facility to receive her narcotic medications (a class of substances that blunt the senses (affects the brain)). b. A review of Resident 2's care plan, with an initiation date of January 16, 2017, indicated the resident was non-compliant with the facility's smoking regulations and did not wear a smoking apron, did not follow the smoking schedule, and did not smoke in the facility's designated smoking areas. A review of Resident 2's care plan, titled At Risk for Safety Hazard, with an initiation date of September 15, 2015, indicated on May 12, 2017 the resident was seen with a lighted cigarette inside the facility and when the resident was told it was not allowed, she threw the lit cigarette inside of the facility's linen cart. The staff's intervention on the care plan indicated for the staff to encourage Resident 2 to follow safe smoking policy and procedures. A review of Resident 2's Smoking Assessment, dated May 11, 2017, and timed at 12:56 p.m., indicated the resident could maintain her own smoking and lighting materials, could smoke with periodic supervision, but Resident 2 refused to wear a smoking apron. A review of Resident 2's Smoking Interdisciplinary Team (IDT) Note, dated July 12, 2017, and timed at 10:30 a.m., indicated the resident declined to participate in the meeting and stated, You are wasting your time. We all know the risks of smoking. That's kindergarten SH-T. According to the note, the staff was to continue encouraging the resident to follow the facility's smoking policy to ensure the safety of all residents in the facility. A review of Resident 2's Nurses Note, dated July 7, 2017, and timed at 7:52 p.m., indicated there was a strong marijuana smell permeating from Resident 2's room, and her body when she passed the staff in her electric wheelchair in the hallway. A review of Resident 2's Nurses Progress Note, dated July 9, 2017, and timed at 12:31 a.m., indicated the resident smelled of a strongly of marijuana. On July 24, 2017 at 9:58 a.m., during an interview, a Licensed Vocational Nurse 1 (LVN 1) stated, The resident (Resident 2) goes out on pass frequently and smoke Marijuana. On July 24, 2017 at 11:08 a.m., during an interview, Resident 3 stated Resident 2 Uses drugs outside, at the other facilities (Skilled Nursing) and then comes back to the facility high. On July 24, 2017 at 1:25 p.m., during an interview, the ADON stated the certified nursing assistants (CNAs) told her they often smell drugs on Resident 2. On July 24, 2017 at 4:31 p.m., during an interview, Resident 2 stated, I smoke marijuana, but not on these premises. On July 25, 2017 at 9:39 a.m., during an interview, Resident 2's Medical Doctor (MD 1) stated Resident 2 had a medical marijuana card, smoked marijuana, and because she knew her rights as a patient, he could not stop her from smoking. On July 26, 2017 at 3:40 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 had smoking privileges and should only smoke in the designated smoking area, which was the large patio. A review of the facility's policy and procedures titled, Smoking Policy, with a revision date of April 2012, indicated the facility would maintain safe resident smoking practices. Residents were to be informed of any limitations on smoking, including designated smoking areas prior to or upon admission. Smoking restrictions were to be enforced in all non-smoking areas. The policy indicated the facility could impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely. c. A review of Resident 2's care plan titled, Episodes of Speeding Electric Wheelchair, with an initiation date of July 22, 2015, without a review date, indicated the resident had episodes of speeding in her electric wheelchair. The care plan had no staff interventions documented. A review of Resident 2's Care Plan Conference Summary, dated June 28, 2017, indicated the resident often drove her powered wheelchair at unsafe speeds. The summary indicated risks included injury to the resident and others. Resident 2 declined participation in the meeting and when staff attempted to discuss the unsafe speeds, Resident 2 stated, Get out of my face, you don't know SH-T. On July 24, 2017 at 11:22 a.m., during an interview, the Social Services Director (SSD) stated, There was an incident where a nurse practitioner (NP) was seeing a resident (Resident 3) and the resident (Resident 2) ran into the NP with her power wheel chair. The SSD stated Resident 2 would leave the facility a lot unsupervised and refused to sign out. On July 25, 2017 at 9:39 a.m., during an interview, MD 1 stated, It's not good judgement that she (Resident 2) takes pain pills and gets into her power chair. She drives so fast in that wheel chair in the facility that she almost ran my foot over one time. I refused to prescribe her pain medicine, because she uses a power wheelchair, but I did refer her out to pain management physician. A review of the facility's policy and procedures titled, Signing Residents Out, with a revision date of August 2006, indicated each resident leaving the premises must be signed out and indicate the expected time of return. The policy and procedure indicated the staff who observed a resident leave the premises without being properly signed out was to notify their supervisor at once. Residents were to be signed in upon return to the facility. A review of the facility's policy and procedures titled, Safety and Supervision of Residents, with a revision date of December 2008, indicated resident safety, supervision, and assistance to prevent accidents were the facility's priorities. The policy indicated the type and frequency of resident supervision was determined by the individual residents assessed needs and identified hazards.

Based on observation, interview, and record review, the facility failed to ensure Resident 2 was free of unnecessary drugs. Resident 2 was receiving excessive amounts of narcotics (drugs that cause sleepiness, relieves pain, or causes lack of awareness) and [MEDICAL CONDITION] medications (used to affect a person's mental state) without adequate monitoring and indication for its use, in duplication, and without attempting a gradual dose reduction. Resident 2 often left the facility, returning with an odor of marijuana. (See F428 for further information). This deficient practice resulted in Resident 2 receiving unnecessary drugs without adequate monitoring, with the potential for adverse reactions, injury and death related to its use. On July 24, 2017, at 4:15 p.m., an Immediate Jeopardy (IJ) was declared and the facility's Administrator, Assistant Administrator, Director of Nursing and Assistant Director of Nursing were notified. The facility submitted a plan of action (POA) on July 24, 2017, however failed to follow the plan. The POA included Resident 2's physician ordering a discharge to a lower level of care, an Interdisciplinary Team (IDT) meeting with the resident, and an in-service for staff to discuss pain management and monitoring. The IJ was lifted on July 26, 2017, at 1:50 p.m., after it was confirmed that the facility's POA was implemented. Findings: a. A review of Resident 2's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's History and Physical (H/P), dated September 30, 2016, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Sheet (MDS), a standardized assessment and care-screening tool, dated May 4, 2017, indicated Resident 2's cognition was intact. The MDS indicated Resident 2 had verbal behavioral symptoms directed toward others on a daily basis and rejected evaluation or care needed to achieve goals for health and well-being on a daily basis. Resident 2 received anti-anxiety and antidepressant medication seven days a week and hypnotic medication six days a week. A review of Resident 2's Order Summary Report, dated July 24, 2017, and timed 2:41 p.m., indicated the resident was prescribed the following medications: [REDACTED] 1.[MEDICATION NAME] milligrams (mg) every 24 hours as needed (PRN) at bedtime for inability to sleep. The order date was listed as December 23, 2016. 2. [MEDICATION NAME] Release 15 mg every 12 hours for chronic pain. The order date was listed as March 17, 2017. 3. [MEDICATION NAME] 10/325 mg every four hours PRN for moderate pain with a maximum of four tablets per day. The order date was indicated as October 25, 2016. 4. [MEDICATION NAME] 10 mg at bedtime PRN for anxiety. The order date was listed as October 25, 2016. 5. [MEDICATION NAME] 0.5 mg every four hours PRN for anxiety with a maximum of four tablets (tabs) per day, may take it with [MEDICATION NAME]. The order date was listed as October 25, 2016. 6. [MEDICATION NAME] 20 mg at bedtime for depression. The order date is listed as September 29, 2016. A review of Resident 2's Medication Administration Record [REDACTED] a.[MEDICATION NAME] administered daily except for the following dates: January 11, January 15, January 24, January 27, January 28, January 29, January 30, and January 31, 2017. b. [MEDICATION NAME] was administered daily except for on the following date: January 14, 2017. c. [MEDICATION NAME] administered daily except for on the following date: January 14, 2017. d. [MEDICATION NAME] was administered daily except for the following dates: January 1, January 9, January 19, and January 20, 2017. e. [MEDICATION NAME] was administered daily except for the following dates: January 1, January 17, January 19, January 25, and January 29, 2017. f. [MEDICATION NAME] was administered daily except for the following dates: January 1, January 9, January 19, January 20, January 23, and January 29, 2017. A review of Resident 2's MAR for the month of February 2017 indicated the following: a.[MEDICATION NAME] administered on the following dates: February 8, February 9, February 14, February 15, February 20, and February 28, 2017. b. [MEDICATION NAME] was administered daily. c. [MEDICATION NAME] administered daily. d. [MEDICATION NAME] was administered daily. e. [MEDICATION NAME] was administered on the following dates: February 3, February 4, February 5, February 17, and February 20, 2017. f. [MEDICATION NAME] was administered daily except for the following dates: February 19, and February 21, 2017. A review of Resident 2's MAR for the month of March 2017 indicated the following: a.[MEDICATION NAME] administered daily. b. [MEDICATION NAME] was administered daily except for the following dates: March 3 and March 4, 2017. c. [MEDICATION NAME] administered daily. d. [MEDICATION NAME] was administered daily except for the following dates: March 17 and March 18, 2017. e. [MEDICATION NAME] was not administered. f. [MEDICATION NAME] was administered daily. A review of Resident 2's MAR for the month of April 2017 indicated the following: a.[MEDICATION NAME] administered daily. b. [MEDICATION NAME] was administered daily except for the following date: April 27, 2017. c. [MEDICATION NAME] administered daily. d. [MEDICATION NAME] was administered daily except for the following dates: April 24, April 25, and April 28, 2017. e. [MEDICATION NAME] was not administered. f. [MEDICATION NAME] was administered daily except for the following dates: April 7, April 11, April 12, April 24, and April 29, 2017. A review of Resident 2's MAR for the month of May 2017 indicated the following: a.[MEDICATION NAME] administered daily except for the following dates: May 8, May 9, and May 10, 2017. b. [MEDICATION NAME] was administered daily. c. [MEDICATION NAME] administered daily. d. [MEDICATION NAME] was administered daily. e. [MEDICATION NAME] was administered daily except for the following dates: May 6, May 11, May 12, May 15, May 21, May 29, May 30, and May 31, 2017. f. [MEDICATION NAME] was administered daily except for the following date: May 5, 2017. A review of Resident 2's MAR for the month of June 2017 indicated the following: a.[MEDICATION NAME] administered daily except for the following date: June 2, 2017. b. [MEDICATION NAME] was administered daily. c. [MEDICATION NAME] administered daily except for the following dates: June 21, June 25, June 27, June 28, and June 29, 2017. d. [MEDICATION NAME] was administered daily except for the following dates: June 23 and June 24, 2017. e. [MEDICATION NAME] was administered daily except for the following dates: June 1, June 7, June 10, June 12, June 13, June 14, June 19, June 25 and June 30, 2017. F. [MEDICATION NAME] was administered daily. A review of Resident 2's MAR for the month of July 2017 indicated the following: a.[MEDICATION NAME] administered daily except for the following dates: July 3, July 8, July 9, July 12, July 13, July 14, July 15, July 20 and July 21, 2017. Resident 2 [MEDICATION NAME] mg for seven months for a sum total of 1,690 mg. b. [MEDICATION NAME] was administered daily. c. [MEDICATION NAME] administered daily except for the following date: July 15, 2017. d. [MEDICATION NAME] was administered daily. e. [MEDICATION NAME] was administered daily except for the following dates: July 1, July 6, July 7, July 11, July 13 and July 19. 2017. Resident 2 received [MEDICATION NAME] 10 mg for five months for a sum total of 990 mg. f. [MEDICATION NAME] was administered daily. A review of Resident 2's May 2017 Medication Administration Record [REDACTED] 1.[MEDICATION NAME] a total of 28 times. 2. [MEDICATION NAME] administered a total of 30 times. 3. [MEDICATION NAME] administered a total of 22 times. 4. [MEDICATION NAME] administered a total of 31 times. A review of Resident 2's June 2017 Medication Administration Record [REDACTED] 1.[MEDICATION NAME] a total of 29 times. 2. [MEDICATION NAME] administered a total of 30 times. 3. [MEDICATION NAME] administered a total of 21 times. 4. [MEDICATION NAME] administered a total of 30 times. A review of Resident 2's July 2017 Medication Administration Record [REDACTED] 1.[MEDICATION NAME] at total of 15 times. 2. [MEDICATION NAME] administered a total of 24 times. 3. [MEDICATION NAME] administered a total of 18 times. 4. [MEDICATION NAME] administered a total of 23 times. A review of Resident 2's Consultant Pharmacist's (CP) Medication Regimen Review (MRR), dated for November 29, 2016, indicated the resident was receiving a hypnotic drug on a routine basis and [MEDICATION NAME] night. The CP's recommendation was to attempt to wean Resident 2 off the medication and document the attempts in the care plan. The MRR indicated the MD may need to adjust the pain medication, [MEDICATION NAME], due to frequent use. According to the MRR, Resident 2 used [MEDICATION NAME] and [MEDICATION NAME], which were both indicated for anxiety, on a daily basis and may be considered duplicative therapy. The MRR [MEDICATION NAME] needed clarification on how close they can be administered at bedtime and that using both at bedtime may be considered duplicative therapy. According to an online site Lexicomp (provider of drug information and clinical content for the healthcare industry), the black box warnings for [MEDICATION NAME] indicated users were exposed to the risks of opioid addiction, abuse, and misuse, which could lead to overdose and death. The site indicated concomitant use of opioid's with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of [MEDICATION NAME]/[MEDICATION NAME] and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. A review of Resident 2's care plan, with an initiation date of November 14, 2015, indicated the resident was at risk for falls related to being on multiple [MEDICAL CONDITION] and narcotic medications. The listed interventions were to monitor for side effects of any medications that can cause gait disturbance, orthostatic [MEDICAL CONDITION] (low blood pressure when changing positions), weakness, sedation, lightheadedness, dizziness, and change in mental status. A review of the PC's Notes to Resident 2's Prescriber indicated there were multiple gradual dose reduction (GDR) requests dating back to January 26, 2016. MD 2 checked the box indicating the current dose was the minimal effective dose, reduction is not indicated at this time. MD 2 documented Resident 2 wished to continue the same amount of medications. A review of Resident 2's care plan, with an initiation date of February 11, 2016, indicated the resident had chronic pain. The staff's interventions included monitoring Resident 2 for side effects of pain medication such as constipation, new onset or increased agitation, restlessness, confusion, nausea, vomiting, dizziness, and falls. A review of Resident 2's [MEDICAL CONDITION] IDT meeting, dated May 25, 2017, indicated there were no changes to Resident 2's [MEDICAL CONDITION] medication due to the resident refusing because of past GDR failed attempts. A review of Resident 2's care plan, with an initiation date of July 8, 2015, without any review dates, only a target date of July 31, 2017, indicated the resident was at risk for drug interactions after staff found Resident 2 with non-prescription marijuana in her room. A review of Resident 2's Nurses Note, dated July 7, 2017, and timed at 7:52 p.m., indicated there was a strong marijuana smell permeating from Resident 2's room, and her body when she passed the staff in her electric wheelchair in the hallway. A review of Resident 2's Nurses Note, dated July 9, 2017, and timed at 12:31 a.m., indicated the resident smelled of a strongly of marijuana. On July 24, 2017 at 9:58 a.m., during an interview, LVN 1 stated Resident 2 went out on pass frequently to smoke marijuana. On July 24, 2017 at 11:08 a.m., during an interview, Resident 3, who was alert, stated Resident 2 uses drugs outside, at the other facilities and comes back to the facility high. On July 24, 2017 at 1:25 p.m., during an interview, the ADON stated the CNAs told her they often smell drugs on Resident 2. On July 24, 2017 at 5:32 p.m., before the IJ was lifted, during an observation and a concurrent interview, Licensed Vocational Nurse 3 (LVN 3) was observed administering medication to Resident 2. Resident 2 was observed leaving the facility immediately after receiving the medication from LVN 3. LVN 3 stated, I gave her [MEDICATION NAME] and [MEDICATION NAME]. I know I should monitor her (Resident 2) after administering those medications. On July 25, 2017 at 9:39 a.m., during a telephone interview, MD 1 stated Resident 2 told him she smoked marijuana and had a medical marijuana card and he stated he could not stop her because she knew her rights. On July 25, 2017 at 5 p.m., during a telephone interview, MD 2 stated, I don't feel comfortable with continuing these medications for the long term, but I don't know what will be next. The resident (Resident 2) refuses a lower dose. Anytime I mention a lower dose, she refuses. On July 26, 2017 at 3:40 p.m., during a record review with the DON, the DON was unable to locate the MD's response to the pharmacist consultants' MRR recommendations, dated November 2016 (eight months prior). The DON was unable to locate any documented GDRs done for Resident 2. A review of the facility's policy titled, Administering Medications, indicated residents using PRN meds frequently needed to be evaluated to consider whether a standing dose of medication is indicated. A review of the facility's policy titled, Psychotherapeutic Drug Management Program, indicated the purpose of the policy was to avoid any unnecessary medication. The policy indicated orders for PRN psychotherapeutic drugs would be time limited. The facility's nursing responsibilities included monitoring residents using psychotherapeutic medication for adverse effects. The pharmacist responsibilities included monitoring psychotherapeutic drug use in the facility to ensure medications were not used in excessive dose, excessive duration and to avoid duplicate therapy. A review of the facility's policy titled, Medication Utilization and Prescribing, with a revision date of April 2013, indicated the physician would provide and document a rationale when indication, dose, duration, or frequency of a prescribed medication differs from accepted practices, manufacturers recommendations, or the medication was high risk compared to relevant alternatives. According to DailyMed [MEDICATION NAME](an opioid medication for severe pain) has a black box warning (BBW) - the strongest warning that the Food and Drug Administration (FDA) requires which indicate under Warning: addiction, abuse, and misuse; life-threatening respiratory depression; and risks from concomitant use with benzodiazepines (e.g. [MEDICATION NAME] and [MEDICATION NAME]) or other CNS depressants (e.g.[MEDICATION NAME]), including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of [MEDICATION NAME] benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. The monograph for [MEDICATION NAME] indicated a BBW with similar side effects for opioid addition, abuse, and misuse, which can lead to overdose and death, and cautioned against concomitant prescribing of [MEDICATION NAME] and benzodiazepine or other CNS depressants. According to DailyMed, peak blood concentrations of oral (by mouth) [MEDICATION NAME] were achieved two hours after administration and for [MEDICATION NAME] were achieved in one to two hours following administration. Both medications included BBWs that indicated: Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Most common side effects included sedation, dizziness, weakness and unsteadiness .The monograph [MEDICATION NAME] similar side effects of sedation and dizziness, and cautioned against use at bedtime with other sedative medications.

Based on interview and record review, the facility failed to act upon the pharmacist consultant's (PC) Medication Regimen Reviews ((MRR) pharmacist assessment and evaluation of residents' medications irregularities) for eight months for one of six sampled residents (Resident 2). Resident 2's MRR indicated the resident was receiving excessive amounts of narcotics (drugs that cause sleepiness, relieves pain, or causes lack of awareness) and psychotropic medications (used to affect a person's mental state) without adequate monitoring and in duplication of use that was not acted upon by the facility (Cross reference to F329). This deficient practice resulted in Resident 2 continuing to receive high doses of narcotics, psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) without adequate monitoring and dose reduction in the present of adverse consequences (agitated behavior) after the PC recommended reduction and changes. On July 24, 2017, at 4:15 p.m., an Immediate Jeopardy (IJ) was declared and the facility's Administrator, Assistant Administrator, Director of Nursing and Assistant Director of Nursing were notified. The facility submitted a plan of action (POA) on July 24, 2017, however failed to follow the plan. The POA included Resident 2's physician ordering a discharge to a lower level of care, an Interdisciplinary Team (IDT) meeting with the resident, and an in-service for staff to discuss pain management and monitoring. The IJ was lifted on July 26, 2017, at 1:50 p.m., after it was confirmed that the facility's POA was implemented. Findings: A review of Resident 2's Admission Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's History and Physical (H/P) Examination, dated September 30, 2016, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Sheet (MDS), a standardized assessment and care-screening tool, dated May 4, 2017, indicated Resident 2's cognition was intact. The MDS indicated Resident 2 had verbal behavioral symptoms directed toward others on a daily basis and rejected evaluation or care needed to achieve goals for health and well-being on a daily basis. According to the MDS, Resident 2 received anti-anxiety and antidepressant medication seven days a week and hypnotic medication six days a week. A review of Resident 2's physician's orders [REDACTED]. 1. Ambien (hypnotic for sleep) 10 milligrams (mg) every 24 hours as needed (PRN) at bedtime for inability to sleep. The order initial date was December 23, 2016. 2. MS Contin Extended Release (strong narcotic pain reliever) 15 mg every 12 hours for chronic pain. The order initial date was March 17, 2017. 3. Percocet (strong narcotic pain reliever) 10/325 mg every four hours PRN for moderate pain with a maximum of four tablets per day. The order initial date was October 25, 2016. 4. Valium (anti-anxiety/muscle relaxer) 10 mg at bedtime PRN for anxiety. The order initial date was October 25, 2016. 5. Xanax (anti-anxiety) 0.5 mg every four hours PRN for anxiety with a maximum of four tabs per day may take it with Percocet. The order initial date was October 25, 2016. 6. Lexapro (anti-anxiety) 20 mg at bedtime for depression. The order initial date was September 29, 2016. A review of Resident 2's Medication Administration Record [REDACTED]. A review of Resident 2's CP's Medication Regimen Review, dated November 29, 2016, indicated the resident was receiving a hypnotic drug on a routine basis and used Ambien whenever necessary (PRN) every night. The PC's recommendation was to attempt to wean Resident 2 off of the medication and document attempts to do so in the care plan. The MRR indicated the following: 1. MD may need to adjust the pain medication Percocet due to frequent use. 2. Valium and Xanax were both for anxiety and may be considered duplicative therapy. 3. Xanax and Valium were ordered to be administered PRN, but were given on a daily basis. 4. Ambien and Valium needed clarification on how close they can be administered at bedtime and using both at bedtime may be considered duplicative therapy. A review of Resident 2's CP's Notes to the Prescriber indicated multiple GDR (gradual dose reduction) requests dating back to January 26, 2016 was not acted upon, MD 2 only checked the box indicating current dose was the minimal effective dose and reduction was not indicated at that time. MD 2 also documented Resident 2 wished to continue the same amount of medications. On July 25, 2017 at 5 p.m., during a telephone interview, MD 2 stated, I don't feel comfortable with continuing these medications for the long term, but I don't know what will be next. The resident (Resident 2) refuses a lower dose and anytime I mention a lower dose, she refuses. On July 26, 2017 at 3:40 p.m., during a record review with the DON, the DON was unable to locate the Resident 2's MD's response to CP's November 2016 MRR recommendations. A review of the facility's policy titled, Medication Utilization and Prescribing, with a revision date of April 2013, indicated the physician would provide and document a rationale when indication, dose, duration or frequency of a prescribed medication differed from accepted practices, manufacturers recommendations, or the medication was high risk compared to relevant alternatives. A review of the facility's policy titled, Psychotherapeutic Drug Management Program, indicated the purpose of the policy was to avoid any unnecessary medication. The policy indicated orders for PRN psychotherapeutic drugs would be time limited. Nursing responsibilities included monitoring residents using psychotherapeutic medication for adverse effects. Pharmacist responsibilities included monitoring psychotherapeutic drug use in the facility to ensure medications were not used in excessive dose, excessive duration and to avoid duplicate therapy.

Based on observation, interview, and record review, the facility failed to ensure when using the patient lift machine (a machine that allows a person to be lifted and transferred with minimum physical effort) to transfer a resident, two staff personnel were to perform the procedure according to the facility policy and care plan and that the staff personnel were to perform safety checks by double checking prior to lifting the resident for one of two sampled residents (Resident 1). Resident 1 was on the wheelchair to be transferred to the bed on 2/15/16. Certified Nurse Assistant (CNA 1 transferred Resident 1 alone using the patient lift machine. Resident 1 was buckled (with seat belt on) in the wheelchair. Resident 1was lifted up with a sling of the mechanical lift at the same time that her body was attached to the seatbelt of the wheelchair during the actual transfer and pulling up 350 pounds or more of the wheelchair weight onto Resident 1's hip/thigh area. Resident 1, who was known to the facility to have osteoporosis (porous bone that is characterized by too little bone formation or excessive bone loss, leading to bone fragility and increased risk of fractures), sustained right proximal femur fracture (broken thigh bone nearest to the hip) and was admitted to the hospital. Resident 1 underwent surgical repair of the right femur fracture. Findings: A review of Resident 1's record titled, Admission Record, indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's care plan, initiated on 11/14/15 and titled, Resident has activities of daily living (ADL) self-care deficit due to MS and dementia, indicated interventions that included safe resident handling and transfer resident with a full body lift with two person assist. A review of Resident 1's record titled, Minimum Data Set ((MDS), a resident assessment and care screening tool), dated 12/5/15, indicated Resident 1's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 1 required full staff performance for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, and standing position) with two person physical assist.Resident 1 had impairment to both lower extremities (hip, knee, ankle, foot) and required wheelchair for mobility. A review of Resident 1's record titled, Weekly Summary, indicated Resident 1 was totally dependent on staff for transfers and the support provided was one person assist for the week of 2/1/16, 2/8/16, and 2/15/16. On 2/15/16, it was indicated that Resident 1 required a patient lift machine to use during transfer and Resident 1 was up in electric wheelchair daily as tolerated. A review of Resident 1's record, dated 2/20/16, titled, SBAR (Situation Background Assessment Recommendation, a technique provides a framework for communication between members of the health care team)/C[NAME] (Change of Condition), indicated that Resident 1 was assessed with [REDACTED]. The SBAR/C[NAME] indicated that the affected area was tender on palpation (using one's hands to examine the body area) and worsened with range of motion (joint mobility), and required pain management with medication. A review of Resident 1's record titled, Medication Administration Record (MAR), for (MONTH) (YEAR) indicated Resident 1 was administered Norco (a combination of acetaminophen and hydrocodone,an opioid (narcotic) pain medication) 5/325 milligrams (mg) one tablet orally for right thigh pain with pain rating of 7 out of 10 (pain rating scale from 0, meaning no pain to 10, meaning worst pain) on 2/20/16 at 2 p.m. A review of Resident 1's record titled, Order Summary Report, dated 2/20/16, indicated to obtain x ray to right femur and pelvis (a large bony structure near the base of the spine to which the legs are attached). A review of Resident 1's diagnostic imaging result, dated 2/20/16, indicated Resident 1 had an acute (occurred suddenly) right femur fracture with marked angulation (rotation or change in bone length caused by loss of bone alignment) and displacement (the bone snaps into two or more parts and moves so that the two ends are not lined up straight). A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's hospital x ray result, dated 2/20/16, indicated Resident 1 had a comminuted (bone breaks into several pieces), markedly displaced angulated fracture involving the right femur. A review of Resident 1's hospital emergency department (ED) physician notes titled, Trauma, Extremity Injury Major, dated 2/20/16, indicated Resident 1 had a right femur fracture and right hip pain that was described as severe, intermittent (off and on), and unprovoked. The ED physician notes indicated Resident 1's right foot toes were pointing posteriorly (towards the back) and to the right, and pulses (regular throbbing of the arteries that can be felt, caused by the successive contractions of the heart) of either foot were undetectable. It indicated the pelvis and right femur x ray results showed a severely displaced fracture of proximal right femur (thigh bone nearest to the hip bone) with 90 degree angulation. Resident 1 was treated with Dilaudid (an opioid pain medication for the management of moderate to severe pain) 1.5 mg intravenously ((IV), given directly into a vein). It indicated that an Orthopedic consult (consultation by a physician who specializes in the study of bones and muscles) was requested immediately (STAT). The ED physician notes indicated that Resident 1's sister was at bedside and said that the accident occurred when moving Resident 1 with a sling from bed to a motorized wheelchair at the facility. A review of Resident 1's hospital record titled, History and Physical (H & P), dated 2/20/16 at 22:51 p.m., indicated Resident 1 stated that she may have fractured her femur 4 to 5 days ago when she was being transferred from her wheelchair to her bed. The H & P indicated Resident 1's right lower extremity (right leg) had an obvious deformity (major difference in the shape of a body part compared to the normal shape of that part) of the femur (the thigh bone) and an exaggerated external rotation (the leg turned away from the body so the knee or foot faces outward). Resident 1's plan for the displaced right femur fracture included: Tylenol (brand name for acetaminophen medication used to treat pain) for mild pain, Norco for moderate pain, and Dilaudid for severe pain. A review of Resident 1's hospital progress note, dated 2/21/16 and 2/22/16, indicated Resident 1 was placed on Bucks traction (a pulling force is applied by strapping the resident's affected leg and attaching weights to immobilize (reduce movement), position, and align the bones) to the right leg with a five pound weight. A review of Resident 1's hospital operative report,dated 2/23/16 at 13:28 p.m., indicated Resident 1underwent an intramedullary hip nailing (a surgical procedure wherein a metal rod was forced in the cavity of a bone to treat fracture) of the right side on 2/22/16. During an interview, on 3/2/16 at 3 p.m., when asked about facility procedure with the use of a patient lift machine, CNA 2 stated two staff personnel were required when using the patient lift machine for resident safety. CNA 2 stated that before lifting residents using the patient lifting machine, the belt used to secure residents to the wheelchair should be unbuckled to prevent severe harm to the resident. A review of Resident 1's hospital record titled, Discharge Summary, dated 3/7/16, indicated Resident 1 was discharged on [DATE] with right femoral open reduction internal fixation ((ORIF), a surgery to repair the bone by using special metal devices, called internal fixators, to hold the bones in place while they heal). On 4/14/16, at 1:20 p.m., Resident 1's wheelchair was observed right outside Resident 1's room and was labeled, Quantum motorized power wheelchair and was equipped with a safety belt. During an interview, on 4/14/16 at 1:43 p.m., CNA1 stated Resident 1, who was on her wheelchair, requested to be placed back onto the bed on 2/15/16. CNA 1 stated the safety belt of the wheelchair remained buckled as Resident 1 was being lifted using the patient lift machine. CNA 1 stopped the patient lift machine to unbuckle Resident 1's safety belt. CNA 1 stated the wheelchair was heavy. CNA 1 stated she could not recall the name of the CNA who assisted her in operating the patient lift machine to transfer Resident 1 from wheelchair to bed. CNA 1 described the assisting CNA as being newly hired CNA. CNA 1 stated she observed a bruise on Resident 1's right thigh area that was purplish discoloration and three centimeters in diameter, and CNA 1 stated on 2/16/16, she reported to the Licensed Vocational Nurse (LVN 1), who was the primary nurse, of Resident 1's right thigh purple discoloration. During an interview, on 4/14/16 at 3:20 p.m., Director of Staff Development (DSD) stated the facility was not able to identify the CNA (CNA X) that assisted CNA 1 in the use of the patient lift machine to transfer Resident 1 on 2/15/16. DSD stated the CNAs that were scheduled on 2/15/16 denied helping CNA 1 in the transfer of Resident 1 using the patient lift machine. DSD stated the most recently hired CNA was CNA 1. According to CNA 1's declaration statement, dated 4/14/16, CNA 1 and CNA X (not identified) were transferring Resident 1 from wheelchair to bed using a patient lift machine on 2/15/16. CNA 1 indicated that she noticed the safety belt was still buckled and told CNA X to stop lifting Resident 1 so that she could unbuckle Resident 1's safety belt. CNA 1 indicated that on the following day (2/16/17), at 8 a.m., CNA 1 observed a bruise on Resident 1's right thigh and reported to the charge nurse. A review of the facility document titled, Nursing Staffing Assignment and Sign-In Sheet, dated 2/15/16, on the 7 a.m. to 3 p.m. shift, indicated there were four CNAs assigned to the same Unit (East) with CNA 1. All four CNAs were interviewed and no one could recall assisting CNA 1 transfer Resident 1 using the patient lift machine on 2/15/16. There were a total of 13 other CNAs in other Units and no one could recall assisting CNA 1 transfer Resident 1 using the patient lift machine on 2/15/16. During an interview, on 4/19/16 at 11:10 a.m., Family 1 stated when she went to the facility (2/16/16) to take Resident 1 to an outpatient physician appointment; Licensed Vocational Nurse (LVN 1) notified her that Resident 1 had a bruise on the right upper leg. Family 1 stated that she did not see the bruise on the right leg because Resident 1 was already dressed and seated in the wheelchair. Family 1 stated Resident 1 told her that staff bumped her leg. Family 1 stated that when she returned from the outpatient physician appointment back to the facility, CNA 1 told her that a newly hired CNA had assisted in the transfer of Resident 1 using the patient lift machine, and they may have hit her leg during the transfer and should have watched Resident 1 carefully. Family 1 stated when the charge nurse notified her of physician's orders [REDACTED]. leg was worsening. Family 1 stated the charge nurse notified her that the x ray result indicated Resident 1 had a femur fracture and the physician ordered for Resident 1 to be transferred to the hospital on [DATE]. Family 1 stated when Resident 1 was transferred to the hospital emergency department; Resident 1's right leg looked twisted and angulated. Family 1 stated Resident 1 could not feel much on her legs because of the baclofen pump (consists of a pump and catheter used to deliver baclofen medication (a muscle relaxer) into the spinal fluid for the treatment of [REDACTED]. During an interview, on 3/21/17 at 12:25 p.m., Consumer Care Representative (CCR 1) stated average Quantum wheelchair weighs about 350 pounds and more when added the weight of the accessories. During an interview, on 3/21/17 at 1 p.m., the Director of Nursing stated Resident 1 was using Quantum motorized power wheelchair. A review of the facility's policy and procedures, dated 10/2010 and titled, Using a Portable Lifting Machine, indicated if the resident cannot participate in the lifting procedure, then two nursing assistants are required to perform the procedure. According to the Food and Drug Administration (FDA), undated, titled, Patient Lifts: Safety Guide, caregiver safety tips on the use of patient lifts included: although most lifts require two or more caregivers to safely operate and lift and handle patient, determine how many caregivers are required to safely lift the patient; check to make sure patient is ready to be placed in a lift; and perform safety checks by double checking position and stability of sling straps and other equipment before lifting patient. http://www.mayoclinic.org/diseases conditions/hip fracture/basics/risk factors/con 033 According to the Mayo Clinic, dated 3/11/15, titled, Hip Fracture, older people are at a higher risk of hip fracture because bones tend to weaken with age and a hip fracture is a serious injury that can be life threatening. A hip fracture requires surgical repair or replacement, followed by months of physical therapy. Complications of a hip fracture are reduce future independence, shorten your life, and increase risk of weakened bones and further falls which places risk for having another hip fracture.

Based on interview and record review, the facility failed to report alleged allegations of abuse including injuries of unknown origin, failed to conduct thorough investigations of abuse, failed to protect residents from abuse and failed to report allegations to proper authorities. These failures allowed the facility's residents to be physically, verbally and sexually abused and had the potential to affect all residents in the facility. A condition of Immediate Jeopardy (IJ) was identified by the survey team for the facility's failure to investigate alleged abuse; the facility's failure to report allegations of abuse; the facility's failure to protect residents from abuse; the facility's failure to respond to alleged instances of abuse; and the facility's failure to maintain employee records in a manner that ensured the safety of the facility's residents. The IJ was called on 8/6/14, at 3:30 PM, by the survey Team Coordinator, Health Facilities Evaluator Manager and one Health Facilities Evaluator Nurse. In addition to the survey team, the following facility staff were present at the time the IJ was called: Facility Administrator, Director of Nurses, and Director of Clinical Services. On 8/7/14, at 2:52 PM, with an acceptable plan of correction, the IJ was abated with the Administrator, Director of Nurses and Director of Clinical Services. Findings: During a record review and concurrent interview with the Administrator on 8/6/14 at 3 PM, the Administrator was asked to provide written evidence of how the facility handled cases of alleged abuse. Three allegations of abuse were requested for review. The Administrator was unable to provide a log or record indicating the allegations he had investigated, however he supplied two records of abuse and the Director of Nursing (DON) supplied the third. He stated he was not aware that injuries of unknown origin were to be reported as allegations of potential abuse to Department of Health Services (DHS). The Administrative folder for allegation number 1 indicated that Resident 38 had made an allegation of physical and verbal abuse on 7/25/14. The SOC 341 (report of an allegation of adult/ elder abuse) had been faxed to the Ombudsmen on 7/28/14 three days after the event was reported. The Administrator stated the report was not sent to the DHS as required. He further stated he does not send a final investigative report of the allegation of abuse within 5 days to DHS as required. The alleged abusers were not suspended to keep Resident 38 safe from further abuse by the alleged abusers. The Administrative folder for allegation number 2 indicated Resident 22 reported an incident of sexual abuse on 4/16/14 at 6:30 PM. The investigative report by the Administrator indicated in part, "after returning from a Good Friday Easter Service, I documented the investigation from home. No DHS fax number on hand. 4/19/14 report made to DHS, (three days after the incident was reported by Resident 22 to facility Administration). The administrative folder did not contain a SOC 341(report of an allegation of adult/ elder abuse) indicating who had been notified, including the Ombudsmen. There was no evidence that the ombudsmen or resident's responsible party had been notified. The Certified Nursing Assistance (CNA's) employee file showed no evidence of suspension. The Administrative folder for allegation number 3 indicated that Random Resident 34 had a complaint of verbal abuse that he addressed with the Administrator on 6/9/14. The Quality Improvement Interview and Observation form dated 6/9/14 indicated, "... the janitor rushed over to him after he finished what he was doing and said, "I was trying to finish something SIR in a irritated tone. He said he was startled the janitor rushed over to him." The Administrator stated he had not reported the allegation to DHS, the Ombudsmen or the resident's responsible party and had not suspended the alleged abuser. During a group meeting on 8/6/14 at 3 PM, Random Resident 34 stated he brought up an incident against a night time janitor (JA 1) to the Administrator which happened a month ago in the dining room but Administrator did not do anything about it. Random Resident 34 stated, JA 1 said to him he can't take it anymore and made an action to hit him. Random Resident 34 stated Resident 28 was in the dining room at that time. Resident 28 nodded her head affirmatively. Resident 21 and two random residents (31 and 33) had incidents of altercations with sampled resident (22) while she was at the facility. Resident 21 stated Resident 22 was speeding on her wheelchair and hit Resident 21 when she was standing at the nurses' station while using their telephone talking to her daughter. Resident 21 stated she almost fell on Resident 22's lap. Resident 21 stated their previous social worker (SS 2) was also standing at the nurses' station during this incident but denied seeing nor hearing anything. Resident 21 stated SS 2 did not do anything about this incident after she brought it up to her. Resident 21 stated her daughter who was on the other line asked what was going on. During a review of the clinical record for Resident 16 and concurrent interview with Licensed Nurse (LN) 4 on 8/6/14 at 10 AM, a form, untitled, dated 2/10/14 was reviewed. LN 4 stated this is Physician 1's Progress note. The note indicated, "Pt (patient) states they beat me up last night they tie me into a chair." When asked what action she would take upon reviewing the note LN 4 stated, "I did not know she got beat up, I would have the CNA check her and put her by the desk to keep her busy." During a telephone interview with Physician 1 on 8/11/14 at 11 AM, he stated he was unaware the statement, "Pt (patient) states they beat me up last night they tie me into a chair" would be considered an allegation of abuse and was not aware if an investigation of the allegation was done by the facility. During an interview with the Administrator on 8/6/14 at 5 PM, the Administrator was asked if he had any reports concerning Resident 22's altercations with Residents 21,33 and 31. He stated he was not aware of any altercations. During a telephone conversation with the facility Ombudsmen Case Manager on 8/12/14 at 10 AM, she stated, "(Resident 38) called me with an allegation of abuse by a staff member and I called the facility Administrator and reminded him that he needed to report this allegation to DHS. I do not have any reports concerning (Residents 22, 28 or 34). I told the Administrator that all allegations of abuse need to be reported to DHS and the Ombudsmen. During an interview with the facility Director of Clinical Services (DCS) on 8/7/14 at 11:30 AM , after she had been made aware of the abuse allegations, she stated, a sweep of 40 alert residents had been conducted and 20 of the residents questioned had new allegations of abuse. The facility policy and procedure titled "Elder Abuse Prevention, dated 3/1/14, indicated, "If an employee, they will be suspended from duty pending the outcome of the investigation." The facility policy and procedure titled "Resident Abuse and Investigation" un-dated indicated, Administrator will notify all parties involved, including notifying DHS or the Long term care Ombudsmen.

Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (16 and 22) and two random residents (34 and 38) were free from physical and verbal abuse. The facility: 1. Failed to thoroughly investigate, report, and protect Random Resident 38 when she reported instances of physical and verbal abuse to the facility Administration. 2. Failed to thoroughly investigate and report Resident 22's allegations of sexual abuse in a timely manner. 3. Failed to thoroughly investigate, report and protect Random Resident 34 from an allegation of verbal abuse and abusive gestures. 4. Failed to investigate a Physician's clinical note allegation of abuse for Resident 16. These failures placed all facility residents at risk of being abused. Findings: During a record review and concurrent interview with the facility Administrator on 8/6/14 at 3 PM, the Administrator was asked to provide written evidence of how the facility handled cases of alleged abuse. Three allegations of abuse were requested for review. The Administrator was unable to provide a log or record indicating the allegations he had investigated, however he supplied three records of abuse. 1. The Administrative folder for allegation number 1 indicated Resident 38 had made an allegation of physical and verbal abuse on 7/25/14 to Licensed Nurse (LN) 7. The facility investigative report, dated 7/28/14, indicated Resident 38 reported being slapped and being rudely treated on 7/25/14. The report indicated Resident 38 is completely cognitively intact and able to make her needs known. The facility actions indicated that Certified Nursing Assistant (CNA) 3 was "removed from the resident's care and that she was reminded of the facilities abuse policy." During an observation and interview with Resident 38 on 8/6/14 at 3:30 PM, she stated, "(CNA 3) hit me twice on my hands during care and stated 'I hate you' both times. Now (LN 9) comes in and is treating me much rougher, she said, none of the nurses here like you." Resident 38 was lying in her bed with the head of the bed raised. She stated she needed assistance with most of her activities of daily living. She was attempting to brush her teeth with her right hand which appeared to be contracted as was her left hand. In the process of brushing her teeth she had a towel placed over her chest that was saturated with water and toothpaste. She stated, "I try so hard to do things for myself but I need a lot of help. I have no reason to lie to you. I just try to pray for these people." During a telephone conversation with the facility Ombudsmen Case Manager on 8/12/14 at 10 AM, she stated, "(Resident 38) called me with an allegation of abuse by a staff member and I called the facility Administrator and reminded him he needed to report this allegation to DHS. I also told him that all allegations need to be reported to DHS and the Ombudsmen". During a review of the clinical record for Resident 38, a form titled "Witness" dated 8/7/14 completed by Licensed Clinical Social Worker (LCSW) 1, indicated, "According to the patient she was mistreated by (CNA 3) on two different occasions. (CNA 3) told her that she hated her and that she hit her hands while she was changing her. (LN 9) then told her, not too many nurses here like you." During a record review and concurrent interview with the Director of Staff Training (DST) on 8/6/14 at 3 PM, the employee file for CNA 3 was reviewed. The DST was unable to find evidence of abuse training and was unable to provide evidence of pre-employment screening including reference checks and criminal record check. The employee file indicated CNA 3 had three previous corrective action reports for complaints made by residents. The file also contained a report dated 9/19/02, from an ambulance company stating that a resident had told him CNA 3 was "rude, impatient and a bully." The file contained no report of disciplinary actions for these reports. The facility DST was unable to provide evidence of monitoring CNA 3 after the allegation of abuse. The file contained no evidence that CNA 3 had ever been suspended. The Employee Counseling Report, undated, indicated, "(Resident 38) reports that CNA 3 stated she hates her and slapped her hand. Under the section titled previous counseling/corrective action, "None." Under the section titled Expected level of performance, "(2) not to say to resident that you hate resident (3) not to touch or hit resident." The facility Policy and Procedure titled "Elder Abuse Prevention, dated 3/1/14, indicated, "If an employee, they will be suspended from duty pending the outcome of the investigation... Periodic on-going in-services (on abuse) will be utilized. Monitoring By the Department head overseeing the employee will be used to confirm that undesirable behavior has abated. Direct observation of the employees conduct must occur for a period of thirty days. Random interviews with Residents will be conducted to determine no recurrence of behavior. These observations will be logged in the employee file." 2. The Administrative folder for allegation number 2 indicated Resident 22 reported an incident of sexual abuse on 4/16/14 at 6:30 PM. The Administrator report indicated Resident 22 stated she was touched inappropriately by CNA 6. During an interview with the facility Director of Clinical Services (DCS) on 8/7/14 at 11:30 AM, after she had been made aware of the abuse allegations, she stated, a sweep of 40 alert residents had been conducted and 20 of the residents questioned had new allegations of abuse. A review of three clinical documents titled Quality Improvement Observation and Interview dated 4/28/24 indicated the DST interviewed three alert residents. These investigative interviews were done 12 days after the allegation of sexual abuse by Resident 22. There was no documented evidence that an assessment had been done for residents who were not able to respond to interview questions. A document signed by LN 13, dated 4/16/14, indicated, "(CNA 6) was telling (Resident 22) that I owe you 50 dollars, (CNA 6) told (Resident 22) to give her a hug, Resident 22 refused but (CNA 6) still hugged her. I (LN 11) asked her what's going on and (Resident 22) said she owes me money for cigarettes and that (CNA 6) is touching her everywhere. Also (someone) told me that (Resident 22) is crying to her that (CNA 6) is touching her". During a record review and concurrent interview with the DST on 8/6/14 at 3 PM, the employee file for CNA 6 was reviewed. The DST was unable to find evidence of abuse training and was unable to provide evidence of pre-employment screening including reference checks and a criminal record check. There was no evidence in the employee file that CNA 6 had been suspended during the investigation of the abuse allegation. The Resident Plan of Care for Resident 22, dated 5/7/14, indicated in part under: Resident Problem: Alleged staff touching her inappropriately. ...Objective: staff will not touch Resident inappropriately. Approach : separate staff from Resident, will report to DHS or ombudsmen- for any allegation. The facility policy and procedure titled "Elder Abuse Prevention, dated 3/1/14, indicated, "If an employee, they will be suspended from duty pending the outcome of the investigation." The facility policy and procedure titled "Resident Abuse and Investigation" un-dated, indicated, Administrator will notify all parties involved, including notifying DHS or the Long term care Ombudsmen. 3. During an interview and concurrent record review, the Administrative folder for allegation number 3 indicated Random Resident 34 had a complaint of verbal abuse that he addressed with the Administrator on 6/9/14. The Quality Improvement Interview and Observation form dated 6/9/14 indicated, " ... the janitor rushed over to him after he finished what he was doing and said, "I was trying to finish something SIR in a irritated tone. He said he was startled the janitor rushed over to him." The Administrator's interview with the Janitor (JA) 1 indicated, ...Resident 34 was making rude comments about JA 1's mother and JA 1 told him to never make rude comments about his mother. JA 1 stated he made no threatening gestures towards Resident 34. The Employee counseling form indicates the Administrator gave JA 1 a copy of the Resident Bill of Rights. No notes of a follow-up with Random Resident 34 was found. During a group meeting on 8/6/14 at 3 PM, Random Resident 34 stated he brought up an incident against a night time janitor (JA 1) to the Administrator which happened a month ago in the dining room but the Administrator did not do anything about it. Resident 34 stated, JA 1 said to him he can't take it anymore and made an action to hit him. Resident 34 stated Resident 28 was in the dining room at that time. Resident 28 nodded her head affirmatively. During a interview with Resident 28 on 8/4/14 at 2:20 PM, she stated, " (JA 1) was angry, loud, What you say about my mama? I thought they were going to duke it out. (JA 1) raised his fist at (Resident 34), we were in the dining room and wanted to play poker, the light was shining on the table and (Resident 28) asked (JA 1) to close the blinds. I told the DON (Director of Nursing) and Administrator. No one asked us anything about it, they just tell us to shut-up. There is so much violence and abuse in this place." During a interview with JA 1 on 8/6/14 at 11:20 PM, he stated, "After asking me to close the blind, I said in a minute and (Resident 28) let out a bunch of vulgarities in Spanish. I said excuse me, I wasn't sure I heard right. I stepped in and told him you leave my family out of this." He stated he did not have abuse training while employed at this facility. During a record review and concurrent interview with the DST on 8/6/14 at 3 PM, the employee file for JA 1 was reviewed. The DST was unable to find evidence of abuse training. There was no evidence in the employee record that JA 1 had been suspended during the abuse investigation or monitored following the allegation of abuse by Resident's 34 and 28. The facility policy and procedure titled "Elder Abuse Prevention", dated 3/1/14, indicated, "If an employee, they will be suspended from duty pending the outcome of the investigation... Periodic on-going in-services (on abuse) will be utilized. Monitoring By the Department head overseeing the employee will be used to confirm that undesirable behavior has abated. Direct observation of the employees conduct must occur for a period of thirty days. Random interviews with Residents will be conducted to determine no recurrence of behavior. These observations will be logged in the employee file." 4. During a review of the clinical record for Resident 16 and concurrent interview with LN 5 on 8/6/14 at 10 AM, a form, untitled, dated 2/10/14 was reviewed. LN 5 stated this is Physician 1's Progress note. The note indicated, "Pt (patient) states they beat me up last night they tie me into a chair." When asked what action she would take upon reviewing the note she stated, "I did not know she got beat up, I would have the CNA check her and put her by the desk to keep her busy." Upon further review of the record there was no documented evidence that staff had acted upon the Physician's Progress Note of 2/10/14. During a telephone interview with Physician 1 on 8/11/14 at 11 AM, he stated he was unaware this statement would be considered an allegation of abuse and was not aware if an investigation was done by the facility. The allegation of abuse was not reported by Physician 1. During an interview with the facility DCS on 8/7/14 at 11:30 AM, after she had been made aware of the abuse allegations, she stated, a sweep of 40 alert residents had been conducted and 20 of the residents questioned had new allegations of abuse. During an interview with Resident 34, on 8/6/14, at 9:50 AM, he stated an incident had happened at the Dining Room while he was playing poker with Resident 28, and Resident 29. Resident 34 had been calling for JA 1 who was also at the dining room area to ask for help closing the shelves. After calling several times, JA 1 closed the shelves and corrected Resident 34 on how to pronounce his name correctly. Resident 34 told JA 1 to go away then JA 1 made a motion to hit the resident with his closed fist. Resident 34 stated he felt scared because he would not have been able to do anything. He stated JA 1 worked almost everyday and he would ask another person to tell him what help he needed. Resident 34 also stated he had reported the incident to the Administrator approximately two days after the incident. The Administrator had replied to the resident "Because you can't say please", and the resident stated he left the Administrator's office and stated "Ok I'm sorry". The resident stated there was no investigation after this report. The resident stated he also spoke with the Laundry-Housekeeping Supervisor and she replied to him "I can't do nothing." He also reported the incident to the DON and notified her that the matter had already been reported to the Administrator. The resident stated there was no investigation that was done after this report. When asked, Resident 34 stated JA 1 had started speaking to him again but he still felt uncomfortable. The resident would still ask another person to notify JA 1 if he needed any help.

Based on interview and record review the facility: 1. Failed to develop and implement written policies and procedures that prohibit abuse of residents according to State and Federal regulations. 2. Failed to implement policy and procedure for the training of abuse prevention when six out of six staff interviewed were unable to identify abuse reporting timelines. These failures had exposed its residents to further situations of abuse. Findings: 1. During a record review and concurrent interview with the Administrator on 8/6/14 at 3 PM, the Administrator was asked to provide written evidence of how the facility handled cases of alleged abuse. Three allegations of abuse were requested for review. The Administrative folder for allegation number 1 indicated that Resident 38 had made an allegation of physical and verbal abuse on 7/25/14. The SOC 341 (report of an allegation of adult/elder abuse) had been faxed to the Ombudsmen on 7/28/14 three days after the event was reported. The Administrator stated that the report was not sent to the Department of Health Services (DHS) as required. He further stated he did not send a final investigative report of the allegation of abuse within 5 days to DHS as required. He stated he was not aware of the requirement. Certified Nursing Assistant (CNA) 3 and Licensed Nurse (LN) 9 were not suspended or monitored to keep the resident safe from further abuse by the alleged abuser. The Administrative folder for allegation number 2 indicated Resident 22 reported an incident of sexual abuse on 4/16/14 at 6:30 PM. The investigative report by the Administrator indicated in part, "after returning from a Good Friday Easter Service, I documented the investigation from home. No DHS fax number on hand. 4/19/14 report made to DHS, (three days after the incident was reported by Resident 22 to facility Administration) The administrative folder did not contain a SOC 341 (report of an allegation of adult/elder abuse) indicating who had been notified, including the Ombudsmen. There was no evidence that the Ombudsmen or resident's responsible party had been notified. The CNA's employee file showed no evidence of suspension or monitoring. The Administrative folder for allegation number 3, indicated that Resident 34 had a complaint of verbal abuse that he addressed with the Administrator on 6/9/14. The Quality Improvement Interview and Observation form dated 6/9/14 indicated, " ... the janitor rushed over to him after he finished what he was doing and said, "I was trying to finish something SIR in a irritated tone. He said he was startled the janitor rushed over to him." The Administrator stated he had not reported the allegation to DHS, the Ombudsmen or the resident's responsible party and had not suspended the alleged abuser. During a group meeting on 8/6/14 at 3 PM, Resident 34 stated he brought up an incident against a night time janitor (JA 1) to the Administrator which happened a month ago in the dining room but the Administrator did not do anything about it. Resident 34 stated, JA 1 said to him he can't take it anymore and made an action to hit him. The MDS (minimum data set) indicated Resident 34 had a BIMS score of 15, (indicates resident's cognitive status) indicating Resident 34 was cognitively intact. During a record review and concurrent interview with the Director Staff Training/Infection Control (DST/IC) on 8/6/14 at 3 PM, the employee file's for CNA 3, LN 9 were reviewed. The DST/IC was unable to find evidence of abuse training and was unable to provide evidence of pre-employment screening including reference checks and a criminal record check. There was no evidence in the employee file that CNA 3 and LN 9 had been suspended during the investigation of the abuse allegation. Three other personnel records were reviewed, no evidence of abuse training was found in all five records reviewed. During a record review and concurrent interview with the Administrator on 8/6/14 at 3 PM, the Administrator was asked to provide written evidence of how the facility handled cases of alleged abuse. Three allegations of abuse were requested for review. The Administrator was unable to provide a log or record indicating the allegations he had investigated, however he supplied two records of abuse and the Director of Nursing (DON) supplied the third. He stated he was not aware that injuries of unknown origin were to be reported as allegations of potential abuse to DHS. The Administrator stated he had not suspended CNA 3, LN 6 and JA 1 when allegations of physical and verbal abuse were made to him. The Administrator stated the reports of allegations of abuse were not sent to the DHS as required. He further stated that he does not send a final investigative report of the allegation of abuse within 5 days to DHS as required. The facility policy and procedure titled "Resident Abuse Prohibition and Investigation", dated 3/1/14, indicated, "In the event an accused individual is an employee, they will be re-assigned or suspended pending the outcome of the investigation... The resident shall be strongly advised to speak to no one regarding this investigation process. The facility policy and procedure titled, "Abuse Prevention: Staff training and Orientation", dated 3/1/14, indicated, "Periodic on-going in-service training and discussion by DST/IC. Formal Employee reviews will be utilized. One on One training will be provided by the Department Heads. This training will be in response to an observed short-coming of the employee, in response to a specific complaint from the resident...." "Monitoring By the Department head overseeing the employee will be used to confirm that undesirable behavior has abated. Direct observation of the employees conduct must occur for a period of thirty days. Random interviews with Residents will be conducted to determine no recurrence of behavior. These observations will be logged in the employee file." During a record review and concurrent interview with the DST/IC on 8/6/14 at 3 PM, the employee file for CNA 3 was reviewed. The DST/IC was unable to find evidence of abuse training and was unable to provide evidence of pre-employment screening including reference checks and criminal record check. The Employee file indicated CNA 3 had three previous corrective action reports for complaints made by residents. The file also contained a report dated 9/19/02, from an ambulance company stating that a resident had told him CNA 3 was "rude, impatient and a bully." The file contained no report of disciplinary actions for these reports. The facility DST/IC was unable to provide evidence of monitoring for CNA 3 after the allegation of abuse. The file contained no evidence that CNA 3 had been suspended. The Employee Counseling Report, undated, indicated, "(Resident 38) reports that CNA 3 stated she hates her and slapped her hand. Under the section titled previous counseling/ corrective action, "None." Under the section titled Expected level of performance, " (2) not to say to resident that you hate resident (3) not to touch or hit resident." 2. During an interview with CNA 1, on 8/6/14, at 1 AM, she stated that as a witness of an abuse situation resulting in serious injury, reporting of the incident can be made within 24 hours. She also stated she was not aware of the written report form to send to the Ombudsman. During an interview with CNA 2, on 8/6/14, at 1:16 AM, she stated she had 24 hours to report serious injury related to a witnessed incident of abuse. During an interview with LN 2, on 8/6/14, at 1:36 AM, she stated serious injury related to resident abuse can be made to proper authorities within 24 hours. LN 2 also stated she would only fill out the facility's incident report to give to the Director of Nursing. During an interview with CNA 4, on 8/6/14, at 10:06 AM, she stated that if she had witnessed an incident of abuse, she would fill out an incident form provided by the charge nurse. No other information was provided. During an interview with the Assistant Director of Nursing (ADON), on 8/6/14, at 10:27 AM, she stated with incidents of abuse, the facility would only call the Ombudsman's office and would not fill out a written report. During an interview with CNA 3, on 8/6/14, at 4:11 PM, she stated as a witness to an incident of abuse, she would only report to the charge nurse who would report to the Administrator. She stated she would only be available for any questions they might have. No other information was provided. During an interview on 8/6/14 at 4:45 PM, LN 7 was asked how she monitored staff for burnout and asked "What would you do if you noticed a staff member being angry towards a resident?" LN 7 stated "I would tell them to take a break, relax, and get some fresh air. "She was asked, "What if it happened everyday?" LN 7 stated, "Once in a while is okay, but not everyday." The "Assembly Bill No. 40- Elder and dependent adult abuse: reporting", approved by the Governor on 9/27/12, indicated mandated reporters were required to report known or suspected instances of elder or dependent adult abuse to the local ombudsman or the local law enforcement agency if the abuse occurred in a long-term care facility. Failure to report physical abuse and financial abuse of an elder or dependent adult under the act is a misdemeanor. It also indicated a suspected abuse that resulted in serious bodily injury required a mandated reporter that a written report be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 2 hours of the reporter observing, obtaining knowledge of, or suspecting the physical abuse.