Every finding on record at Los Feliz Healthcare & Wellness Center, LP

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received proper clinical management of an indwelling (a tube or device left inside the body) Foley catheter (a sterile, flexible tube inserted through the urethra [the thin, muscular tube that carries urine from the bladder out of the body] directly into the bladder [an organ that stores the urine] to continuously drain urine.The facility failed to:Monitor and document Resident 1's intake and output (I&O - the official record to measure and document the exact amount of fluids a resident consumes versus the amount they eliminate over a 24-hour period) for 30 days.Notify the physician on 7/3/2026, 7/9/2026, and 7/31/2026 when Licensed Vocational Nurse 2 (LVN 2) and LVN 4 had documented positive signs and symptoms (signs and symptoms of infection, nothing cloudiness, color, a sediment, blood, odor, and amount of urine output) in Resident 1's Treatment Administration Record (TAR - a legal document used by nurses to track, verify, and log all medical treatments given to a resident that are not oral or injectable medications).These failures have the potential to result in delayed identification and treatment of urinary tract infections, avoidable complications related to the indwelling Foley catheter, deterioration in the resident's condition, and increased risk for hospitalization.Findings:During a review of Resident 1's Face Sheet (FS - a one page chart summary containing a resident's vital demographic, contact, insurance, and medical data), the FS indicated the facility initially admitted Resident 1 on 9/29/2025, and readmitted on [DATE], with diagnoses that included malignant neoplasm (cancer-abnormal cell growth) of the prostate (a reproductive male gland [an organ that creates and releases substances]), functional quadriplegia (a person is completely unable to move their arms and legs), other neuromuscular dysfunction of bladder (a bladder [an organ that holds the urine] control problem), and infection and inflammatory reaction due to indwelling urethral catheter (Foley catheter - a flexible, sterile tube inserted through the urethra and directly into the bladder to continuously drain urine into a collecting bag).During a review of Resident 1's physician's telephone order, dated 12/29/2025, the telephone order's Order Summary indicated treatment foley catheter 16 French (Fr - a unit of measurement) with 10 cubic centimeter (cc - a unit of measurement) [NAME] (a small, inflatable rubber located near the tip of an indwelling Foley catheter that anchors the tube safely inside the bladder) via gravity drainage for neurogenic bladder (a loss of bladder control).During a review of Resident 1's Clinical Admission, dated 12/29/2025, the Clinical admission indicated Resident 1 was readmitted to the facility with a patent (tube is open or unblocked) 16 Fr Foley catheter.During a review of Resident 1's Care Plan Report (CP) for Bowel (gut) and Bladder, initiated on 12/14/2025, the CP indicated foley status and that Resident 1 was at risk for development of urinary tract infection (UTI - an infection in any part of the urinary system). The Interventions indicated monitor for signs and symptoms of UTI and notify Medical Doctor (MD) of any unusual observation.During a review of Resident 1's CP for Foley Catheter/Indwelling Suprapubic Catheter, initiated on 12/14/2025, the CP indicated the following interventions:1. Monitor urine for sediments (the solid bits, like tiny cells, crystals, or germs that settle at the bottom of the urine), cloudy, odor (smell), blood, and amount.2. Report any of the above (sediments, cloudy, odor, blood and amount) or fever promptly to the Medical Doctor (MD). 3. Monitor/record/report to MD signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, .During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/6/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 had an indwelling urinary catheter.During a review of Resident 1's Progress Note (Physician), dated 7/7/2026, the Progress Note indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's TAR, dated 7/1/2026 to 7/31/2026, the TAR indicated for the treatment to monitor urinary drainage for signs and symptoms of infection, nothing cloudiness, color, a sediment, blood, odor and amount of urine output, LVN 2 and LVN 4 documented plus sign which indicated Resident 1 had positive signs and symptoms of infection on 7/3/2026, 7/9/2026, and 7/31/2026 at night shift (11 p.m. to 7 a.m.).During a review of Resident 1's Order Recapitulation Report (ORR - a comprehensive list of all active physician orders for a resident), for the active orders as of 8/1/2026 to 8/31/2026, the ORR indicated the following physician orders:Foley catheter 16 Fr with 10 cc balloon via gravity drainage for neurogenic bladder with an order date of 12/29/2025.Monitor urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine output every shift with an order date of 12/29/2025.During a review of Resident 1's Progress Notes, dated 7/3/2026 to 8/1/2026, the Progress Notes indicated no documented evidence of physician notification about Resident 1 was experiencing positive signs and symptoms (infection, nothing cloudiness, color, a sediment, blood, odor and amount of urine output) of infection on 7/3/2206, 7/9/2026, and 7/31/2026.During a review of Resident 1's Situation Background Assessment Recommendation (SBAR - technique that provides a framework for communication between members of the health care team about a resident's condition) Communication Form, dated 8/6/2026, the SBAR Communication Form indicated Foley catheter noted with no urine output. The SBAR Communication Form indicated two nurses attempted Foley catheter removal after balloon was deflated and encountered resistance. The SBAR Communication Form indicated Registered Nurse (RN) was notified, RN assessed catheter and attempted removal of the Foley catheter, but resistance persisted. The SBAR Communication Form indicated that the physician was notified on 8/6/2026, at 11:04 p.m. and ordered to transfer Resident 1 to GACH for further evaluation and treatment.During a review of Resident 1's ORR, for the active orders as of 8/7/2026, the ORR indicated to transfer Resident 1 to emergency room (a specialized section of a hospital designed to provide immediate, around-the-clock medical care to patients) for evaluation due to mild bleeding on Foley catheter and not being able to remove the Foley catheter after deflating the balloon (let the air out) with an order date of 8/6/2026.During a review of Resident 1's GACH 1 Computed Tomography (CT - a medical imaging test that uses combination of X-rays [a test that captures images of the structures inside the body] and computer technology to create highly detailed pictures of the body/organ) scan of the abdomen and pelvis (bony structure inside hips and buttocks, base of the spine), dated 8/7/2026, the CT scan indicated moderately distended urinary bladder that contains an air fluid level and malpositioned (wrong position) Foley catheter.During a review of Resident 1's GACH 1 Emergency Documentation (ED notes), dated 8/7/2026, at 9:50 a.m., the ED notes indicated Resident 1 was initially sent to GACH 1 due to Foley catheter not draining urine and Skilled Nursing Facility (SNF) staff were unable to pull Foley catheter out. The ED notes indicated the Foley was crusted over (solid mineral [a hard, rock-like buildup that forms when natural minerals dissolved in a urine clump together] deposits, bacteria, and crystalized waste products [natural waste products and minerals found in urine that have transformed from a dissolved liquid into solid, sharp, sand-like crystals] have formed a hard, crusty, and gritty layer on the surfaces of the catheter tube, which can block the urine flow) and appeared to have been in place for months. The ED notes indicated multiple attempts were made to extract (remove) the Foley overnight but were unsuccessful. The ED notes indicated CT scan of the abdomen and pelvis indicated Foley was not in the bladder with moderate bladder dilatation (the stretching, or enlarging of a body opening, or hollow organ). The ED notes indicated when Foley catheter was removed, it was completely crystalized (mineral deposits have built up on the device) within the lumen (internal channels or pathways running inside a flexible medical tube) which is likely the etiology (cause) for the obstruction (blockage). The ED notes indicated the Foley catheter seemingly been in place for exceedingly long time.During a review of Resident 1's GACH 1's urinalysis (a medical test that checks a sample of urine [pee]), dated 8/7/2026, collected at 2:48 p.m., the urinalysis test indicated Resident 1 had cloudy urine positive for blood (the lab found red blood cells [blood cell] in the urine sample), for protein (it means kidneys [an organ that filters blood] are letting protein leak into the urine) and for nitrite (indicates bacterial infection), the urine white blood cell count (white blood cells [WBC - primary cells of the body's immune system] present in the urine) was more than 100 (indicates that person has a high level of inflammation or a significant infection in the urinary tract) per high power filed (HPF - per one single zoomed - in view under a microscope, normal value 0-5 per HPF), and urine had many bacteria.During a review of Resident 1's GACH 1 History and Physical (H&P), dated 8/7/2026, at 9:40 p.m., the H&P indicated Resident 1 was [NAME] in from nursing home due to change in condition, nonfunctioning Foley, poor output, as well as septicemia (a severe, life-threatening bloodstream infection that occurs when bacteria from a localized infection enter the blood and rapidly spread throughout the body) signs and symptoms. The GACH 1's Physical Examination indicated Foley was draining cloudy urine and signs of infection present.During an interview on 8/14/2026, at 10:12 a.m., with LVN 3, LVN 3 stated the facility only change Foley catheter as needed if clogged or leaked. LVN 3 stated the Treatment Nurses (TN - a specialized licensed nurse who focuses primarily on managing wounds and specialized medical treatments) provide Foley catheter care and the Certified Nursing Assistants (CNAs) empty the urinary bag. LVN 3 stated they (nurses) check the urine output, but they do not document. LVN 3 stated Resident 1 had prostate cancer and neurogenic bladder.During a concurrent interview, and record review on 8/14/2026, at 10:53 a.m. with RN 2, Resident 1's CP, dated 12/14/2025, for at risk for development of UTI was reviewed. The CP indicated to monitor urine for sediments, cloudy, odor, blood, and amount. RN 2 stated Resident 1 had 16 Fr Foley catheter with 10 cc balloon. RN 2 stated the nurses check the urine for signs and symptoms of infection like cloudy urine. RN 2 stated the facility has a bladder scanner (a small, painless machine that uses safe sound waves to measure how much urine is in the bladder) if the resident complained of distention and had low urine output. RN 2 stated urine output should have been documented as indicated in the care plan to monitor how much Resident 1's urine output was and to notify the physician if urine output was low.During an interview on 8/14/2026, at 11:14 a.m., with TN 1, TN 1 stated she (TN 1) was not sure when Resident 1's Foley catheter was inserted and when the last time it was changed. TN 1 stated she (TN 1) does not measure the urine output per shift. TN 1 stated the CNA empties the urinary bag and communicates to her (TN 1) if urine output for the shift is below 250 cc.During a concurrent interview and record review on 8/14/2026, at 11:42 a.m. with the Assistant Director of Nursing (ADON), Resident 1's TAR, dated 7/2026, was reviewed. The TAR indicated treatment to monitor urinary drainage for signs and symptoms of infection, nothing cloudiness, color, a sediment, blood, odor, and amount of urine output. The ADON stated that there was no documentation for urine output, whether it was adequate or not.During an interview on 8/14/2026, at 11:55 a.m. with the ADON, the ADON stated that there was no documented urine output monitoring for the first 30 days after Resident 1's readmission on [DATE]. ADON stated the facility failed to document urine output monitoring.During a concurrent interview, and record review on 8/14/2026, at 12:55 p.m., with the Minimum Data Set Nurse (MDSN), Resident 1's TAR, dated 7/2026, and the facility's policy and procedure (P&P) titled, Intake and Output Recording, revised on 1/1/2012, and last reviewed on 7/29/2026, were reviewed. The TAR indicated on 7/3/2026, 7/9/2026, and 7/31/2026, at night shift (11 a.m. to 7 a.m.), Resident 1 had positive signs of infection. The P&P indicated The licensed nurse is responsible for notifying the Attending Physician (AP) of abnormalities such as: . a. no output for four to eight hours. b. complaints of bladder discomfort and/or output falls outside of physician parameter. The MDSN stated that LVN 2 and LVN 4 documented positive urinary signs of infection. The MDSN stated that LVN 2 and LVN 4 should have created an SBAR and notified the Physician. The MDSN stated that the policy for Intake and Output Recording was not followed.During an interview on 8/14/2026, at 1:15 p.m., with RN 3, RN 3 stated if Resident 1's TAR had documentation of positive signs of infection, LVN 2 and LVN 4 should have called and reported to the Physician and developed an SBAR. RN 3 stated that there were no documented SBAR for positive urinary signs of infection.During a concurrent interview and record review on 8/14/2026, at 1:35 p.m., with the DON, facility's P&P titled, Intake and Output Recording, revised on 1/1/2012, and last reviewed on 7/29/2026, and CNA's task dated 1/2026, were reviewed, The P&P indicated, Intake and output (I&O) of fluids is documented when indicated by an Attending Physician order or by Nursing per the resident's diagnosis and/or treatment. Nursing Staff will be responsible for completing the subtotal I&O Record at the end of each shift and recording it on the I&O Sheet. I&O recording may be instituted (started) per an Attending Physician's order or by a Licensed Nurse for any resident with the following: . D. Urinary catheter. I&O recording is required for patients with indwelling catheters. For such residents: i. The resident will be placed on I&O for 30 days, until the resident output has been deemed stable by a Licensed Nurse. ii. After 30 days, the resident must be reevaluated by the Licensed Nurse to determine further need for the recording of I&O. VI. I&O Recording. A. Properly date all I &O records. B. Record all per mouth fluids in the proper column as soon as possible to maintain accuracy. E. Use a urinal or measuring device to measure outputs from indwelling catheters to ensure accuracy. J. Information obtained from the I&O will be totaled daily and reviewed to ensure that resident's intake and output are sufficient to meet the resident's needs. VII. The Licensed Nurse conducts and documents a review of the I&O Record at least weekly to assess the resident's fluid status and determine if I&O recording is still required. VIII. I&O Recording may be discontinued if either of the criteria is met. A. After the Nursing assessment that indicates that residents are taking adequate intake and have adequate output, if I&O was instituted by Nursing Department. B. The Attending Physician deems the residents to be stable. The DON stated that the policy was not followed. The DON stated that there were no documented I&O for the first 30 days upon Resident 1's readmission on [DATE], with Foley. The DON stated that the CNA should have documented the urine output in Resident 1's electronic medical record under task. The DON stated that the CNA task did not include I&O documentation. The DON stated that the nurses should have documented a Foley catheter output monitoring at the end of every shift.During an interview on 8/14/2026, at 1:38 p.m. with the DON, the DON stated that there should be separate documentation of the urinary output which needs to be separated from monitoring for signs and symptoms of infection. The DON stated that if LVN 2 and LVN 4 had documented positive signs and symptoms of urinary infection, they should have created an SBAR and called the Physician for any new orders. The DON stated that LVN 2 and LVN 4 had documented signs of urinary infection but did not notify the physician which could lead to Resident 1's health decline and Resident 1 could develop infection if not treated timely.During a follow up interview on 8/14/2026, at 1:42 p.m. with the DON, the DON stated the facility failed to monitor and document Resident 1's intake and output for the first 30 days, failed to evaluate after 30 days if there is a need for recording of I&O, failed to develop an SBAR and notify the Physician on 7/3/2026, 7/9/2026, and 7/31/2026, when LVN 2 and LVN 4 had documented positive signs and symptoms of urinary infection.During a concurrent interview and record review on 8/14/2026, at 4 p.m., with the DON, facility's P&P, titled, Change of Condition, revised on 4/1/2015, and last reviewed on 7/29/2026, was reviewed. The P&P indicated, It is the responsibility of the person who observes the change to report the change to the Licensed Nurse.A Licensed Nurse will notify the resident's Attending Physician and legal representative or an appropriate family member when there is an: .C. A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications. The DON stated if nurses notice any change in condition with abnormal findings, the nurses should have done an SBAR, and monitoring could have been started and continued by the next shift. The DON stated the importance of creating SBAR was to monitor the residents. The DON stated if SBAR was not done, monitoring will not be done, and Physician will not be aware of the early signs of infection. The DON stated that Resident 1's infection will not be treated timely. The DON stated the importance of monitoring and documenting I&O was to observe if there is any possible change in condition and to find out if Resident 1 was tolerating fluids or retaining urine.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled resident (Resident 1) by not accurately documenting Resident 1's change in condition on 8/6/2026.This failure had the potential to cause confusion in care due to the medical records containing inaccurate documentation.Findings:During a review of Resident 1's Face sheet (admission record), the Face Sheet indicated the facility initially admitted Resident 1 on 9/29/2025 with diagnoses that included malignant neoplasm (cancer - abnormal cell growth/division) of the prostate (a male reproductive gland), functional quadriplegia (a person is completely unable to move their arms and legs), other neuromuscular dysfunction of bladder (a bladder [a hollow organ that holds urine] control problem), infection and inflammatory reaction due to indwelling (a tube or device left inside the body) urethral catheter (Foley catheter - a hollow tube inserted into the bladder to drain or collect urine).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/6/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 had a urinary catheter.During a review of Resident 1's Progress Note (Physician's), dated 7/7/2026, the Progress Note indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Situation Background Assessment Recommendation (SBAR - technique that provides a framework for communication between members of the health care team about a resident s condition) Communication Form, dated 8/6/2026, the SBAR Communication Form indicated clogged gastrostomy 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) and with mild serosanguinous (a thin, watery liquid mixed with a little bit of blood) bleeding noted at the G-tube stoma (opening)/tubing. The SBAR Communication Form's Appearance section indicated Foley catheter noted with no urine output. The SBAR Communication Form's Appearance section indicated two CNs (charge nurses) attempted Foley catheter removal but encountered resistance. The SBAR Communication Form's Appearance section indicated Medical Doctor (MD) notified with an order to transfer Resident 1 to the hospital for further evaluation/management.During a concurrent interview and record review on 8/14/2026, at 9:53 a.m. with the Assistance Director of Nursing (ADON), Resident 1's SBAR Communication Form, dated 8/6/2026, was reviewed. The SBAR indicated clogged G-tube. The ADON stated Resident 1 did not have G-tube. The ADON stated it was a wrong documentation.During an interview on 8/14/2026, at 10:12 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that Resident 1 did not have G-tube and was able to eat on his (Resident 1) own. During an interview on 8/14/2026, at 1:35 p.m., with the Director of Nursing (DON), the DON stated Resident 1's SBAR Communication Form, dated 8/6/2026, was inaccurate since Resident 1 did not G-tube.During a concurrent interview and record review on 8/14/2026, at 1:42 p.m., with the DON, the facility's policy and procedure, titled, Completion and Correction, dated 3/25/2026, was reviewed. The P&P indicated, Entries will be recorded in a timely manner and will be complete, legible, and accurate. Documentation will reflect medically relevant information concerning the Resident and will be documented in a professional manner. The DON stated the facility's P&P was not followed. The DON stated nurses should document accurately.During an interview on 8/14/2026, at 3:08 p.m., with LVN 1, LVN 1 stated Certified Nursing Assistant 1 (CNA 1) reported that Resident 1 had low urine output. LVN 1 initially stated that he (LVN 1) flushed the G-tube three times and had resistance but then confirmed that Resident 1 did not have a G-tube and that Resident 1's Foley catheter was clogged. LVN 1 stated he (LVN 1) completed and reviewed the SBAR. LVN 1 stated he (LVN 1) made a mistake in the SBAR instead of documenting clogged Foley he (LVN 1) had documented clogged G-tube.During an interview on 8/14/2026, at 4 p.m., with the DON, the DON stated accurate documentation reflects the condition of Resident 1. The DON stated that the importance of accurate documentation was to prevent confusion in care and for the accurate staff communication.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Residents 1) to address Resident 1's refusal to chemotherapy (a medical treatment that uses strong drugs to kill fast-growing cancer [abnormal cell growth/division] cells or stop them from splitting and making new cells).This failure had the potential for delays in the delivery of necessary care and services, and Resident 1's unmet needs.Findings:During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility initially admitted Resident 1 on 9/29/2025 with diagnoses that included malignant neoplasm (cancer) of the prostate (a male reproductive gland), functional quadriplegia (a person is completely unable to move their arms and legs), other neuromuscular dysfunction of bladder (a bladder [a hollow organ that holds urine] control problem), infection and inflammatory reaction due to indwelling (a tube or device left inside the body) urethral catheter (Foley catheter - a hollow tube inserted into the bladder to drain or collect urine).During a review of Resident 1's Progress Note (Physician's), dated 1/13/2026, the Progress Notes indicated oncology consultation follow up for possibility of chemotherapy treatment.During a review of Resident 1's Progress Note, dated 1/14/2026, timed at 9:36 a.m., the Progress Note indicated Resident 1 wished to cancel his (Resident 1) chemotherapy treatment.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/6/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 had a urinary catheter (Foley catheter).During a review of Resident 1's Progress Note (Physician's), dated 7/7/2026, the Progress Note indicated Resident 1 had the capacity to understand and make medical decisions.During an interview on 8/14/2026, at 1:25 p.m., with the Case Manager (CM), CM stated that Resident 1 had an oncologist's (a medical doctor who studies, finds, and treats cancer) appointment on 12/2025, and Resident 1 refused chemotherapy. The CM stated the care plan should have been developed for Resident 1's refusal of chemotherapy.During an interview on 8/14/2026, at 1:42 p.m., with the Director of Nursing (DON), the DON stated there was no care developed for Resident 1's refusal of chemotherapy.During a concurrent interview and record review on 8/14/2026, at 4 p.m., with the DON, facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 9/7/2023, and last reviewed on 7/29/2026, reviewed. The P&P indicated, The comprehensive care plan will be periodically reviewed and revised by Interdisciplinary Team (IDT - a coordinated group of experts from several different fields who work together) after each assessment which means after each MDS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times:i. Onset of new problems;ii. Change of condition;iii. In preparation for discharge;iv. To address changes in behavior and care; andv. Other times as appropriate or necessary.The DON stated the P&P was not followed because care plan was not developed for Resident 1's refusal of chemotherapy. The DON stated the importance of developing a care plan was to communicate to staff on how to care for the resident.

Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBP - a safety practice used in nursing homes where staff wear gowns and gloves during close-contact care to stop the spread of dangerous, hard-to-treat germs) were followed for one of six sampled residents (Resident 8) when on 8/3/2026 Resident 8 was receiving wound care.This deficient practice had the potential to result in contamination and spread of Multidrug Resistant Organisms (MDROs - germs, mostly bacteria, that resist many common types of antibiotics [a medication used to treat infections caused by the bacteria]).Findings:During a review of Resident 8's Face Sheet (FS - a summary document at the very front of a resident's medical chart), the FS indicated the facility admitted Resident 8 on 7/4/2026 and readmitted on [DATE] with diagnoses including encounter for orthopedic (a specialized medical treatment, rehabilitation, and support a resident receives after surgery or when treating a bone, joint, or muscle injury) aftercare following surgical amputation (the removal of a body part, like an arm, leg, hand, foot, toe, or finger), acquired absence of left foot, sepsis (a dangerous, extreme body reaction to an infection), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 8's History and Physical Examination (H&P - a comprehensive medical document that outlines resident's complete health background and current physical condition), dated 7/16/2026, the H&P indicated Resident 8 had the ability to make needs known but could not make medical decisions. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 7/21/2026, the MDS indicated Resident 8 rarely understood and was rarely understood. The MDS indicated Resident 8 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 8's Order Summary Report (OSR), for the active orders as of 8/3/2026, the OSR indicated:- Left above the knee amputation (AKA - a surgical removal of the portion of the leg above the knee) stump (a residual limb - the portion of a limb that remains after an amputation surgery) surgical incision: cleanse with normal saline (NS - a saltwater solution), pat dry, apply barrier skin preparation, then cover with abdominal pad foam bordered dressing (a highly absorbent wound dressing), every day and as needed for 30 days. The OSR indicated an order date of 7/16/2026.-Right sacrum pressure injury (a pressure sore located in the sacrum [the large, triangular bone at the base of spine, situated right between hips and just above the tailbone] area): cleanse with NS, pat dry, apply zinc oxide (a mineral-based topical compound used to protect, sooth, and heal irritated skin), then cover with bordered foam dressing every day and as needed for 30 days. The OSR indicated an order date of 7/21/2026.- Santyl (a prescription medical ointment used to clean and heal severe burns and deep skin sores [ulcers]) external ointment 250 units per gram (a unit of measurement), apply to left sacrum topically (applied directly to a specific spot on the outside of the body) as needed for pressure injury. The OSR indicated an order date of 7/21/2026.- Santyl, external ointment 250 Units/GM, apply to left sacrum topically as needed for left sacrum pressure injury: cleanse with NS, pat dry, apply Santyl ointment, calcium alginate (a natural, jelly-like substance made from brown seaweed) dressing, then cover with bordered foam dressing every day and as needed. The OSR indicated an order date of 7/21/2026.- Santyl, external ointment 250 Units/GM, apply to right lower leg, lateral, topically as needed for pressure injury (damage to the skin and the tissue underneath). The OSR indicated an order date of 7/21/2026.- Santyl, external ointment 250 Units/GM, apply to right lower leg, lateral, topically every day, for lower right leg lateral pressure injury: cleanse with NS, pat dry, apply Santyl ointment nickel thick foam boarder (a specialized foam padding), calcium alginate dressing then cover with abdominal pad and wrap with kerlix rolled gauze (a gauze wrapping) every day and as needed. The OSR indicated an order date of 7/21/2026.- Left posterior thigh (the back of the thigh) open blister (a skin injury when protective outer layer of the skin peels away, exposing the tissue underneath), reddened blanching: cleanse with NS, pat dry, apply xeroform gauze (a sterile dressing), then cover with bordered dressing every day and as needed for 30 days. The OSR indicated an order date of 7/29/2026.During a review of Resident 8's Care Plan Report (CP), initiated on 7/16/2026, the CP indicated Resident 8 was on EBP due to wounds on the left AKA stump site, right sacrum pressure injury, right lower leg lateral pressure injury. The CP interventions included implementing EBP to prevent the spread of infections for specific care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care of any skin opening requiring dressing. During an observation on 8/3/2026 at 10:54 a.m. outside of Resident 8's room, observed Registered Nurse (RN) 1 was wearing a gown in Resident 8's room. RN 1 called Certified Nursing Assistant (CNA) 1 for assistance. Observed CNA 1 entered Resident 8's room after using alcohol-based hand rub (ABHR - a liquid, gel, or foam containing alcohol that used for hands to kill germs), applying gloves, and without donning (putting on clothes, shoes, or safety gear) a gown (a protective isolation gown that staff must wear when performing EBP). During an interview on 8/3/2026 at 10:58 a.m. with RN 1, RN 1 sated CNA 1 assisted RN 1 with Resident 8's wound care. RN 1 stated CNA 1 was not wearing a gown but should have been wearing a gown because they were doing wound care. RN 1 stated that based on the facility's policy, CNA 1 should have been wearing a gown and that there was a potential for cross contamination. During an interview on 8/3/2026 at 4:49 p.m. with the Director of Nursing (DON), the DON stated EBP used for residents with history of MDROs, gastrostomy tubes (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems), wounds, catheters (a thin, flexible tube used in medicine to put fluids into the body or take fluids out). The DON stated EBP is used to stop the spread of MDROs and to protect other residents from getting MDROs. The DON stated for the tasks with direct and close contact, they must wear gowns and gloves. The DON stated for Resident 8 the wound care considered close contact and CNA 1 should have been wearing a gown. The DON stated if the staff is not wearing the gown, there might be cross contamination and concerns with infection control, especially with MDROs. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, last reviewed on 7/29/2026, the P&P indicated when transmission-based precautions are not appropriate and in addition to Standard Precautions, Enhanced Barrier Precautions will be used for novel or targeted multi-drug resistant organisms (MDROs) in the facility, based on the Centers for Disease Prevention & Control (CDC) guidance. The P&P indicated the purpose of the policy is to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. The Process indicated: 6. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of MDROs:a. dressingb. bathing/showeringc. transferringd. providing hygienee. changing linensf. changing briefs or assisting with toiletingg. device care or use: central line (a tube placed into a large vein), urinary catheter, feeding tube, tracheostomy (a surgically created opening in the neck that provides direct access to the airway)/ventilator (a machine that mechanically pumps oxygen-rich air into the lungs) h. Wound care: any skin opening requiring a dressingi. Per CDC, this generally includes residents with chronic wounds, and not those with only shorter-lasting wounds, such as skin breaks, or skin tears covered with band-aids or similar dressing.ii. examples of chronic wounds include but not limited to:1. Pressure ulcers, diabetic foot ulcers, and chronic venous stasis ulcers. 7. Enhanced barrier precautions: required Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) gloves and gown prior to the high contact care activity.

Based on observation, interview, and record review, the facility failed to maintain privacy of confidential information when Registered Nurse (RN) 1 left the electronic health record (EHR - a digital version of a patient's paper chart) open and unattended for one of six sampled residents (Resident 8).This deficient practice violated Resident 8's right to privacy and confidentiality of medical records.Findings:During a review of Resident 8's Face Sheet (FS - a summary document at the very front of a resident's medical chart), the FS indicated the facility admitted Resident 8 on 7/4/2026 and readmitted on [DATE] with diagnoses including encounter for orthopedic (a specialized medical treatment, rehabilitation, and support a resident receives after surgery or when treating a bone, joint, or muscle injury) aftercare following surgical amputation (the removal of a body part, like an arm, leg, hand, foot, toe, or finger), acquired absence of left foot, sepsis (a dangerous, extreme body reaction to an infection), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 8's History and Physical Examination (H&P - a comprehensive medical document that outlines resident's complete health background and current physical condition), dated 7/16/2026, the H&P indicated Resident 8 had the ability to make needs known but could not make medical decisions. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 7/21/2026, the MDS indicated Resident 8 rarely understood and was rarely understood. The MDS indicated Resident 8 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During an observation on 8/3/2026 at 10:46 a.m. outside of Resident 8's room, observed Resident 8's computer with opened and unattended EHR on top of the treatment cart in the hallway. Observed RN 1 exited Resident 8's room and placed soiled gloves into the trash can on the treatment cart at 10:50 a.m., then RN 1 re-entered Resident 8's room while Resident 8's EHR was still open in the hallway. At 10:58 a.m., observed Resident 8's EHR signed off due to inactivity. During an interview on 8/3/2026 at 10:58 a.m. with RN 1, RN 1 stated EHR should be on standby or closed. RN 1 stated Resident 8's EHR was left open and unattended. RN 1 stated that when residents' EHR is open, the staff should monitor it. RN 1 stated he (RN 1) was not within eyesight of Resident 8's EHR and that he was behind the curtain. RN 1 stated that leaving EHR open and unmonitored can result in unauthorized individuals obtaining or accessing residents' confidential information from EHR. During an interview on 8/3/2026 at 4:49 p.m. with the Director of Nursing (DON), the DON stated that for EHR, staff must put the computer on privacy and/or close the computer screen when they are not directly in front of the computer. The DON stated RN 1 should have closed the computer. The DON stated that leaving the computer open and unattended can lead to authorized individuals accessing residents' records. The DON stated it is a Health Insurance Portability and Accountability Act (HIPAA - a federal law that keeps personal medical and health insurance information private and secure) violation.During a review of the facility's Policy and Procedure (P&P) titled, Electronic Protected Health Information Security, last reviewed on 7/29/2026, the P&P indicated computers or other electronic devices will be located in areas that limit access to residents and visitors. ii. When possible, monitors should face away from public view. During a review of the facility's P&P titled, Disclosure of PHI, last reviewed on 7/29/2026, the P&P indicated to limit the access, use the disclosure of Protective Health Information (PHI) to the minimum necessary needed to accomplish the intended purpose of the use, disclosure or request for PHI. The P&P indicated:ii. Medical records use and storage:Facility staff will keep medical records secure and confidential. b. Care should be taken to keep a medical record shielded and inaccessible to other residents or to the general public.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when Licensed Vocational Nurse (LVN) 1 did not wear personal protective equipment (PPE - a specialized clothing such as gown, gloves and other garments, designed to protect the wearer from spread of infection) in enhanced barrier precautions (EBP - infection control strategy requiring staff to use gowns and gloves during high-contact care for residents) room for one of two sampled residents (Resident 1) when taking blood pressure and applying lidocaine patch (a medicated adhesive strips applied directly to the skin to provide targeted pain relief). This failure had the potential to contaminate the care environment, increase risk of cross contamination, and place residents at risk for infection.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including spinal stenosis (the narrowing of the spaces within spine [backbone]), muscle weakness, and dysphagia (difficulty swallowing).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/6/2026, the MDS indicated Resident 1 had moderate cognitive skills (a person has noticeable changes in memory, thinking, or reasoning skills) for daily decision making and needed maximal assistance (helper does more than half the effort) for oral hygiene and toileting hygiene. During a review of Resident 1's Care Plan Report (CP) titled, Enhanced Barrier Precaution, initiated on 6/30/2026, the CP indicated a goal will reduce the risk of Multidrug - Resistant Organism (MDRO - a germ that has become resistant to many of the standard antibiotics commonly used to treat infections) transmission through the next review date. The CP interventions indicated, Implement EBP to prevent the spread of infections for specific care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. During a concurrent observation and interview on 7/16/2026 at 8:55 a.m., with LVN 1, observed EBP signage on Resident 1's door. LVN 1 entered Resident 1's room with blood pressure machine (a blood pressure monitor). LVN 1 applied the blood pressure cuff (a fabric sleeve that wraps around a person's upper arm to measure blood pressure) to Resident 1's left arm. LVN 1 brought two lidocaine patches, lifted Resident 1's shirt, and applied the patches to Resident 1's neck to treat pain. LVN 1 did not perform hand hygiene or put on the required PPE (gown) before proving direct resident care activities. LVN 1 stated he (LVN 1) did not wear PPE (gown) because he (LVN 1) did not notice the EBP sign posted outside Resident 1's room. LVN 1 stated that he (LVN 1) was unaware that Resident 1 required EBP. During an interview on 7/16/2026 at 11:47 a.m. with Assistant Director of Nursing (ADON), the ADON stated that staff are required to follow EB precautions for direct or high contact tasks with residents who have a EBP sign outside residents' door. ADON stated that staff must perform hand hygiene and don (put on) the appropriate gown and gloves before initiating high contact resident care activities, including obtaining Resident 1's blood pressure and applying lidocaine patch. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised 10/15/2024, the P&P indicated EBP will be used for novel or targeted MDROs in the facility. The P&P indicated the purpose of the policy is to reduce the risk of transmission of epidemiologically important microorganisms by direct and indirect contact. The P&P indicated for residents for whom the EBP are indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of MDRO. The P&P indicated gowns and gloves are to be donned before each high contact task, not prior to entering the room.

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled resident's (Resident 2) suprapubic urinary catheter (a hollow, flexible tube inserted directly into the bladder [an organ for the storage of urine] through a small incision in the lower abdomen, just above the pubic bone) was not kinked (the flexible drainage tube has become bent, twisted, or pinched) and urine was not backflowing during an observation on 7/15/2026 at 9:16 a.m.The deficient practices had the potential for Resident 1 developing urinary tract infection (UTI, a common infection that occurs when bacteria enter and multiplies in the urinary system).Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), neuromuscular disfunction of bladder (a condition where nerve damage disrupts the signals between brain and bladder), and quadriplegia (paralysis from the neck down, including legs and arms, usually due to a spinal cord injury). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 2 had moderate cognitive impairment (a person has noticeable changes in memory, thinking, or reasoning skills) and was dependent (helper does all of the efforts) for toileting hygiene, showers, lower body dressing, putting on/taking off footwear, and eating.During a review of Resident 2's History and Physical Examination (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 6/3/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report (OSR), active orders as of 7/16/2026, the OSR indicated an order for:- Indwelling (a medical device is left inside the body for the period of time for draining)/Super Pubic Catheter (an indwelling tube used to drain urine directly from the bladder through a small surgical opening in the abdomen), size 16 French (FR - a measuring unit) with balloon (the catheter has a small, inflatable bubble near the tip that holds the tube securely inside the bladder so it cannot slip out) 10 milliliters (ml - a metric unit to measure amount of liquid) via gravity drainage (a urine flows naturally downward out of the bladder and into the collecting bag by gravity) for muscular disfunction of bladder with an order date of 6/2/2026. - SP (Super Pubic) catheter care to be provided every shift with an order date of 6/2/2026.- Change urinary catheter drainage bag when SP catheter is changed as needed for leaking, contamination, occlusion, dislodgment or malfunction as needed with an order date of 6/2/2026.During a concurrent observation and interview on 7/15/2026 at 9:16 a.m. with Licensed Vocational Nurse (LVN) 2, inside Resident 2's room, observed Resident 2's suprapubic catheter tubing was kinked with yellow urine backflowing. LVN 2 stated that Resident 2's suprapubic catheter was kinked and was blocking the flow of the urine causing it to back up into the bladder. LVN 2 stated that it was important to ensure that Resident 2's suprapubic catheter was not kinked to prevent resident from getting a urinary tract infection. During an interview on 7/15/2026 at 1:28 p.m. with Treatment Nurse (TXT), TXT nurse stated that LVN 2 unkinked Resident 2's foley. TXT nurse stated that it was important to monitor Resident 2's suprapubic catheter to ensure that it was not kinked and was below the resident's bladder. During an interview on 7/16/2026 at 11:47 a.m. with Assistant Director of Nursing (ADON), the ADON stated that nursing staff are responsible for ensuring that the foley catheter remains unkinked and positioned below the resident's bladder to reduce infection risk. During a review of the facility's policy and procedure (P&P) titled, Suprapubic Catheter Re-insertion and Management, revised 1/30/2026, the P&P indicated:Nursing staff shall monitor for and promptly report:a. Signs of infectionb. Leakage around the insertion site c. Decrease or absent urine outputd. Blood in urinee. Catheter blockage or dislodgement.

Based on observation, interview and record review, the facility failed to remove the intravenous (IV-a thin, flexible tube inserted into a vein, usually in the back of the hand, the lower part of the arm, or the foot to draw blood or give fluids) catheter for one of three sampled residents (Resident 2) after Resident 2 completed the IV antibiotic (medication used to treat infection) on 5/21/2026.This deficient practice had the potential to cause infection and discomfort to Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/14/2025, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and essential hypertension (HTN- high blood pressure).During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 2/14/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Physician Order, dated 5/18/2026, the Physician Order indicated ceftriaxone sodium (medication used to treat infection) solution one gram IV in the morning for back abscess (a painful, swollen lump filled with pus [collection of germs, dead tissue, and white blood cells that rushed to the area to battle the germs]) for three days.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 6/5/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's IV Administration Record (IVAR- flowsheet that indicates IV medications given to a resident), dated 5/2026, the MAR indicated Registered Nurse 1 (RN 1) administered the first and second dose of ceftriaxone on 5/19/2026, and 5/20/2026. The MAR indicated RN 2 administered the third and last dose on 5/21/2026.During an observation on 6/12/2026, at 8:40 a.m., at Resident 2's bedside, gauze 24 (a very thin, small-diameter needle) IV noted and dated 5/19/2026.During a concurrent observation and interview on 6/12/2026, at 9 a.m., with Licensed Vocational Nurse 1 (LVN1) at Resident 2's bedside, Resident 2's IV site dated 5/19/2026. LVN 1 stated IV should be changed every three days.During an interview on 6/12/2026, at 9:11 a.m., with the Assistant Director of Nursing (ADON), the ADON stated IV should be changed every 72 hours to prevent infection in the blood. The ADON stated the last time IV was used was on 5/21/2026. The ADON stated RN should be changing the IV every 72 hours. The ADON stated there was no physician order to continue the IV.During an interview on 6/16/2026, at 8:17 a.m., with the Director of Nursing (DON), the DON stated the night RN should have removed the IV after the last dose of antibiotic on 5/21/2026. The DON stated infection could result if IV was left for too long.During a review of facility's policy and procedure (P&P) titled, Infusion Guidelines and Procedures, undated, and last reviewed on 5/23/2025, the P&P indicated, 8. Peripheral Infusion devices shall be removed routinely every 72 hours. Residents with limited peripheral venous access may be maintained at longer intervals with a physician's order.25. Label the dressing with the date and time the site was inserted, the gauge and length of the catheter inserted, and the initials of the inserting nurse.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one person towards another) and verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) for one of four sampled residents (Resident 1) when:1. On 5/22/2026, around 8:30 p.m., Resident 1, who was in the Facility Recreational Room, was approached by Visitor (VS) 1 who used verbal profanities towards Resident 1. VS 1 and Resident 1 continued to both use verbal profanity and derogatory slur towards each other as they walked down the hallway toward Resident 1's room, VS 1 was in front of Resident 1 and turned around and spat (the intentional, aggressive act of ejecting saliva, phlegm, or other mouth contents directly at another person) at Resident 1's face. After RN 1 witnessed the verbal altercation between Resident 1 and VS1, RN 1 stated she (RN1) did not ask VS 1 to leave the facility and VS 1 left when she was done the visitation with Resident 4. RN 1 stated she did not see when VS 1 left the facility.2.On 5/22/2026, around 8:30 p.m. after Resident 1 and VS 1 had both a physical and verbal altercation, the facility failed to follow it policy and procedures (P&P) titled, Visitation Rights, that indicated visitor who is subjected to abusing, exploiting or coercing a resident will be denied access or provided limited and supervised access to the resident until an investigation has cleared the visitor of all allegations.This deficient practice placed Resident 1 at risk of being subjected to continued physical abuse and verbal abuse.Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/26/2025 with diagnoses including abnormalities of gait and mobility, metabolic encephalopathy (a change in brain function caused by a chemical imbalance in the body, not a direct physical injury to the brain), and cognitive communication deficits (a difficulty with talking, listening, reading, or writing, caused by a problem with brain function rather than a physical speech issue).During a review of Resident 1's History and Physical Examination (H&P - a comprehensive medical evaluation conducted upon admission), dated 9/30/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 1 had the ability to understand and to be understood. The MDS indicated Resident 1 had intact cognitive function. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting, showering, upper and lower body dressing, putting on and taking off footwear, and with personal hygiene.During a review of Resident 1's Change in Condition (COC) Evaluation, dated 5/22/2026 at 8:30 p.m., the COC Evaluation indicated verbal altercation towards other patient's power of attorney (POA - a legal document that grants a trusted person or the agent the legal authority to make critical decisions on behalf of person) with no injuries. The COC Evaluation's Summarize your observation, evaluation and recommendation section indicated Resident 1 reported verbal encounter with female resident's POA (VS 1), allegedly spit on his face, incident occurred in facility.During a review of Resident 1's Care Plan Report (CP), initiated on 5/22/2026, the CP's Focus indicated Resident 1 was at risk for emotional distress related to verbal altercation with another resident's family member; resident alleged that family spit on his face. The CP included interventions to assess Resident 1 for signs and symptoms of distress every shift and to encourage to express feelings and concerns.During a telephone interview on 6/1/2026 at 10:17 a.m. with Resident 1, Resident 1 stated about five months ago he (Resident 1) started having issues with VS 1. Resident 1 stated he (Resident 1) and Resident 4 are in a relationship but nothing physical. Resident 1 stated VS1 threatened him by saying that she (VS 1) will call to deport him (Resident 1) and by having her (VS 1) son beat up Resident 1. Resident 1 stated he was in constant fear. Resident 1 stated the facility's supervisors (unidentified staff) were aware of VS 1's threats and would just tell Resident 1 to go to his room. Resident 1 stated, on 5/22/2026, around 8 p.m., he (Resident 1) and Resident 4 were in the facility's activity room (Facility Recreational Room), sitting in the table across from each other, when VS 1 came in and began to yell at Resident 1 and Resident 4. Resident 1 stated VS 1 told that she did not want Resident 1 to speak to Resident 4. Resident 1 stated then he (Resident 1) left and walked towards his (Resident 1's) room and began to laugh because he (Resident 1) thought it was funny which made VS 1 madder. Resident 1 stated VS1 was also walking in the hallway when she (VS1) turned around and spat at Resident 1's face, covering his (Resident 1's) face and glasses with her (VS 1's) spit. Resident 1 stated VS 1 attempted to hit Resident 1 but Certified Nursing Assistant (CNA) 1 intervened and stopped VS 1 from hitting Resident 1. Resident 1 stated he (Resident 1) was then sent to his room, but he (Resident 1) went to the nurses' front desk and wanted to contact the local police department. Resident 1 stated he (Resident 1) called the police.b. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 12/30/2025 with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (generalized), and essential (primary) hypertension (HTN - high blood pressure).During a review of Resident 1's History and Physical (H&P - a comprehensive medical evaluation conducted upon admission), dated 12/31/2025, the H&P indicated Resident 4 was alert and oriented.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had the ability to understand and be understood. The MDS indicated Resident 4 had intact cognition. The MDS indicated Resident 4 required supervision or touching assistance with toileting/tub/shower transfers, sit to stand, and chair to bed transfers. During an interview on 6/1/2026 at 12 p.m. with Resident 4, Resident 4 stated that she (Resident 4) and Resident 1 are friends, they get along well, and that they spend time together in the patio and in activities. Resident 4 stated on 5/22/2026, around 8 p.m., she (Resident 4) and Resident 1 were in the activity room (Facility Recreational Room) when VS 1 came in and yelled at Resident 4 and Resident 1. Resident 4 stated VS 1 did not like Resident 4 and Resident 1 talking to each other. Resident 4 stated Resident 1 then left the activity room (Facility Recreational Room), and Resident 4 and VS 1 also left but VS 1 and Resident 1 were still arguing while Resident 1 was walking down the hallway back to his (Resident 1) room. Resident 4 stated she (Resident 4) was telling at VS 1 to stop and that was when VS 1 spat at Resident 4. Resident 4 stated she saw Resident 1 with spit on his glasses and face. Resident 4 stated she saw VS 1 attempt to push Resident 1 when CNA 1 intervened and stopped VS 1 from pushing Resident 1. Resident 4 stated VS1 was not asked to leave the facility and that she left on her (VS1) own terms, when she (VS1) was ready. Resident 4 stated the next day the Administrator (ADM) called VS1 and informed that VS 1 was not allowed to come to the facility anymore.During an interview on 6/1/2026 at 12:59 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she (LVN 1) worked on 5/22/2026 and when she (LVN1) had just come back from lunch around 8 to 8:30 p.m., Registered Nurse (RN) 1 called LVN 1 and informed LVN1 that there had been an incident with another resident's family member (VS 1). LVN 1 stated she witnessed Resident 1 and VS 1 by the Facility Recreational Room talking but they were speaking in Spanish. LVN 1 stated she did not understand what they (Resident 1 and VS 1) were talking about but Resident 1's and VS 1's tone was higher and argumentative. LVN 1 stated then RN 1 asked them (Resident 1 and VS 1) to go into the Facility Recreational Room. LVN 1 stated then RN 1 instructed her (LVN1) to return to her station.During an interview on 6/1/2026 at 1:55 p.m. with RN 1, RN 1 stated that on 5/22/2026, around 8:30 p.m., she (RN 1) was made aware of the incident because Resident 1 approached RN 1 and stated that there was a verbal altercation with VS 1 and that VS 1 spat at his (Resident 1's) face. RN 1 stated Resident 1 walked away, and RN 1 followed Resident 1 (Resident 1). RN 1 stated Resident 1 was walking towards the Facility Recreational Room where VS 1 met up with them. RN 1 stated Resident 1 and VS 1 then began to yell at each other, RN 1 tried to de-escalate the situation by having VS 1 and Resident 1 go into the Facility Recreational Room. RN 1 stated after speaking to VS 1, she (RN 1) went to speak to Resident 1 and Resident 1 informed him that he (Resident 1) already called the police. RN 1 stated she (RN 1) did not ask VS 1 to leave the facility and VS 1 left when she (VS 1) was done visiting with Resident 4. RN 1 was not sure when VS 1 left the facility and stated that she (RN1) did not see when she (VS1) left but knows VS1 left the facility.During a concurrent telephone interview on 6/1/2026 at 3:36 p.m. with Resident 1, Resident 1 stated the incident of verbal yelling and spitting was about 30 minutes. Resident 1 stated he (Resident 1) and Resident 4 were in the activity room (Facility Recreational Room) (Resident 1) when Resident 1 stand up and walked out of the activity room. Resident 1 stated VS 1 told Resident 4 to get up, and they (Resident 4 and VS 1) began to follow Resident 1 in the hallway. Resident 1 stated he (Resident 1) just laughed at VS 1 then in the hallway, near Resident 1's room, VS 1 kept yelling at Resident 1 when suddenly VS 1 turned around and spit on Resident 1's glasses and his entire face. Resident 1 stated he felt disabled because Resident 1 could not do anything since VS 1 was a woman. Resident 1 stated he (Resident 1) felt inferior to VS 1, he felt disrespected, he (Resident 1) felt awful because no one has ever spat at him. Resident 1 stated that after VS 1 spat at him (Resident 1), he cleaned his face with his hands, and it felt disgusting. Resident 1 stated that is when he went to speak to RN 1, informed RN 1 of the incident with VS 1, and asked for the police number. Resident 1 stated he is traumatized by this experience, and he feels like one day VS 1 would come and hurt him. Resident 1 stated the spitting was unhygienic and made him feel degraded and mistreated.During a telephone interview on 6/1/2026 at 4:15 p.m. with VS 1, VS 1 stated, on 5/22/2026, around 8 p.m., Resident 1 and Resident 4 were standing in the activity room (Facility Recreational Room). VS 1 stated Resident 1 started using vulgar language. VS 1 stated she (VS 1) did spit on Resident 1 and that she (VS 1) is not going to deny it. VS 1 stated she did threaten Resident 1 to call the immigration and called him (Resident 1) derogatory slur. VS 1 stated she (VS 1) knows she should have never done this, but she (VS 1) did spit at Resident 1. VS 1 stated she (VS 1) spit on Resident 1's face and told Resident 1 derogatory slur because she did not like the way Resident 1 was speaking to her. VS 1 stated the whole incident was about five minutes long. VS 1 stated they were in the hallway when she spit at Resident 1. VS 1 stated she was not asked to leave the facility after the incident and that VS 1 left the facility when she wanted.During an interview on 6/1/2026 at 4:33 p.m. with the Administrator (ADM), the ADM stated he is the abuse coordinator. The ADM stated that he (ADM) was aware of Resident 1 and VS 1 concerns and that VS 1 was not happy with a prior comment made by Resident 1. The ADM stated on 5/22/2026, he (ADM) was notified that there was a verbal disagreement between Resident 1 and VS 1 and that Resident 1 had called the police. The ADM stated the police informed him (ADM) that this may be considered a hate crime since VS 1 had verbalized calling Immigration and Customs Enforcement (ICE - is a federal law enforcement agency under the Department of Homeland Security) and made comments about Resident 1 that were derogatory slur. The ADM stated it was verbal abuse and both were cussing at each other. The ADM stated that VS 1 informed the ADM that she (VS 1) had threatened to call ICE on Resident 1. The ADM stated RN 1 spoke to Resident 1 and Resident 1 stated he felt threatened because VS 1 told Resident 1 she would get her brother to beat up Resident 1 and would also call ICE. The ADM stated VS 1 did tell him that she (VS 1) did in fact spit on Resident 1. The ADM stated for Resident 1 and VS 1 was verbal abuse, spitting is physical but ADM not sure because he (ADM) received different interviews. The ADM stated that when there are visitors and there is an allegation of abuse, the aggressor needs to be separated, should have gotten interview and monitored the visitor. The ADM stated the facility does not have the footage to show VS 1 was being monitored. The ADM stated not removing visitors after alleged abuse, can be a concern for escalating abuse and can put residents at risk for continued abuse.During a review of the facility provided P&P titled, Visitation Rights, revised on 4/29/2026, the P&P indicated the facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. The P&P's section IV. Temporary Limitation of Visitation Rights indicated:A.When the Facility has good cause to believe that a visitor has or is engaging in behavior that violates the Facility policy or places the health, safety or security of other residents at risk, the facility may temporarily restrict that individual from visiting the resident or take other measures consistent with state and federal law until the behavior in question ceases.C. A visitor who is subjected to abusing, exploiting or coercing a resident will deny access to providing limited and supervised access to the resident until an investigation has cleared the visitor of all allegations. If a visitor has been found to be abusing, exploiting or coercing a resident, they will be prohibited from visiting the resident.During a review of the facility P&P titled, Abuse, Prevention, Screening & Training Program, revised on 4/29/2026, the P&P indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops facility P&P, training programs, and screening and prevention systems to promote and environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.The P&P's Procedure indicated, Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint. Verbal abuse is defined as any use of oral, written, gestured communication, or sound that willfully includes disparaging and derogatory terms directed to residents within hearing distance, regardless of age, ability to comprehend, or disability. Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. The P&P's Prevention indicated:N. The facility ensures the health, safety and welfare of residents with regard to visitors.

Based on interview and record review, the facility failed to report a physical abuse incident (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA) no later than two hours for one of four sampled residents (Resident 1), as indicated in the facility's policy and procedure (P&P) titled, Reporting Abuse, when:On 5/22/2026, around 8:30 p.m., Resident 1, who was in the Facility Recreational Room, was approached by Visitor (VS) 1 who used verbal profanities towards Resident 1. VS 1 and Resident 1 continued to both use verbal profanity and derogatory slur towards each other as they walked down the hallway toward Resident 1's room, VS 1 was in front of Resident 1 and turned around and spat (the intentional, aggressive act of ejecting saliva, phlegm, or other mouth contents directly at another person) at Resident 1's face.This deficient practice had the potential to result in unidentified abuse and placed Resident 1 at risk for further abuse.Findings:a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/26/2025 with diagnoses including abnormalities of gait and mobility, metabolic encephalopathy (a change in brain function caused by a chemical imbalance in the body, not a direct physical injury to the brain), and cognitive communication deficits (a difficulty with talking, listening, reading, or writing, caused by a problem with brain function rather than a physical speech issue).During a review of Resident 1's History and Physical Examination (H&P - a comprehensive medical evaluation conducted upon admission), dated 9/30/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/2/2026, the MDS indicated Resident 1 had the ability to understand and to be understood. The MDS indicated Resident 1 had intact cognitive function. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting, showering, upper and lower body dressing, putting on and taking off footwear, and with personal hygiene.During a review of Resident 1's Change in Condition (COC) Evaluation, dated 5/22/2026 at 8:30 p.m., the COC Evaluation indicated verbal altercation towards other patient's power of attorney (POA - a legal document that grants a trusted person or the agent the legal authority to make critical decisions on behalf of person) with no injuries. The COC Evaluation's Summarize your observation, evaluation and recommendation section indicated Resident 1 reported verbal encounter with female resident's POA (VS 1), allegedly spit on his face, incident occurred in facility.During a review of Resident 1's Care Plan Report (CP), initiated on 5/22/2026, the CP's Focus indicated Resident 1 was at risk for emotional distress related to verbal altercation with another resident's family member; resident alleged that family spit on his face. The CP included interventions to assess Resident 1 for signs and symptoms of distress every shift and to encourage to express feelings and concerns.During a telephone interview on 6/1/2026 at 10:17 a.m. with Resident 1, Resident 1 stated about five months ago he (Resident 1) started having issues with VS 1. Resident 1 stated he (Resident 1) and Resident 4 are in a relationship but nothing physical. Resident 1 stated VS1 threatened him by saying that she (VS 1) will call to deport him (Resident 1) and by having her (VS 1) son beat up Resident 1. Resident 1 stated he was in constant fear. Resident 1 stated the facility's supervisors (unidentified staff) were aware of VS 1's threats and would just tell Resident 1 to go to his room. Resident 1 stated, on 5/22/2026, around 8 p.m., he (Resident 1) and Resident 4 were in the facility's activity room (Facility Recreational Room), sitting in the table across from each other, when VS 1 came in and began to yell at Resident 1 and Resident 4. Resident 1 stated VS 1 told that she did not want Resident 1 to speak to Resident 4. Resident 1 stated then he (Resident 1) left and walked towards his (Resident 1's) room and began to laugh because he (Resident 1) thought it was funny which made VS 1 madder. Resident 1 stated VS1 was also walking in the hallway when she (VS1) turned around and spat at Resident 1's face, covering his (Resident 1's) face and glasses with her (VS 1's) spit. Resident 1 stated VS 1 attempted to hit Resident 1 but Certified Nursing Assistant (CNA) 1 intervened and stopped VS 1 from hitting Resident 1. Resident 1 stated he (Resident 1) was then sent to his room, but he (Resident 1) went to the nurses' front desk and wanted to contact the local police department. Resident 1 stated he (Resident 1) called the police.b. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 12/30/2025 with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (generalized), and essential (primary) hypertension (HTN - high blood pressure).During a review of Resident 1's History and Physical (H&P - a comprehensive medical evaluation conducted upon admission), dated 12/31/2025, the H&P indicated Resident 4 was alert and oriented.During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had the ability to understand and be understood. The MDS indicated Resident 4 had intact cognition. The MDS indicated Resident 4 required supervision or touching assistance with toileting/tub/shower transfers, sit to stand, and chair to bed transfers.During an interview on 6/1/2026 at 12 p.m. with Resident 4, Resident 4 stated Resident 1 and she (Resident 4) are friends, they get along well, and that they spend time together in the patio and in activities. Resident 4 stated on 5/22/2026, around 8 p.m., she (Resident 4) and Resident 1 were in the activity room (Facility Recreational Room) when VS 1 came in and yelled at Resident 4 and Resident 1. Resident 4 stated VS 1 did not like Resident 4 and Resident 1 talking to each other. Resident 4 stated Resident 1 then left the activity room (Facility Recreational Room), and Resident 4 and VS 1 also left but VS 1 and Resident 1 were still arguing while Resident 1 was walking down the hallway back to his (Resident 1) room. Resident 4 stated she (Resident 4) was telling VS 1 to stop and that was when VS 1 spat at Resident 4. Resident 4 stated she saw Resident 1 with spit on his glasses and face. Resident 4 stated she saw VS 1 attempt to push Resident 1 when CNA 1 intervened and stopped VS 1 from pushing Resident 1. Resident 4 stated VS1 was not asked to leave the facility and that she left on her (VS1) own terms, when she (VS1) was ready. Resident 4 stated the next day the Administrator (ADM) called VS1 and informed that VS 1 was not allowed to come to the facility anymore.During an interview on 6/1/2026 at 3:18 p.m. with the Director of Staff Development (DSD), the DSD stated, on 5/22/2026, around 9 p.m. to 10 p.m., the Administrator (ADM) asked him (DSD) to help the police officers who arrived at the facility around 10 p.m. The DSD stated he (DSD) was the one who reported the alleged abuse to SSA. The DSD reviewed the fax confirmation and stated it was faxed to SSA on 5/23/2026 at 1:26 a.m. The DSD stated if there is no physical abuse, the facility must report within 24 hours and if there is physical abuse, the facility must report within two (2) hours. The DSD stated he (DSD) was not aware of the allegation of spitting when he submitted the report to SSA. The DSD stated he received all the information from the police and did not speak to Resident 1 and/or other staff involved in the investigation. The DSD stated spitting is considered physical and added that the incident with Resident 1 and VS 1 occurred at 8:30p.m. and it involved spitting. The DSD stated he was made aware of incident around 10 p.m., then the police were in the facility for about two hours. The DSD stated he would have educated the staff that if it was spitting and it was considered physical, it must be reported within two hours. During a concurrent telephone interview on 6/1/2026 at 3:36 p.m. with Resident 1, Resident 1 stated the incident of verbal yelling and spitting was about 30 minutes. Resident 1 stated he (Resident 1) and Resident 4 were in the activity room (Facility Recreational Room) he (Resident 1) when Resident 1 stand up and walked out of the activity room. Resident 1 stated VS 1 told Resident 4 to get up, and they (Resident 4 and VS 1) began to follow Resident 1 in the hallway. Resident 1 stated he (Resident 1) just laughed at VS 1 then in the hallway, near Resident 1's room, VS 1 kept yelling at Resident 1 when suddenly VS 1 turned around and spit on Resident 1's glasses and his entire face. Resident 1 stated he felt disabled because Resident 1 could not do anything since VS 1 was a woman. Resident 1 stated he (Resident 1) felt inferior to VS 1, he felt disrespected, he (Resident 1) felt awful because no one has ever spat at him. Resident 1 stated after VS 1 spat at him (Resident 1), he cleaned his face with his hands, and it felt disgusting. Resident 1 stated that's when he went to speak to RN 1, informed RN 1 of the incident with VS 1, and asked for the police number. Resident 1 stated he is traumatized by this experience, and he feels like one day VS 1 would come and hurt him. Resident 1 stated the spitting was unhygienic and made him feel degraded and mistreated.During an interview on 6/1/2026 at 4:15 p.m. with VS 1, VS 1 stated, on 5/22/2026, around 8 p.m., Resident 1 and Resident 4 were standing in the activity room (Facility Recreational Room). VS 1 stated Resident 1 started using vulgar language. VS 1 stated she (VS 1) did spit on Resident 1 and that she (VS 1) is not going to deny it. VS 1 stated she did threaten Resident 1 to call the immigration and called him (Resident 1) derogatory slur. VS 1 stated she (VS 1) knows she should have never done this, but she (VS 1) did spit at Resident 1. VS 1 stated she (VS 1) spit on Resident 1's face and told Resident 1 derogatory slur because she did not like the way Resident 1 was speaking to her. VS 1 stated the whole incident was about five minutes long. VS 1 stated they were in the hallway when she spit at Resident 1. VS 1 stated she was not asked to leave the facility after the incident and that VS 1 left the facility when she wanted. During an interview on 6/1/2026 at 4:33 p.m. with the Administrator (ADM), the ADM stated he is the abuse coordinator. The ADM stated ADM was aware Resident 1 and VS 1 concerns and that VS 1 she was not happy with a prior comment made by Resident 1. The ADM stated on 5/22/2026 he (ADM) was notified that there was a verbal disagreement between Resident 1 and VS 1 and that Resident 1 had called the police. The ADM stated the police informed him (ADM) that this may be considered a hate crime since VS 1 had verbalized calling Immigration and Customs Enforcement (ICE - is a federal law enforcement agency under the Department of Homeland Security) and made comments about Resident 1 that were derogatory slur. The ADM stated it was verbal abuse and both were cussing at each other. The ADM stated that VS 1 informed the ADM that she (VS 1) had threatened to call ICE on Resident 1. The ADM stated RN 1 spoke to Resident 1 and Resident 1 stated he felt threatened because VS 1 told Resident 1 she would get her brother to beat up Resident 1 and would also call ICE. The ADM stated VS 1 did tell him that she (VS 1) did in fact spit on Resident 1. The ADM stated for Resident 1 and VS 1 was verbal abuse, spitting is physical but ADM not sure because he (ADM) received different interviews. The ADM stated because it was only thought of as verbal abuse, he (ADM) thought he had 24 hours to report. The ADM stated physical abuse must be reported within two (2) hours. The ADM confirmed the abuse report was faxed to SSA on 5/23/2026 at 1:26 a.m. During a review of the facility's Transmission Verification Form, dated 5/23/2026, the Transmission Verification Form indicated the facility faxed the abuse report to SSA on 5/23/2026 at 1:26 a.m. During a review of the facility's P&P titled, Reporting Abuse, revised on 4/29/2026, the P&P indicated the purpose of the policy is to ensure compliance with federal and state laws and regulations regarding reporting of incidents and suspected incidents of abuse, neglect and mistreatment of residents. The P&P indicated the facility will report known or suspected instances of physical abuse to the proper authorities. The P&P indicated, in addition, a written report shall be made to SSA within two (2) hours of the observation, knowledge, or suspicion of the physical abuse. During a review of the facility P&P titled, Abuse, Prevention, Screening & Training Program, last revised on 4/29/2026, the P&P indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops facility P&P, training programs, and screening and prevention systems to promote and environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.The P&P's Procedure indicated, Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint. Verbal abuse is defined as any use of oral, written, gestured communication, or sound that willfully includes disparaging and derogatory terms directed to residents within hearing distance, regardless of age, ability to comprehend, or disability. Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. The P&P's Prevention indicated:N. The facility ensures the health, safety and welfare of residents with regard to visitors.

Based on interview and record review, the facility failed to implement its written abuse policy and procedures (P&P) titled, Abuse Prevention and Management, when one of three sampled residents (Resident 2) had an allegation of physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) on 3/31/2026 and the facility did not report this to the State Survey Agency (SSA) and did not conduct a thorough investigation. This failure had the potential to subject Resident 2 to further physical abuse. Cross-reference F609 and F610. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/8/2026 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting right side dominant side, dementia (a progressive state of decline in mental abilities), depression (feeling of sadness, emptiness, and loss of interest in activities). During a review of Resident 2's Minimum Data set (MDS - a resident assessment tool), dated 4/13/2026, the MDS indicated that Resident 2's cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. The MDS indicated that Resident 2 required maximal assistance (helper does more than half the effort) with oral hygiene, lower body dressing and personal hygiene. The MDS indicated that Resident 2 was dependent (helper does all of the effort) with toileting and showers. During a review of Resident 2's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 1/8/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During an interview on 5/14/2026 at 10:37 a.m. with Resident 2's Responsible Party (RP), the RP stated that he (RP) arrived around 7 a.m. on 3/31/2026 to visit Resident 2 during breakfast and observed a bruise and scratch on the right side of Resident 2's cheek. The RP stated that he had visited Resident 2 the previous night during dinner and had not observed any bruising on the right side of Resident 2's cheek. The RP stated that Resident 2 said, he hit me, and demonstrated how she (Resident 2) was struck by making a fist with her (Resident 2) left hand and motioning toward the right side of her (Resident 2) face. The RP stated that he (RP) reported the incident to Registered Nurse (RN) 1 that same morning (3/31/2026). The RP stated that the Director of Nursing (DON) visited Resident 2 while the RP was present, and Resident 2 demonstrated to the DON how she (Resident 2) had been hit. The RP stated he (RP) spoke with the DON and Administrator (Admin) regarding his (RP) concerns, and the facility decided to contact law enforcement to interview Resident 2 regarding the allegation of physical abuse. During a concurrent interview and record review on 5/15/2026 at 12:24 p.m. with the DON, the facility's P&P titled, Abuse Prevention and Management, dated 3/25/2026, was reviewed. The DON stated that the facility did not report Resident 2's allegation of abuse to the SSA because she (DON) believed no abuse had occurred. The DON stated that the facility should have reported the allegation of physical abuse because the state agency will investigate to determine whether abuse occurred or not. The DON further stated that the facility did not follow their Abuse Prevention and Management policy because they did not report the allegation to the Ombudsman (advocates for residents of nursing homes, board and care homes, and assisted living facilities) or SSA and did not conduct a thorough investigation. During a review of the facility's P&P titled, Abuse Prevention and Management, dated 3/25/2026, the P&P indicated, 5. Administrator as Abuse Prevention Coordinator. a. Allegations of abuse . are to be reported to the Administrator or designated representative immediately. b. When the Administrator or designated representative receives a report of an allegation of resident abuse . the Administrator or designated representative, will initiate an investigation immediately 7. Notification of Outside Agencies for All Allegations of Abuse. a. The Administrator or designated representative will . send a written SOC 341 [Report of Suspected Dependent Adult/Elder Abuse] report to the Ombudsman, . and CDPH [California Department of Public Health] Licensing and Certification within (2) hours 11. Providing State Survey Agency and Other Agencies of the Results. a. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken, to the [CDPH] Licensing and Certification and others that may be required by state or local laws, within five (5) working days of the reported allegation.

Based on interview and record review, the facility failed to report an allegation of physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) within two hours for one of three sampled residents (Resident 2) when on 3/31/2026, there was an allegation that Resident 2 was punched in the face. This deficient practice had the potential to place Resident 2 at an increased risk for further abuse and additional unreported incidents. Cross-reference F607 and F610. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/8/2026 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting right side dominant side, dementia (a progressive state of decline in mental abilities), depression (feeling of sadness, emptiness, and loss of interest in activities). During a review of Resident 2's Minimum Data set (MDS - a resident assessment tool), dated 4/13/2026, the MDS indicated that Resident 2's cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. The MDS indicated that Resident 2 required maximal assistance (helper does more than half the effort) with oral hygiene, lower body dressing and personal hygiene. The MDS indicated that Resident 2 was dependent (helper does all of the effort) with toileting and showers. During a review of Resident 2's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 1/8/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 2's Change of Condition (COC - recording of a significant, unpredicted improvement or decline in a resident's health, mental status, or functional ability compared to their established baseline), dated 3/31/2026, the COC indicated [Resident 2] observed with bruise to right jaw. [Responsible Party (RP)] present at bedside during assessment. During an interview on 5/14/2026 at 10:37 a.m. with Resident 2's Responsible Party (RP), the RP stated that he (RP) arrived around 7 a.m. on 3/31/2026 to visit Resident 2 during breakfast and observed a bruise and scratch on the right side of Resident 2's cheek. The RP stated that he had visited Resident 2 the previous night during dinner and had not observed any bruising on the right side of Resident 2's cheek. The RP stated that Resident 2 said, he hit me, and demonstrated how she (Resident 2) was struck by making a fist with her (Resident 2) left hand and motioning toward the right side of her (Resident 2) face. The RP stated that he (RP) reported the incident to Registered Nurse (RN) 1 that same morning (3/31/2026). The RP stated that the Director of Nursing (DON) visited Resident 2 while the RP was present, and Resident 2 demonstrated to the DON how she (Resident 2) had been hit. The RP stated he (RP) spoke with the DON and Administrator (Admin) regarding his (RP) concerns, and the facility decided to contact law enforcement to interview Resident 2 regarding the allegation of physical abuse. During an interview on 5/14/2026 at 12:01 p.m. with RN 1, RN 1 stated that Resident 2's RP reported concerns that night-shift staff had handled Resident 2 roughly, which allegedly caused bruising to Resident 2's right cheek. RN 1 stated that he (RN 1) informed the RP he (RN 1) would investigate the allegation. RN 1 stated that he (RN 1) notified the DON and the Admin because the allegation involves physical abuse. RN 1 stated that the facility must investigate and report all abuse allegations to state agency within two hours. RN 1 stated that he (RN 1) did not submit a report because he (RN 1) was not sure if it was abuse. During an interview on 5/14/2026 at 1:12 p.m. with the DON, the DON stated Resident 2's RP expressed concerns about bruising on Resident 2's right cheek. The DON stated the Admin and RP spoke with Resident 2 and Resident 2 informed them she (Resident 2) was punched in the face. The DON stated that the facility did not report the allegation to the state agency because she (DON) believed no abuse had occurred and the bruise on Resident 2's right side of the cheek was from a fall Resident 2 had on 3/29/2026. The DON further stated the facility should have reported the allegation of physical abuse because the state agency will investigate to determine whether abuse occurred or not. During an interview on 5/14/2026 at 1:42 p.m. with the Admin, the Admin stated that he was aware of Resident 2 having some marks. The Admin stated Resident 2's RP requested an investigation. In response, the facility contacted law enforcement because the Admin wanted an outside agency to investigate. The Admin stated that he (Admin) did not consider the allegation to be abuse. The Admin stated that Resident 2's RP did not want the state agency to get involved and the Admin stated that he (Admin) would conduct the investigation. The admin further stated that he (Admin) did not investigate allegation of Resident 2's physical abuse. During a review of the facility's Policy and Procedure (P&P) titled, Reporting Abuse, dated 3/25/2026, the P&P indicated, The facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential tool as required by state and federal regulations.report shall be made to the local Ombudsman, California Department of Public Health within two (2) hours of the observation, knowledge, or suspicion of physical abuse.

Based on interview and record review, the facility failed to thoroughly investigate and submit the investigation report of all allegations of abuse to the California Department of Public Health (CDPH) within five days of the incident for one of three sampled residents (Resident 2) when the facility failed to thoroughly investigate and submit investigative reports to CDPH when an allegation of abuse was made on 3/31/2024 by Resident 2's Responsible party (RP) that an unidentified staff member hit Resident 2 on right side of the cheek. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported. Cross-reference F607 and F609. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/8/2026 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting right side dominant side, dementia (a progressive state of decline in mental abilities), depression (feeling of sadness, emptiness, and loss of interest in activities). During a review of Resident 2's Minimum Data set (MDS - a resident assessment tool), dated 4/13/2026, the MDS indicated that Resident 2's cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses) was moderately impaired. The MDS indicated that Resident 2 required maximal assistance (helper does more than half the effort) with oral hygiene, lower body dressing and personal hygiene. The MDS indicated that Resident 2 was dependent (helper does all of the effort) with toileting and showers. During a review of Resident 2's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 1/8/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During an interview on 5/14/2026 at 10:37 a.m. with Resident 2's Responsible Party (RP), the RP stated that he (RP) arrived around 7 a.m. on 3/31/2026 to visit Resident 2 during breakfast and observed a bruise and scratch on the right side of Resident 2's cheek. The RP stated that he had visited Resident 2 the previous night (3/30/2026) during dinner and had not observed any bruising on the right side of Resident 2's cheek. The RP stated that Resident 2 said, he hit me, and demonstrated how she (Resident 2) was struck by making a fist with her (Resident 2) left hand and motioning toward the right side of her (Resident 2) face. The RP stated that he (RP) reported the incident to Registered Nurse (RN) 1 that same morning (3/31/2026). The RP stated that the Director of Nursing (DON) visited Resident 2 while the RP was present, and Resident 2 demonstrated to the DON how she (Resident 2) had been hit. The RP stated he (RP) spoke with the DON and Administrator (Admin) regarding his (RP) concerns, and the facility decided to contact law enforcement to interview Resident 2 regarding the allegation of physical abuse. During an interview on 5/14/2026 at 1:42 p.m. with the Admin, the Admin stated that he (Admin) was aware of Resident 2 having some marks. The Admin stated Resident 2's RP requested an investigation. In response, the facility contacted law enforcement because the Admin wanted an outside agency to investigate. The Admin stated that he (Admin) did not consider the allegation to be abuse. The Admin stated that Resident 2's RP did not want the state agency to get involved and the Admin stated that he (Admin) would conduct the investigation. The admin further stated that he (Admin) did not investigate allegation of Resident 2's physical abuse. During an interview on 5/15/2026 at 12:24 p.m. with the DON, the DON stated that the facility did not report the allegation to CDPH because she (DON) believed no abuse had occurred. The DON stated that the facility should have reported the allegation of physical abuse because CDPH will investigate to determine whether abuse occurred or not. The DON further stated that the facility did report the allegation to CDPH within five days because an investigation was not done for the allegation of physical abuse. During a review of the facility's policy and procedure (P&P) titled, Reporting Abuse, dated 01/2014, the P&P indicated The administrator or his or her designee, shall provide the appropriate agencies or individuals with a written report of the findings of the investigation within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken and documented.

Based on interview and record review, the facility failed to maintain accurate clinical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 1) when on 5/11/2026, Licensed Vocational Nurse (LVN) 5 failed to accurately document in Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) when LVN 5 documented in Resident 1's MAR as if Resident 1 was still in the facility when Resident 1 was already discharged to General Acute Care Hospital (GACH) 1. This deficient practice resulted in inaccurate documentation of Resident 1's records.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 3/10/2026 Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), hydrocephalus (an abnormal buildup of cerebrospinal fluid deep within the brain's cavities [ventricles]), venous insufficiency (occurs when the tiny, one-way valves in your leg veins are damaged or weakened), and peripheral vascular disease (a slow and progressive circulation disorder). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/16/2026, the MDS indicated Resident 1 had the ability to understand and be understood. During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 4/4/2026, the H&P indicated Resident 1 did not have the capacity to understand or make medical decisions. During a review of Resident 1's Order Summary Report (OSR), dated 3/10/2026, the OSR indicated the following orders:- Famotidine oral tablet 20 milligrams (mg - a unit of measurement) give one tablet by mouth two times a day for Gastroesophageal Reflux Disease (GERD - a chronic condition where stomach acid frequently flows back up into the tube connecting your mouth and stomach) administered two times a day before meals.- fluticasone propionate suspension 50 micrograms (mcg- a unit of measurement) one spray in each nostril two times a day for allergic rhinitis (the inflammation of the inside of the nose caused by an allergic reaction).During a review of Resident 1's OSR, dated 3/11/2026, the OSR indicated an order for Culturelle oral capsule (lactobacillus rhamnosus- good bacterium naturally found in the human gut and urinary tract) give one capsule by mouth two times a day for supplement.During a review of Resident 1's OSR, dated 5/1/2026, the OSR indicated Lasix (also known as furosemide, water pill that helps your body get rid of extra salt and water by increasing the amount of urine produced) oral tablet 20 mg give two tablets by mouth two times a day for pitting edema (a type of swelling caused by excess fluid trapped in your body's tissues) on bilateral lower extremities (BLE) give two tablets for a total of 40 mg. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a standard tool used to communicate critical information), dated 5/11/2026, the SBAR indicated bilateral (two-sided) swelling of upper eyelids and Medical Doctor made aware with new orders to transfer to GACH 1 for bilateral eye swelling and pain. During a review of Resident 1's Skilled Nursing Facility (SNF) to Hospital Transfer Form, dated 5/11/2026, the SNF to Hospital Transfer Form indicated Resident 1 was transferred to GACH 1 on 5/11/226 at 11:20 a.m. During a review of Resident 1's MAR for May 2026, the MAR indicated the following:- 5/11/2026 at 4:30 p.m. Famotidine oral tablet 20 mg give one tablet by mouth two times a day for GERD administered two times a day before meals, was administered by LVN 5.- 5/11/2026 at 5p.m. Culturelle Oral capsule give one capsule by mouth two times a day for supplement, was administered by LVN 5.- 5/11/2026 at 5p.m. fluticasone propionate suspension 50 mcg 1 spray in each nostril two times a day for allergic rhinitis, was administered by LVN 5.- 5/11/2026 at 5 p.m. Lasix oral table 20 mg give two tablets by mouth two times a day for pitting edema on BLE give two tablets for a total of 40 mg, was administered by LVN 5. During an interview on 5/13/2026 at 3:20 p.m. with LVN 5, LVN 5 stated she (LVN 5) worked on 5/11/2026 from 3 p.m. to 11 p.m. and Resident 1 was not in the facility when she (LVN 5) came in to work at 3 p.m. LVN 5 stated when doing medication pass, she (LVN 5) must go into the resident's room, check vital signs (core measurements that show how well your body is functioning), explain what she (LVN 5) is going to do, explain each medication prior to giving the mediation, then once the medications are taken by the resident, will then document in the MAR that the medications were given. LVN 5 stated for Resident 1, she (LVN 5) must have signed off the medication by accident. LVN 5 stated she (LVN 5) should be signing the mediations off when she (LVN 5) is in front of the resident and not after. During a concurrent interview and record review on 5/13/2026 at 3:44 p.m. with the Director of Nursing (DON), Resident 1's May 2026 MAR was reviewed. The DON stated medication pass can be done one-hour before or after the scheduled time. The DON stated staff must follow protocol for medication pass that includes the right resident, time, route, order, must explain the medications to the residents and the residents have the right to refuse medications. The DON stated medications should be administered at the bedside with the resident and signed off immediately when given on the MAR. The DON reviewed Resident 1's MAR and stated LVN 5 signed off medications as given when Resident 1 was not in the facility. The DON stated LVN 5 should have documented on the MAR with 6, indicating Resident 1 is in the hospital. The DON stated believes this is willful LVN 5 was not following the facility protocol of pour, pass, and sign. The DON stated if the nurse is doing this it will give the wrong documentation this is not accurate condition of the resident which will cause confusion. The DON stated the oncoming shift may think Resident 1 was still in the facility when in fact Resident 1 was not. The DON stated this can cause confusion with documentation and communication.During a review of the facility's policy and procedure (P&P) titled, Medication Administration, last reviewed on 4/29/2026, the P&P indicated to establish standardized procedures for the safe, effective, and accurate administration of medications in compliance with state and federal regulations and best practices standards. d. License Nurse will verify the resident's identity before administering the medication using the six (6) rights of medications.During a review of the facility's P&P titled, Falsification and Omission, last reviewed on 4/29/2026, the P&P indicated entries in a medical record at the facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to services provided.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical, mental, and psychosocial well-being when: (A) On 3/13/2026, Resident 1 pressed the call light in order for Resident 1's soiled diaper and bed sheets to be changed. Certified Nursing Assistant (CNA 1) was Resident 1's assigned CNA. CNA 1 entered Resident 1's room, turned off the call light, exited the room and did not return to change Resident 1, in accordance with Resident 1's verbal request. Resident 1 called the facility's front desk and asked to be changed. Resident 1 waited about one hour before Resident 1's soiled diaper and bed sheets were changed by another CNA who was not assigned to Resident 1. (B) On 3/27/2026, Resident 3 asked CNA 1 to change Resident 3's soiled diaper to which CNA 1 replied no. CNA 1 was Resident 3's assigned CNA. Resident 3 reported the verbal exchange involving CNA 1 to Licensed Vocational Nurse (LVN 1), and Resident 3 requested to be cleaned and changed by another CNA who was not assigned to Resident 3. These deficient practices resulted in Resident 1 feeling upset at waiting about one hour for Resident 1's soiled diaper and bed sheets to be changed, and Resident 3 feeling very uncomfortable sitting in a soiled diaper. Findings: (A) During a review of Resident 1's admission Record, dated 4/3/2026, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included bilateral osteoarthritis of the knee (when the lining of both knees are worn down over time and causes the bones to rub against each other), bilateral osteoarthritis of the hip (when the lining of both hips are worn down over time and causes the bones to rub against each other), and morbid obesity (a condition defined as being 100 pounds over a person's ideal body weight). During a review of Resident 1's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 3/8/2026, the H&P indicated Resident 1 was re-admitted to the facility after sustaining a fall at home while using her wheelchair. The H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 1 required moderate assistance for toileting hygiene, shower/bathe, and lower body dressing (a helper does less than half the effort). The MDS indicated Resident 1 required maximal assistance (a helper does more than half the effort) for bed to chair transfer (the ability to transfer to and from a bed to a chair/wheelchair) and toilet transfer (the ability to get on and off of a toilet). During an interview on 4/2/2026 at 9:38 a.m. with Resident 1, Resident 1 stated she uses the toilet only for bowel movements (passing stool out of the body), and Resident 1 uses an adult diaper for urinating. Resident 1 stated about a few weeks ago around 9 p.m., Resident 1 pressed the call light because her diaper and bed sheets were wet and needed to be changed. Resident 1 stated about 30 minutes after pressing the call light, CNA 1 came to Resident 1's room and turned off the call light. Resident 1 stated while CNA 1 was inside Resident 1's room, Resident 1 told [CNA 1] that [Resident 1] needed to be changed, but [CNA 1] just turned around and left Resident 1's room. Resident 1 stated, I thought [CNA 1] left to get supplies to change the mattress, but [CNA 1] never came back. Resident 1 stated she waited another 20-30 minutes, but when CNA 1 did not return, Resident 1 stated she had to call the front desk and let them know I needed to be changed. Resident 1 stated, I waited a long time like over an hour and I was so upset. Resident 1 stated, My diaper and bed sheets were soaked and wet. My mattress was all wet, too. Resident 1 stated, I was so upset, but another CNA helped me. I waited for an hour before I was cleaned and dry. During a phone interview on 4/2/2026 at 11:25 a.m. with Registered Nurse (RN 1), RN 1 stated Resident 1 is alert and verbalizes her needs well and the staff can understand [Resident 1's] needs. RN 1 stated that on 3/13/2026 at around 9 p.m., RN 1 was sitting at the front desk when Resident 1 called stating Resident 1 needed a CNA. RN 1 stated she paged CNA 1, who is Resident 1's assigned CNA. RN 1 stated some minutes later, CNA 2 approached RN 1 and reported that Resident 1 was not being changed. RN 1 stated she went to Resident 1's room and saw right away that [Resident 1] was soaking wet [and] the bed sheet was really wet. RN 1 stated Resident 1 reported to RN 1 that CNA 1 came in the room, turned off the call light, turned her back on [Resident 1] and then left. RN 1 stated Resident 1 told CNA 1 that Resident 1 needed to be changed. RN 1 stated she paged CNA 1 again and went to look for CNA 1. RN 1 stated she found CNA 1 inside the conference room looking at her cell phone. RN 1 stated she told CNA 1 about Resident 1's complaints. RN 1 stated she and CNA 1 were walking down the hallway toward Resident 1's room when CNA 1 got offended and said RN 1 was ganging on [CNA 1]. RN 1 stated she replied to CNA 1, I'm not ganging on you. I'm questioning you about your patients. RN 1 stated CNA 1 replied, I'm going home. RN 1 stated CNA 1 left the facility prior to the shift ending, and RN 1 had to ask another CNA to clean Resident 1. RN 1 stated she reported the incident involving Resident 1 and CNA 1 to the Administrator (ADMIN), Director of Nursing (DON), and Director of Staff Development (DSD) via text using the nurse's phone. RN 1 stated the nurse's phone is a specific phone that licensed nurses use in the facility to communicate to doctors and to upper management, including ADMIN, DON, and DSD. When asked if RN 1 documented the incident involving Resident 1 and CNA 1 on 3/13/2026, RN 1 stated she documented a late entry progress note. During a review of Resident 1's Nursing Progress Notes, dated 3/21/2026, the Nursing Progress Notes indicated the following: Late entry - 03/13/26. At approximately past 2200 [10:00 p.m.] on 3/13/26, [Resident 1] was found with a visible soaking wet diaper and wet bedsheet. Incontinence care was provided promptly and the patient was made clean, dry, and comfortable. Bedding was changed. No (acute) distress, noted. During a phone interview on 4/2/2026 at 4:37 p.m. with LVN 1, LVN 1 stated several weeks ago, LVN 1 recalls CNA 1 being paged overhead to attend to [Resident 1]. LVN 1 stated about 20 minutes later, LVN 1 saw Resident 1's call light was still on, so LVN 1 had CNA 1 paged again. LVN 1 stated she then noticed the call light was off, so LVN 1 asked Resident 1 if Resident 1 had been cleaned and changed. LVN 1 stated Resident 1 replied that [Resident 1] told [CNA 1] that [Resident 1] needed to be changed and that [CNA 1] ignored her. When asked if LVN 1 reported what Resident 1 had said, LVN 1 stated: Yes, I reported this to [RN 1] right after I spoke with [Resident 1]. LVN 1 stated she could not find CNA 1 and later heard that CNA had walked out of the facility. LVN 1 stated she had to ask another CNA (name not indicated) to clean and change Resident 1. During a phone interview on 4/2/2026 at 5:15 p.m. with CNA 2, CNA 2 stated she recalled an incident involving Resident 1 about 3 weeks ago. CNA 2 stated when she was making rounds (visually checking on the residents) at about 9:30 p.m., CNA 2 asked Resident 1 if Resident 1 was okay. CNA 2 stated Resident 1 replied that she was just waiting to be changed. CNA 2 stated about 50 minutes later, CNA 2 heard a page overheard regarding Resident 1. CNA 2 stated she went to Resident 1's room and Resident 1 reported to CNA 2 that CNA 1 came in, turned off the call light and left. CNA 2 stated Resident 1 was upset, and Resident 1 told CNA 2, Look at my bed. It is all wet. CNA 2 stated, I saw [Resident 1's] bed was wet. CNA 2 stated she went to RN 1 and reported what Resident 1 told CNA 2 about CNA 1. CNA 2 stated leaving [a resident] soaked [in urine] can cause skin breakdown. During an interview on 4/3/2026 at 9:19 a.m. with RN 2, RN 2 stated the responsibilities of certified nursing assistants include answering call lights and changing residents when their diapers become soiled. RN 2 stated a possible consequence of leaving a resident in a soiled, wet diaper is that the skin can breakdown and it can lead to infection. During a phone interview on 4/3/2026 at 10:01 a.m. with CNA 3, CNA 3 stated the responsibilities of certified nursing assistants include taking care of patients. CNA 3 stated, We feed the patients. We wash the patients and make sure they are clean and dry. When asked what could possibly happen if a resident is left in a wet diaper, CNA 3 stated the urine is so strong that it will break skin. During a phone interview on 4/3/2026 at 10:24 a.m. with CNA 1, CNA 1 was asked if she recalled Resident 1, to which CNA 1 stated, I don't know who that is. Who is that? When asked if CNA 1 had any issues with any of CNA 1's assigned residents, CNA 1 stated: Patients are always going to complain about something. If you are sitting in a nursing home and can't leave, you'll find a reason to complain about something. A lot of them are bedbound. When asked if CNA 1 left any of CNA 1's assigned residents in a soiled diaper for about an hour, CNA 1 stated, No, that's a lie. CNA 1 stated, No one has never complained since I have been doing this. During an interview on 4/3/2026 at 4:22 p.m. with the DON, the DON stated it is part of the standard of practice and job duties of certified nursing assistants to answer call lights and make sure all [residents'] needs are attended to, including changing residents' diapers. The DON stated if a resident is waiting to be changed and sitting in a soiled diaper, possible consequences include a risk for skin breakdown, feeling not comfortable and in distress, and a risk for fall because a resident might try to get out of bed or wheelchair and walk to the bathroom. (B) During a review of Resident 2's admission Record, dated 4/3/2026, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and most recently re-admitted on [DATE]. The admission Record indicated Resident 2's diagnoses included bilateral osteoarthritis of hip (when the lining of both hips are worn down over time and causes the bones to rub against each other), malignant neoplasm of prostate (cancer in the prostate), and type 2 diabetes mellitus (a condition where the body cannot properly use or make enough of the hormone called insulin, leading to high blood sugar levels). During a review of Resident 2's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 2/1/2026, the H&P indicated Resident 2 has the capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/30/2026, the MDS indicated Resident 2 is dependent for toileting hygiene (a helper does all of the effort of the activity). The MDS indicated Resident 2 required substantial assistance for shower/bathe and lower body dressing (a helper does more than half the effort of the activity). During a phone interview on 4/2/2026 at 11:25 a.m. with RN 1, RN 1 stated on 3/27/2026 at approximately 9:45 p.m., CNA 1 told RN 1 that CNA 1 needed to go out of the facility for a few minutes and that DSD was aware. RN 1 stated after CNA 1 had left the facility, RN 1 learned through LVN 1 that Resident 2 reported that he had asked to be changed by [CNA 1] at around 8:40 p.m. and [CNA 1] had responded no. RN 1 stated Resident 2 was later cleaned and changed by another CNA. During a phone interview on 4/2/2026 at 4:37 p.m. with LVN 1, LVN 1 stated Resident 2 is in a wheelchair due to muscle weakness and Resident 2 is incontinent. LVN 1 stated approximately a week ago at around 8:30 p.m., LVN 1 was a witness to an incident involving Resident 2 and CNA 1. LVN 1 stated it happened right next to my desk. LVN 1 stated Resident 2 was in his wheelchair and approached LVN 1 at the nursing station asking for LVN 1 to call CNA 1 so that Resident 2's soiled diaper can be changed. LVN 1 stated she called CNA 1 twice overhead. LVN 1 stated when CNA 1 approached LVN 1, LVN 1 told CNA 1 to change Resident 2. LVN 1 stated Resident 2 was still at the nursing station and asked CNA 1 why CNA 1 did not change Resident 2 when he had asked CNA 1 earlier. LVN 1 stated CNA 1 basically gave excuses that CNA 1 was on break and that she was busy. LVN 1 stated CNA 1 then told Resident 2, Do you want me to change you, yes or no? LVN 1 stated, I started to look for another CNA because [Resident 2] was getting frustrated. I asked [Resident 2] if he wanted someone else to change him and he said yes. LVN 1 stated she requested another CNA to help clean and change Resident 2. LVN 1 stated she reported the incident involving CNA 1 and Resident 2 to RN 1. During a phone interview on 4/3/2026 at 10:24 a.m. with CNA 1, CNA 1 stated CNA 1 did not know or recall Resident 2. When asked if there was an argument or an incident involving Resident 2, CNA 1 stated: [Resident 2] is right in front of nursing station. There was no argument with [Resident 2]. When asked if CNA 1 ever left her shift early without permission, CNA 1 stated: If I have a family emergency or I'm taking care of personal things, I leave for just 30 minutes. I didn't abandon anyone because these [nurses] are licensed. You didn't go to school to just pass out Advil. During an observation and interview on 4/3/2026 at 11:48 a.m. with Resident 2, Resident 2 was observed sitting in his wheelchair and able to move around in the hallway by himself. When asked if something had happened to Resident 2 involving being cleaned and changed, Resident 2 stated, Yeah, that was something that should not happen. She was supposed to do her duty to help me. When asked to clarify who was supposed to help Resident 2, Resident 2 stated CNA 1. Resident 2 stated: I asked [CNA 1] to clean me because I had an accident. Some kind of diarrhea so my diaper was dirty. I asked [CNA 1] if she could help me and she said no. Resident 2 stated he told LVN 1 about CNA 1 refusing to clean and change Resident 2. Resident 2 stated: I wasn't very happy about it. Most of the time, the other nurses treat me with dignity and respect. When I ask them to help me, they help me. That is why I was surprised [CNA 1] said no. Resident 2 stated, [CNA 1] made me feel very uncomfortable. That thing never happened to me. Resident 2 stated he did not want CNA 1 to be assigned to him because it will remind [Resident 2] of what happened. During an interview on 4/3/2026 at 4:22 p.m. with DON, DON was asked about the 3/27/2026 incident involving Resident 2 and CNA 1. DON stated DON recalled RN 1 sending a text that another CNA was changing CNA 1's patients because [CNA 1] was nowhere to be found. DON stated the facility has a buddy system in which certified nursing assistants work in pairs and can cover each other if one CNA is preoccupied with another resident. DON stated it's not fair to one CNA if that CNA is doing all the work of the other CNA because it can lead to delayed care for the residents. DON stated the CNA who is covering another CNA's patients will have an increased workload and will be in a rush when providing services which affects patient care. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/1/2012, the P&P indicated the following: Residents of skilled nursing facilities have a number of rights under state and federal law. The Facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care. Employee are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. During a review of the facility's job description for CNA titled, Certified Nursing Assistant Job Description, undated, the job description indicated the general job duties and responsibilities of certified nursing assistants include [NAME][ing] rounds,.answer residents' call lights promptly,.and provide assigned personal hygiene care in accordance with facility procedures.to maintain resident cleanliness, dignity, and comfort.

Based on observation, interview, and record review, the facility failed to ensure the personal privacy of one of three sampled residents (Resident 2) was provided when Certified Nursing Assistant (CNA 1) entered Resident 2's room without knocking and began speaking to CNA 4 through a gap in the curtain, while CNA 4 was changing Resident 2's diaper and providing peri-care (the cleaning of genitals particularly for individuals with limited mobility and/or loss of bladder/bowel control). This deficient practice resulted in failing to provide Resident 2 with privacy during personal hygiene care. Findings: During a review of Resident 2's admission Record, dated 4/3/2026, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. The admission Record indicated Resident 2's diagnoses included hemiplegia (a form of paralysis that causes severe or complete loss of movement on one side of the body) and hemiparesis (weakness on one side of the body, affecting the arm, leg, and sometimes the face) following cerebral infarction (occurs when blood flow to part of the brain is blocked or a blood vessel bursts, resulting in loss of oxygen to the brain), syncope (fainting), and overactive bladder (a condition where the bladder muscles squeeze involuntarily, creating a sudden, urgent need to pee, even when the bladder is not full). During a review of Resident 2's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 2/13/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 2/18/2026, the MDS indicated Resident 2 was dependent for toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and personal hygiene (a helper does all of the effort of the activity). During a phone interview on 4/2/2026 at 11:25 a.m. with Registered Nurse (RN 1), RN 1 stated on 3/19/2026 at around 9 p.m., CNA 4 reported to RN 1 that CNA 1 was not at her assigned residents' area but in the conference room. RN 1 stated she asked CNA 4 to accompany RN 1 when speaking to CNA 1 because RN 1 need[ed] to have a witness. RN 1 stated: I saw [CNA 1] in the conference room with her cell phone. There (were) no more meal breaks at that time because it was near the end of shift, and it was the CNAs' last rounds to attend to patients. RN 1 stated she asked CNA 1 why CNA 1 was in the conference room, to which CNA 1 replied that CNA 1 was on her break. RN 1 stated she told CNA 1 there is no more scheduled breaks because the shift was almost ending, and it was the last rounds to do your tasks. RN 1 stated CNA 1 got offended and started to record RN 1 and CNA 4 with CNA 1's cell phone. RN 1 stated she left to obtain the nurse's phone (a specific phone that licensed nurses use in the facility to communicate to doctors and to facility upper management) and reported CNA 1's actions. RN 1 stated later during that same shift, CNA 4 reported to RN 1 that CNA 1 had recorded CNA 4 while CNA 4 was changing a resident. During a phone interview on 4/2/2026 at 7:43 p.m. with CNA 4, CNA 4 stated on 3/19/2026, some of the charge nurses were paging [CNA 1] and they couldn't find her. CNA 4 stated RN 1 asked CNA 4 to go with her because [RN 1] needed somebody to witness when [RN 1] talks to [CNA 1]. CNA 4 stated RN 1 spoke to CNA 1 about going back to her [assigned] station. CNA 4 stated CNA 1 took her phone and started videoing (recording) us. CNA 4 stated she went to Resident 2's room because the call light was on. CNA 4 stated Resident 2 is alert and wanted her diaper to be changed. CNA 4 stated, CNA 1 showed up right away inside [Resident 2's] room and hold up [CNA 1's cell] phone. CNA 4 stated: I'm in the middle of changing [Resident 2's] diaper. [CNA 1] showed up and didn't even knock on the door. [CNA 1] went inside the room and acting like she is getting gloves. CNA 4 stated she already took out the old diaper and Resident 2 was naked on the bottom part, when CNA 1 entered Resident 2's room without knocking. CNA 4 stated she told CNA 1 to get out of here so that I can change my patient. CNA 4 stated Resident 2 was surprised and asked what CNA 1 was doing in Resident 2's room. When asked if the privacy curtain was pulled completely around Resident 2's bed, CNA 4 stated there was a gap of about 1 to 2 feet where CNA 1 showed up. CNA 4 stated after she changed Resident 2, CNA 4 went to her assigned nursing station where she saw CNA 1. CNA 4 stated she told CNA 1, Next time, don't do that because we need to give residents some privacy. CNA 4 stated that CNA 1 took her cell phone out, pointed it to CNA 4, and videoed CNA 4. CNA 4 stated she reported to RN 1 and also sent a written statement via text to Director of Staff Development (DSD). CNA 4 stated: Patients have rights like privacy. We have to protect their dignity. During a concurrent observation and interview on 4/3/2026 at 9:08 a.m. with Resident 2, Resident 2 stated she recalled pressing her call light at nighttime for her diaper to be changed. Resident 2 stated when CNA 4 arrived in the room, CNA 4 forgot to slide the curtain all the way. Resident 2 stated when CNA 4 was changing Resident 2's diaper, Resident 2 saw a second person appear where there was a gap in the privacy curtain. Resident 2 stated, I saw the person there. Resident 2 was observed to be pointing at the foot of her bed on the right side from Resident 2's point of view while lying in bed. Resident 2 stated the second person who appeared began talking to CNA 4. Resident 2 stated she then told CNA 4, Can you please be mindful and not let anybody come here? When asked if Resident 2 had already been cleaned and changed when the second person appeared, Resident 2 stated: No, I was still being changed. I was already exposed. Resident 2 stated the second person left the room after Resident 2 asked for the privacy curtain to be closed. Resident 2 stated she felt embarrassed because [Resident 2] was exposed. Resident 2 stated: Some CNAs are more mindful of privacy. They knock on the door and ask for permission. That [second] person didn't knock on the door. During a phone interview on 4/3/2026 at 10:01 a.m. with CNA 3, CNA 3 stated when changing a resident's soiled diaper, First, I knock on the door. I introduce myself and close the curtain for privacy. CNA 3 stated if privacy is not given to residents when they are being cleaned and changed, it is possible they will feel sad even if the patient cannot talk. CNA 3 stated video recording is not allowed in the facility because it does not help with giving residents privacy. During a phone interview on 4/3/2026 at 10:24 a.m. with CNA 1, CNA 1 was asked if she had recorded with her cell phone while in the facility. CNA 1 stated: Yes, I did record. I felt threatened. There was [CNA 4] and one nurse. It took 2 people to come talk to me. I was feeling I was being ganged and harassed, and I feared for my life. When asked if CNA 1 recorded a resident in the facility, CNA 1 stated, That's not true. CNA 1 stated she recorded a nurse and a CNA in the conference room, and CNA 1 only recorded because they are harassing CNA 1. When asked if CNA 1 entered a resident's room while CNA 4 was providing direct care, CNA 1 stated, I went inside a resident's room to get some gloves. CNA 1 was asked if she had an assigned resident in the same room where CNA 4 was providing resident care, to which CNA 1 stated: It doesn't matter. Is there a law that I can't go to any patient's room to get gloves? During an interview on 4/3/2026 at 4:22 p.m. with the Director of Nursing (DON), the DON stated when nursing staff is providing peri-care, the nursing staff needs to explain what they are doing and provide privacy. DON stated a possible consequence if a resident is not given privacy during peri-care is emotional distress and feeling embarrassed. DON stated there is no recording with cell phones allowed in the facility because of the possibility of violating residents' privacy. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/1/2012, the P&P indicated, Residents of skilled nursing facilities have a number of rights under state and federal law. The Facility will promote and protect those rights. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. The P&P further indicated, State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to.privacy and confidentiality. During a review of the facility's job description for CNA titled, Certified Nursing Assistant Job Description, undated, the job description indicated the general job duties and responsibilities of certified nursing assistants include .provid[ing] assigned personal hygiene care in accordance with facility procedures.to maintain resident cleanliness, dignity, and comfort.

Based on interview and record review, the facility failed to ensure the medical record of one of two sampled residents (Resident 1) was accurately documented in accordance with the facility's policy, when Licensed Vocational Nurse (LVN) 1 documented in advance that Resident 1 was transferred to a new isolation room (a room that is specifically assigned to a resident who is infected with a specific germ in order to prevent the spread of infection to other residents) when the transfer had not yet occurred. This deficient practice resulted in an inaccurate medical record for Resident 1. Findings: During a review of Resident 1's admission Record, dated 2/5/2026, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included cerebral ischemia (when blood flow to the brain is blocked or significantly reduced), spinal stenosis (when the space around the spinal cord becomes too narrow, which puts pressure on the nerves and spinal cord), and paroxysmal atrial fibrillation (when the heart pumps in an irregular and abnormally fast rhythm). During a review of Resident 1's History and Physical Examination (H&P - a comprehensive assessment of a resident's medical condition), dated 1/9/2026, the H&P indicated Resident 1 was re-admitted to the facility on [DATE] after being treated at an acute hospital for a urinary tract infection. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2026, the MDS indicated Resident 1 needs maximal assistance for eating, personal hygiene, and upper body dressing (a helper does more than half the effort of the activity). The MDS also indicated Resident 1 is dependent for toileting hygiene and shower/bathe (a helper does all of the effort of the activity). During an interview on 2/4/2026 at 10:16 a.m. with LVN 1, LVN 1 stated the facility does not have a designated (specifically reserved) isolation room. LVN 1 stated that if a resident needs to be placed on isolation, the nursing staff will first assess if the resident can stay in their room or if they have to move. LVN 1 stated that as an example, residents who are on enhanced barrier precautions (when facility staff must wear gowns and gloves when providing direct contact care to residents who are at high risk of germs that are resistant to antibiotics) are not compatible and must be separated from residents who are on contact isolation (residents who are specifically separated because they have germs that spread through contact, such as touching the infected residents or items in their room). LVN 1 stated the facility currently has two residents on contact isolation and approximately 30 to 40 residents on enhanced barrier precautions. During a concurrent interview and record review on 2/4/2026 at 10:25 a.m. with LVN 1, Resident 1's electronic medical record was reviewed. LVN 1 stated that on 1/31/2026, Resident 1 had several episodes of diarrhea. LVN 1 stated a stool sample (sample of Resident 1's diarrhea) was collected for testing, and the results came back positive for c-diff (presence of clostridioides difficile which is a type of bacteria can cause infection in the intestine resulting in severe diarrhea) on 2/3/2026. LVN 1 stated that after receiving Resident 1's positive c-diff test results, Resident 1 had to be transferred to a new room and placed on contact isolation. LVN 1 stated Resident 1's new room was private (Resident 1 would not have to share the room with another resident) but still needed to be cleaned prior to Resident 1's transfer. LVN 1 stated: [The new room] was getting cleaned so we were waiting for it to be done. Around noon time, we put Resident 1 in [the new room]. During a concurrent interview and record review on 2/4/2026 at 11:11 a.m. with LVN 1, Resident 1's Infection Note, dated 2/3/2026 was reviewed. The Infection Note was documented at 9:07 a.m. and indicated that Resident 1 had been placed in a private room. When asked why the Infection Note that was documented at 9:07 a.m. indicated Resident 1 was already transferred to the private room, when LVN 1 previously stated that Resident 1 was transferred to the new room around noon time, LVN 1 stated: I probably did the note before [Resident 1] was transferred. LVN 1 stated the Infection Note that was documented at 9:07 a.m. was inaccurate at the time LVN 1 entered it in the facility's computer system. When asked why licensed nurses should not document in advance before an event occurs, LVN 1 stated: Some things might have happened differently, such as if Resident 1 was not transferred to the private room. During an interview on 2/4/2026 at 12:42 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated CNA 1 recalls transferring Resident 1 on 2/3/2026. CNA 1 stated that housekeeping (facility staff whose job duties consist of cleaning and disinfecting) had to clean Resident 1's new, private room before Resident 1 could be transferred. CNA 1 stated that CNA 1 transferred Resident 1 to the private room right before CNA 1 went on lunch break at approximately 11:30 a.m. During an interview on 2/4/2026 at 3:21 p.m. with Director of Nursing (DON), DON stated licensed nurses should chart whatever they did. DON stated licensed nurses should not document an event in advance before the event actually occurs because anything can happen, such as the patient's condition can change. When asked about possible consequences of documenting an event ahead of time, DON stated, it's not reflecting the accurate condition of patient, and it is not an accurate record. DON stated it is important to make sure a resident's medical record is complete and accurate because it reflects the actual condition of the patient so that nursing staff can provide better care. During a review of the facility's policy and procedure (P&P) titled, Completion & Correction, dated 1/1/2012, the P&P indicated the purpose of the policy is to ensure that medical records are complete and accurate. The P&P indicated entries will be recorded as the events or observations occur. The P&P further indicated [a]n event is never to be documented before it occurs.

Based on interview and record review, the facility failed to inform the medical doctor (MD) of one of five sampled residents (Resident 4) when: 1. On 9/9/2025 at 6 a.m. Resident 4 refused fasting blood sugar (FSBS- a measure of the glucose in your blood after you've gone at least 8 hours without eating or drinking anything except water). 2. On 9/9/2025 at 7 p.m. Resident 4's blood glucose (blood sugar- the main source of energy for your body's cells, especially your brain, and comes from the carbohydrates you eat) was 379. These deficient practices had the potential to result in a delay of care to Resident 4. Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 9/8/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), essential (primary) hypertension (HTN-high blood pressure), gastrotomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and chronic kidney disease (CKD- condition where the kidneys are damaged and cannot function properly over an extended period). During a review of Resident 4's History and Physical (H&P- a foundational medical assessment where a clinician interviews a patient [the history] to understand their symptoms and health background, and then performs a physical exam by observing and palpating the patient's body to find signs of illness or injury) dated 9/9/2025, the H&P indicated Resident 4 did not have the capacity to make healthcare decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 9/9/2025, the MDS indicated Resident 4 sometimes understood and was sometimes understood. During a review of Resident 4's Order Summary Report dated 9/8/2025, the Order Summary Report indicated:- Novolin N FlexPen 100 units/milliliter (ml- a unit of measurement) suspension pen-injector, inject 10 units subcutaneously (subq- under the skin) in the morning for DM hold if blood sugar is less than 100 and inject 12 units subq at bedtime for DM hold if blood sugar is less than 100. - Fasting blood sugar (FSBS- a measure of the glucose in your blood after you've gone at least 8 hours without eating or drinking anything except water) every six (6) hours with no insulin sliding scale coverage, if blood sugar is less than 70 follow the hypoglycemia protocol, if blood sugar is above 250 call and notify the MD and or Nurse Practitioner (NP- a registered nurse with advanced education and training who can perform many tasks similar to a doctor, including diagnosing illnesses, ordering tests, and prescribing medication) every six (6) hours for DM. During a review of Resident 4's Medication and Administration Record (MAR- - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for September 2025, the MAR on 9/9/2025 at 6 a.m. indicated:- FSBS every 6 hours with no insulin sliding scale coverage, if blood sugar is less than 70 follow hypoglycemia protocol if blood sugar is more than 250 call and notify the MD and or the NP every 6 hours for DM, the MAR indicated 2 (the MAR chart code indicated 2 means drug refused) - Novolin N flexpen 100 units/ml suspension pen injector, inject 10 units subq in the morning for DM hold if the blood sugar is less than 100, the MAR indicated 9 (the MAR chart code indicated 9 means other and or see progress note). During a review of Resident 4's Change in Condition (COC) Evaluation, dated 9/9/2025 at 10:11 p.m., the COC Evaluation indicated Resident 4 transferred to hospital related to hypotension, elevated blood sugar level. At 7 p.m. Resident 4 in bed, family at bedside, Resident 4 noted difficult to arouse, checked blood sugar noted at 379. The COC evaluation indicated Resident 4's vital signs (basic measurements that reflect how well your body's essential functions are working, including body temperature [a measure of how hot or cold something is, normal range 97.8 to 99], pulse [heart rate- the number of times your heart beats in one minute, normal rate 60 to 100 beats per minute], respiratory [breathing] rate, and blood pressure [normal range systolic pressure (top number) less than 120, diastolic pressure (bottom number) less than 80 millimeters of mercury [mmHg-a unit of measurement]) on 9/9/2025 at 7:05 p.m. indicated a blood pressure of 84/49 mmHg, pulse 95, respiration rate 20, temperature of 97.9, oxygen saturation (a medical measurement of the amount of oxygen carried by your red blood cells, expressed as a percentage) 99% on room air (normal range 95 to 100%) and a blood glucose (the amount of glucose [sugar] in the blood) 379 (normal random range less than 125 milligrams per deciliter [mg/dL-a unit of measurement) mg/dL. The Medical Doctor (MD 1) was made aware of Resident 4's condition on 9/9/2025 at 7:30 p.m. During a review of Resident 4's GACH 2's Emergency Documentation (ED) dated 9/9/2025, the GACH 2's ED indicated Resident 4 chief complaint was hypotension (low blood pressure) systolic blood pressure (sbp- the top, higher number in a blood pressure reading, measuring the force of blood against artery walls when the heart beats and pumps blood out) 80, unresponsive for 90 minutes prior to arrival, high blood sugar greater than 500 on 9/9/25 at 7:53 p.m. with positive acetone breath (a distinctive, fruity, or nail polish remover-like odor on your breath). The GACH 2's ED indicated Resident 4's laboratory results for glucose were 1,443. Final diagnosis indicated altered mental status (AMS), DKA and hyperkalemia (having too much potassium in your blood). During a concurrent interview and record review on 9/25/2025 at 1:10 p.m. of Resident 4's September MAR with the Assistant Director of Nursing (ADON), the ADON reviewed blood sugar on MAR and the ADON stated Resident 4's blood sugar was check at 12:04 a.m. it was121 then check at 11:56 a.m. Resident 4's blood sugar was 109. The ADON stated staff should have gotten another blood sugar check at 6 a.m. to have an accurate level. The ADON stated based on both (12 a.m. and 11 a.m.) blood sugars Resident 4 should have gotten the NOVOLIN at 6 a.m., because order indicates to hold if the blood sugar is under 100 and in both blood sugar the level was not under 100. During a concurrent interview and record review on 9/25/2025 at 2:39 p.m. of Resident 4's MAR with the Director of Nursing (DON), the DON reviewed the MAR for blood sugar check on 9/9/25 for the 6 a.m. check and the DON stated Resident 4 refused to get blood sugar taken. The DON stated the doctor should have been notified with the blood sugar refusal. The DON reviewed MAR for Novolin, and the DON stated indicated 9 meaning needs a progress note, should have a progress note but does not see any progress note, there is also no doctor notification. The DON stated the doctor should be notified of refusal of missed insulin dose as it can result in complications such as DKA. The DON stated for resident refusal there is no indication of a limit, rule is after three times to notify the doctor but if a resident refused must notify the doctor as soon as possible to address the situation. The DON stated the doctor must be notified and Resident 4 should be monitored due to the refusal and possible risk for DKA. During an interview on 9/25/2025 at 3:52 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated when residents refuse blood sugar check will let the doctor know. LVN 4 stated there is no progress note for Resident 4's refusal of the blood sugar check, LVN 4 stated cannot prove LVN 4 called the doctor because he did not document it. LVN 4 stated if there is no documentation, cannot prove the doctor was notified. During an interview on 9/25/2025 at 3:52 p.m. with LVN 4, LVN 4 stated that when residents refuse any medication or treatment, we try three times and when residents continue to refuse then we must notify the doctor. LVN 4 stated if the doctor is not notified the doctor will not be aware of the residents' condition and cannot provide orders or monitoring. LVN 4 stated that when the doctor is not notified there can be a potential for a delay in care. During an interview on 9/25/2025 at 4 p.m. with LVN 1, LVN 1 stated notification to the doctor for Resident 4's change of condition was done after Resident 4 was transferred to the hospital. LVN 1 stated Resident 4's head of bed was lowered to Trendelenburg position (when a person lies flat on their back with their feet raised higher than their head, often by tilting the operating table), rechecked the blood pressure and it was still low. LVN 1 stated nothing else was done for Resident 4's low blood pressure. LVN 1 stated nothing was done for the blood sugar, checked the orders for insulin and none at that time, no intravenous (IV- is a way to give fluids, medications, or nutrients directly into a person's vein, allowing them to enter the bloodstream and be absorbed quickly) started. LVN1 stated we usually call the doctor to get orders for insulin to get orders for high blood sugar, LVN 1 stated did not call the doctor we called 911. LVN 1 stated if we had called the doctor they may have ordered for as needed insulin, possibly could have ordered fluids for the low blood pressure. During an interview on 9/25/2025 at 4:26 p.m. with the Registered Nurse (RN) 1, RN 1 stated on 9/9/2025 around 7 p.m. Resident 4 was not responsive, had a low blood pressure of 80/40 and was not responding to painful stimuli. RN 1 stated he stopped Resident 4's feeding and placed Resident in Trendelenburg position, RN 1 stated did this to help with the low blood pressure, but it was ineffective and the blood sugar was in the 300's. RN 1 stated called 911 did not call the doctor because would have taken more time. RN 1 stated Resident 4 did not have orders for insulin, called the doctor once Resident 4 was being transported to the hospital around 7:25 p.m. RN 1 stated when we have residents with low blood pressure we call the doctor and get orders for fluids and for the high blood sugar Resident 4 did not have any sliding scale and or as needed orders. RN 1 stated could have called the doctor to get orders for the insulin but did not. RN 1 stated is aware Resident 4 has orders to call the doctor if the sugar is above 250 but did not call the doctor because Resident 4 was not responsive. During a concurrent interview and record review on 9/29/2025 at 3 p.m. of Resident 4's MAR with the Assistant Director of Nursing (ADON), the ADON stated when residents refuse medications and or blood sugar checks the doctor must be notified then there must be documentation that the doctor was notified with the orders given and we must document the monitoring of the refusal. The ADON stated because there is no documentation cannot say the doctor was informed of Resident 4's refusal of the blood sugar check. The ADON stated LVN 4 did not notify the doctor of the refusal after an hour, there can be adverse effects that can result in adverse effects due to the refusal, we don't know where Resident 4's blood sugar level was, if Resident 4 is going to need the insulin or not. The ADON stated when there is an emergency, we call 911 initially then we call the doctor while we wait for the paramedics to arrive. The ADON stated must notify the doctor of what is going on with the resident at that time, the doctor may order something in the meantime. The ADON stated can result in a delay in care and treatment if the doctor is not notified. During a review of the facility's Policy and Procedure (P&P) titled, Medication, Administration, last reviewed on 4/30/2025, the P&P indicated all medications shall be administered by licensed nursing staff according to physician orders, current best practice, and federal and stated regulations.1. Refusing Medication2. A. The License Nurse will attempt to give the medication several times, but if residents continue to refuse after an hour, the refused medication will be destroyed.3. Licensed Nurse will notify the prescribing provider and document in the medical record including the reason for refusal. During a review of the facility's P&P titled, Diabetic Care, last reviewed on 4/30/2025, the P&P indicated the attending physician will write parameters for notification for blood sugar that is out of control.A. In any case where the resident's blood sugar is less than 70 or greater than 350, the Attending Physician must be notified, unless otherwise noted on the Physician's order. During a review of the facility's P&P titled, Blood Glucose Monitoring, last reviewed on 4/30/2025, the P&P indicated blood glucose testing will be performed as ordered by the attending physician. Insulin and other medications will be given as ordered by the attending physician. The Attending Physician will be notified of blood sugar level lower than 70 or higher than 350, unless otherwise indicated in the physician order.

Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4), who was dependent on enteral feeding (a way to deliver nutrients, liquids, and medications directly into the stomach or small intestine through a tube, bypassing the mouth and throat) was provided the prescribed diet. This deficient practice resulted in Resident 4 not receiving the prescribed diet. Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 9/8/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), essential (primary) hypertension (HTN-high blood pressure), gastrotomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and chronic kidney disease (CKD- condition where the kidneys are damaged and cannot function properly over an extended period). During a review of Resident 4's History and Physical (H&P- a foundational medical assessment where a clinician interviews a patient [the history] to understand their symptoms and health background, and then performs a physical exam by observing and palpating the patient's body to find signs of illness or injury) dated 9/9/2025, the H&P indicated Resident 4 did not have the capacity to make healthcare decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 9/9/2025, the MDS indicated Resident 4 sometimes understood and was sometimes understood. During a review of Resident 4's Order Summary Report dated 9/8/2025, the Order Summary Report indicated enteral feed order in the afternoon for off at 10 a.m. or until dose is completed Glucerna 1.5 at 55 milliliters (ml- a unit of measurement) an hour via kangaroo pump (an electronic, portable medical device that delivers liquid nutrition or hydration through a feeding tube) for 20 hours a total of 1,1100 ml per 24 hours, 1650 kilocalorie (kcal- a unit of measurement) per 24 hours via gastrostomy 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) diagnosis of dysphagia on at 2 p.m. and off at 10 a.m. or until dose is completed. During a review of Resident 4's Clinical admission dated 9/8/2025 at 8:10 p.m., the Clinical admission indicated Resident 4 was admitted to Skilled Nursing Facility (SNF) 1 on 9/8/2025 at 8 p.m. with vitals signs (basic measurements that reflect how well your body's essential functions are working, including body temperature [a measure of how hot or cold something is, normal range 97.8 to 99], pulse [heart rate- the number of times your heart beats in one minute, normal rate 60 to 100 beats per minute], respiratory [breathing] rate, and blood pressure [normal range systolic pressure (top number) less than 120, diastolic pressure (bottom number) less than 80 millimeters of mercury [mmHg-a unit of measurement]) taken at 8 p.m. as follows: blood pressure 136/68, heart rate 66, respiration rate 16, and oxygen 96% on room air. During a review of Resident 4's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for September of 2025, the MAR indicated enteral feed order two times a day provide Glucerna 1.5 at 55 ml an hour for 20 hours to provide 1,1100 ml, 1650 kcal in 24 hours via g-tube off at 10 a.m. and on at 2 p.m. or until dose is consumed. May hold feedings during ADL care, showers and transfer. The MAR indicated start date as of 9/9/2025 at 10 a.m.- 9/9/2025 at 10 a.m. off.- 9/9/2025 at 2 p.m. on. During a review of Resident 4's Medication Admin Aduit Report (a document that summarizes a formal check of how medications are handled and given to patients) for September 8th to September 9th 2025, the Medication Admin Aduit Report indicated enteral feed order two times a day provide Glucerna 1.5 at 55 ml an hour for 20 hours to provide 1,1100 ml, 1650 kcal in 24 hours via g-tube off at 10 a.m. and on at 2 p.m. or until dose is consumed. May hold feedings during ADL care, showers and transfer.- Scheduled time on 9/9/2025 at 10 a.m. was signed off on 9/9/2025 at 11:09a.m. as off.- Scheduled time on 9/9/2025 at 2 p.m. was signed off on 9/9/2025 at 1:43 p.m. as on. During a concurrent interview and record review on 9/29/2025 at 3 p.m. of Resident 4's MAR and orders with Assistant Director of Nursing (ADON), the ADON stated when a new resident is admitted to the facility the doctor is notified then the nurse will send over the medication recap form from the hospital to let the doctor decide if they wish to continue the medications. The ADON stated once the doctor approves the medication the nurse will input all orders in and start the orders within the hour when the resident was admitted to the facility. The ADON stated for Resident 4 if there were orders for the morning would have started the next day but if it were for bedtime, it would start that same night. The ADON stated orders will automatically start the next shift unless the nurse goes in and edits the order to start that shift. The ADON reviewed Resident 4's order for the g-tube feeding and the ADON stated the facility has in-house supply of the formula and pump that were ordered for Resident 4, the ADON stated the feeding should have been set up right away. The ADON reviewed MAR and Medication Audit Report, the ADON stated nurse signed g-tube was off at 10 a.m. but never signed that the g-tube was started prior to the 10 a.m. off time. The ADON stated Resident 4 missed out on 14 hours of the feeding. The ADON stated if Resident 4 is missing out on 14 hours of the feeding this can cause Resident 4's blood sugar to drop, risk for dehydration, and a concern with Resident 4 to feel hungry. The ADON stated the order indicates Resident 4 to have the feeding at a rate of 55 ml an hour, Resident 4 missed out on 770 ml of the feeding. During a review of the facility's Policy and Procedure (P&P) titled, Enteral Feeding, last reviewed on 4/30/2025, the P&P indicated enteral feeding will be administered via pump as ordered by the Attending Physician.

Based on interview and record review the facility failed to ensure one of five sampled residents (Resident 4) received treatment and care in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 failed to follow the physician's orders to contact the physician if blood sugar (blood glucose- the amount of a simple sugar called glucose in your blood, which serves as the main source of energy for your body's cells and brain), is above 250.This deficient practice resulted in a delay in care and treatment for Resident 4 who was transferred to the General Acute Care Hospital (GACH) 2 on 9/9/2025. Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 9/8/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), essential (primary) hypertension (HTN-high blood pressure), gastrotomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and chronic kidney disease (CKD- condition where the kidneys are damaged and cannot function properly over an extended period). During a review of Resident 4's History and Physical (H&P- a foundational medical assessment where a clinician interviews a patient [the history] to understand their symptoms and health background, and then performs a physical exam by observing and palpating the patient's body to find signs of illness or injury) dated 9/9/2025, the H&P indicated Resident 4 did not have the capacity to make healthcare decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 9/9/2025, the MDS indicated Resident 4 sometimes understood and was sometimes understood. During a review of Resident 4's Order Summary Report dated 9/8/2025, the Order Summary Report indicated:- Novolin N FlexPen 100 units/milliliter (ml- a unit of measurement) suspension pen-injector, inject 10 units subcutaneously (subq- under the skin) in the morning for DM hold if blood sugar is less than 100 and inject 12 units subq at bedtime for DM hold if blood sugar is less than 100. - Fasting blood sugar (FSBS- a measure of the glucose in your blood after you've gone at least 8 hours without eating or drinking anything except water) every six (6) hours with no insulin sliding scale coverage, if blood sugar is less than 70 follow the hypoglycemia protocol, if blood sugar is above 250 call and notify the MD and or Nurse Practitioner (NP- a registered nurse with advanced education and training who can perform many tasks similar to a doctor, including diagnosing illnesses, ordering tests, and prescribing medication) every six (6) hours for DM. During a review of Resident 4's Clinical admission dated 9/8/2025 at 8:10 p.m., the Clinical admission indicated Resident 4 was admitted to Skilled Nursing Facility (SNF) 1 on 9/8/2025 at 8 p.m. with vitals signs (basic measurements that reflect how well your body's essential functions are working, including body temperature [a measure of how hot or cold something is, normal range 97.8 to 99], pulse [heart rate- the number of times your heart beats in one minute, normal rate 60 to 100 beats per minute], respiratory [breathing] rate, and blood pressure [normal range systolic pressure (top number) less than 120, diastolic pressure (bottom number) less than 80 millimeters of mercury [mmHg-a unit of measurement]) taken at 8 p.m. as follows: blood pressure 136/68, heart rate 66, respiration rate 16, and oxygen 96% on room air. During a review of Resident 4's Medication and Administration Record (MAR- - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for September 2025, the MAR on 9/9/2025 at 6 a.m. indicated:- FSBS every 6 hours with no insulin sliding scale coverage, if blood sugar is less than 70 follow hypoglycemia protocol if blood sugar is more than 250 call and notify the MD and or the NP every 6 hours for DM, the MAR indicated 2 (the MAR chart code indicated 2 means drug refused) - Novolin N flexpen 100 units/ml suspension pen injector, inject 10 units subq in the morning for DM hold if the blood sugar is less than 100, the MAR indicated 9 (the MAR chart code indicated 9 means other and or see progress note. During a review of Resident 4's Change in Condition (COC) Evaluation, dated 9/9/2025 at 10:11p.m., the COC Evaluation indicated Resident 4 transferred to hospital related to hypotension, elevated blood sugar level. At 7p.m. Resident 4 in bed, family at bedside, Resident 4 noted difficult to arouse, checked blood sugar noted at 379. The COC evaluation indicated Resident 4's vital signs (basic measurements that reflect how well your body's essential functions are working, including body temperature [a measure of how hot or cold something is, normal range 97.8 to 99], pulse [heart rate- the number of times your heart beats in one minute, normal rate 60 to 100 beats per minute], respiratory [breathing] rate, and blood pressure [normal range systolic pressure (top number) less than 120, diastolic pressure (bottom number) less than 80 millimeters of mercury [mmHg-a unit of measurement]) on 9/9/2025 at 7:05p.m. indicated a blood pressure of 84/49 mmHg, pulse 95, respiration rate 20, temperature of 97.9, oxygen saturation (a medical measurement of the amount of oxygen carried by your red blood cells, expressed as a percentage) 99% on room air (normal range 95 to 100%) and a blood glucose (the amount of glucose [sugar] in the blood) 379 (normal random range less than 125 milligrams per deciliter [mg/dL-a unit of measurement) mg/dL. The Medical Doctor (MD 1) was made aware of Resident 4's condition on 9/9/2025 at 7:30p.m. During a review of Resident 4's GACH 2's Emergency Documentation (ED) dated 9/9/2025, the GACH 2's ED indicated Resident 4 chief complaint was hypotension (low blood pressure) systolic blood pressure (sbp- the top, higher number in a blood pressure reading, measuring the force of blood against artery walls when the heart beats and pumps blood out) 80, unresponsive for 90 minutes prior to arrival, high blood sugar greater than 500 on 9/9/25 at 7:53 p.m. with positive acetone breath (a distinctive, fruity, or nail polish remover-like odor on your breath). The GACH 2's ED indicated Resident 4's laboratory results for glucose were 1,443. Final diagnosis indicated altered mental status (AMS), DKA and hyperkalemia (having too much potassium in your blood). During an interview on 9/25/2025 at 4 p.m. with LVN 1, LVN 1 stated notification to the doctor for Resident 4's change of condition was done after Resident 4 was transferred to the hospital. LVN 1 stated Resident 4's head of bed was lowered to Trendelenburg position (when a person lies flat on their back with their feet raised higher than their head, often by tilting the operating table), rechecked the blood pressure and it was still low. LVN 1 stated nothing else was done for Resident 4's low blood pressure. LVN 1 stated nothing was done for the blood sugar, checked the orders for insulin and none at that time, no intravenous (IV- is a way to give fluids, medications, or nutrients directly into a person's vein, allowing them to enter the bloodstream and be absorbed quickly) started. LVN1 stated we usually call the doctor to get orders for insulin to get orders for high blood sugar, LVN 1 stated did not call the doctor we called 911. LVN 1 stated if we had called the doctor they may have ordered for a as needed insulin, possibly could have ordered fluids for the low blood pressure. During an interview on 9/25/2025 at 4:26p.m. with the Registered Nurse (RN) 1, RN 1 stated on 9/9/2025 around 7 p.m. Resident 4 was not responsive, had a low blood pressure of 80/40 and was not responding to painful stimuli. RN 1 stated he stopped Resident 4's feeding and placed Resident in Trendelenburg position, RN 1 stated did this to help with the low blood pressure but it was ineffective and the blood sugar was in the 300's. RN 1 stated called 911 did not call the doctor because would have taken more time. RN 1 stated Resident 4 did not have orders for insulin, called the doctor once Resident 4 was being transported to the hospital around 7:25 p.m. RN 1 stated when we have residents with low blood pressure we call the doctor and get orders for fluids and for the high blood sugar Resident 4 did not have any sliding scale and or as needed orders. RN 1 stated could have called the doctor to get orders for the insulin but did not. RN 1 stated is aware Resident 4 has orders to call the doctor if the sugar is above 250 but did not call the doctor because Resident 4 was not responsive. During a concurrent interview and record review on 9/29/2025 at 3 p.m. of Resident 4's MAR and orders with Assistant Director of Nursing (ADON), the ADON stated when a new resident is admitted to the facility the doctor is notified then the nurse will send over the medication recap form from the hospital to let the doctor decide if they wish to continue the medications. The ADON stated once the doctor approves the medication the nurse will input all orders in and start the orders within the hour when the resident was admitted to the facility. The ADON stated for Resident 4 if there were orders for the morning would have started the next day but if it were for bedtime, it would start that same night. The ADON stated orders will automatically start the next shift unless the nurse goes in and edits the order to start that shift. The ADON reviewed Resident 4's order for the g-tube feeding and the ADON stated the facility has in-house supply of the formula and pump that were ordered for Resident 4, the ADON stated the feeding should have been set up right away. The ADON reviewed MAR and Medication Audit Report, the ADON stated nurse signed g-tube was off at 10 a.m. but never signed that the g-tube was started prior to the 10 a.m. off time. The ADON stated Resident 4 missed out on 14 hours of the feeding. The ADON stated if Resident 4 is missing out on 14 hours of the feeding this can cause Resident 4's blood sugar to drop, risk for dehydration, and a concern with Resident 4 to feel hungry. The ADON stated the order indicates Resident 4 to have the feeding at a rate of 55 ml an hour, Resident 4 missed out on 770 ml of the feeding. The ADON stated when there is an emergency, we call 911 initially then we call the doctor while we wait for the paramedics to arrive. The ADON stated must notify the doctor of what is going on with the resident at that time, the doctor may order something in the meantime. The ADON stated can result in a delay in care and treatment if the doctor is not notified. During a review of the facility's P&P titled, Medication, Administration, last reviewed on 4/30/2025, the P&P indicated all medications shall be administered by licensed nursing staff according to physician orders, current best practice, and federal and stated regulations.Refusing MedicationA. The License Nurse will attempt to give the medication several times, but if residents continue to refuse after an hour, the refused medication will be destroyed.Licensed Nurse will notify the prescribing provider and document in the medical record including the reason for refusal. During a review of the facility's P&P titled, Diabetic Care, last reviewed on 4/30/2025, the P&P indicated the attending physician will write parameters for notification for blood sugar that is out of control.In any case where the resident's blood sugar is less than 70 or greater than 350, the Attending Physician must be notified, unless otherwise noted on the Physician's order. During a review of the facility's P&P titled, Blood Glucose Monitoring, last reviewed on 4/30/2025, the P&P indicated the Attending Physician will be notified of blood sugar level lower than 70 or higher than 350, unless otherwise indicated in the physician order.

Based on observation, interview and record review, the facility failed to ensure the residents were free from physical abuse for two of four sampled residents (Resident 1 and Resident 3). The facility failed to: 1. Ensure Resident 1, who had a history of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), was free from physical abuse. On 4/21/2024 at 8:20 a.m., Resident 1 reported to Restorative Nursing Assistant 1 (RNA 1) that Resident 2 threw a cup at Resident 1 ' s face. 2. Ensure Resident 3, who had a cognitive communication deficit (difficulty with thinking and how someone uses language), was free from physical abuse. On 4/19/2024 at 10:30 a.m., Licensed Vocational Nurse 2 (LVN 2) witnessed Resident 4 hit Resident 3 in the left shoulder. These deficient practices resulted in: 1. On 4/21/2024, Resident 1 sustained a right cheek skin tear measured 1.0 centimeter ([cm] a unit of measurement) long and 1.0 cm wide, with bleeding, pain, swelling, and blurred vision. On 4/22/2024, Resident 1 was transferred to a General Acute Care Hospital 1 (GACH 1) for evaluation and further management of right upper cheek swelling and increasing pain. 2. Resident 3 sustaining psychological (related to the mental and emotional state of a person) harm manifested by crying when remembering and talking about the incident with Resident 4 on 4/19/2024 and feeling humiliated and embarrassed. Based on the Reasonable Person Concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial [pertaining to the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors] outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Residents 1 and 3 ' s impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering), skills for daily decision making and medical condition, an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self). Findings: 1. During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] disease that cause airflow blockage and breathing-related problems), dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and difficulty in walking. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 2/1/2024, the MDS indicated Resident 1 required a moderate assistance from staff for toileting, personal hygiene, and transfers. The MDS indicated Resident 1 used a wheelchair for mobility. During a review of Resident 1 ' s History and Physical (H&P), dated 3/30/2024, H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Change in Condition ([CIC]-a significant change in a member's health or functional status that will not normally resolve itself without further intervention), dated 4/21/2024, the COC indicated there was a resident-to-resident altercation. The COC indicated Resident 1 had swelling, abrasion (a superficial rub or wearing off of the skin, usually caused by a scrape or a brush burn), and bleeding to the right side of the face. During a review of Resident 1 ' s Weekly Skin/Wound Assessment, dated 4/21/2024, the Weekly Skin/Wound Assessment indicated Resident 1 had the right cheek bone skin tear measured 1.0 cm long and 1.0 cm wide, and the right eye periorbital (around the eye) swelling. During a review of Resident 1 ' s Progress Notes, dated 4/21/2024, the Progress Notes indicated on 4/21/2024 at 8:20 a.m., Restorative Nursing Assistant 1 (RNA 1) notified Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had an altercation with Resident 2. The Progress Note indicated Resident 2 threw a cup at Resident 1 ' s face on 4/21/2024 at 7 a.m. During a review of Resident 1 ' s Progress Note, dated 4/22/2024, the Progress Note indicated Resident 1 was transferred to GACH 1 for evaluation and management of right upper cheek swelling and pain. During a review of Resident 1 ' s Ophthalmology (medical science of eye diseases) Exam/ Consult and Report, dated 4/24/2024, the Ophthalmology Exam/ Consult and Report indicated Resident 1 had evaluation of the right eye vision due to redness. The Ophthalmology Exam/ Consult and Report indicated Resident 1 had ecchymosis (a small bruise caused by blood leaking from broken blood vessels into the tissues of the skin or mucous membranes) and contusion (an injury that causes bleeding and tissue damage underneath the skin, usually without breaking the skin) to the orbit (cavity or socket/hole of the skull in which the eye is situated) of the right eye. During a review of Resident 2 ' s Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non dominant side, hypertension (high blood pressure) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During a review of Resident 2 ' s H&P, dated 3/30/2024, the H&P indicated the resident had capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated the resident had an intact cognition. During a review of Resident 2 ' s COC dated 4/21/2024, the COC indicated there was a resident-to-resident altercation. The COC indicated Resident 2 threw a cup at Resident 1. During a review of Resident 2 ' s Interdisciplinary ([IDT]-a coordinated group of experts from several different fields who work together) team Care Conference Notes, dated 4/22/2024, the IDT team Care Conference notes indicated Resident 1 made racial slur comments and threw a cup at Resident 2 first and Resident 2 responded by throwing the cup back at Resident 1. The IDT team Care Conference notes indicated Resident 2 was on Seroquel (medication used to treat schizophrenia) for schizophrenia manifested by auditory hallucinations (when you hear voices or noises that aren't there) as evidenced by hearing his name repeatedly. During a concurrent observation and interview on 5/1/2024 at 8:55 a.m., with Resident 1 inside his room, Resident 1 was observed lying in bed with two pillows under his head and covered with white sheet from waist down. Resident 1 was observed to have a black scab (a dry, rough protective crust that forms over a cut or wound during healing) on the right cheek. Resident 1 stated Resident 2 threw a hard plastic cup at him resulting in skin cut and pain on his right side of the face. Resident 2 stated his pain was eight out of ten on a pain scale (a tool use to help assess a person's pain) from zero to ten where zero is no pain and 10 is the worse pain possible. Resident 1 stated he had blood all over his face. Resident 1 stated the doctor did not came to see him and he was sent to the hospital where he had an x-ray (an imaging test to view internal body structure) two days after he was hit. Resident 1 stated he did not have any vision problem before the incident but now his vision is blurry, and he cannot see well. During an interview on 5/1/2024 at 9:08 a.m., Resident 2 stated Resident 1 was making racial slur comments at him. Resident 2 stated Resident 1 threw the cup initially at him, so he threw it back. Resident 2 stated the cup thrown by Resident 1 did not hit him. During an interview on 5/1/2024 at 9:12 a.m., RNA 1 stated on 4/21/24 at 8:20 a.m., he went inside Resident 1 and Resident 2 ' s room and saw Resident 1 lying in bed with blood on his right side of the face. RNA 1 stated that Resident 2 was on his bed. RNA 1 stated Resident 1 reported, while pointing at Resident 2 ' s direction, that Resident 2 hit him with a cup. RNA 1 stated Resident 2 replied that Resident 1 was making racial slur comments. RNA 1 stated he called LVN 1 who was walking in the hallway. RNA 1 stated when LVN 1 came inside the room, RNA 1 went out and called Registered Nurse 1 (RN 1) and Treatment Nurse 1 (TN 1). During an interview on 5/1/2024 at 9:22 a.m., LVN 1 stated on 4/21/2024, RNA 1 notified her that Resident 1 and Resident 2 had an altercation. LVN 1 stated when she went inside the residents ' room she saw Resident 1 ' s right side of the face with blood, bruise, and a bump. LVN 1 stated Resident 2 reported that Resident 1 ' s television was loud and he asked Resident 1 to turn the volume down, but Resident 1 responded by making racial slur comments. LVN 1 stated Resident 2 admitted throwing the cup back at Resident 1 after Resident 1 threw it at him first. During a concurrent interview and record review on 5/1/2024 at 9:40 a.m., TN 1, Resident 1 ' s Weekly Skin/Wound Assessment, dated 4/21/2024, was reviewed. The Weekly Skin/ Wound Assessment indicated Resident 1 had a right cheek skin tear measured 1.0 cm long by 1.0 cm wide and the right periorbital eye swelling. TN 1 stated on 4/21/2024, LVN 1 notified him of Resident 1 and Resident 2 altercation. TN 1 stated when he went inside the residents ' room, he saw Resident 1 with blood coming down from his right cheek and his (Resident 1) face looked swollen. During an interview on 5/3/2024 at 8:49 a.m., the Director of Staff Development (DSD) stated abuse is the unintentional hurting of someone. The DSD stated the incident between Resident 1 and Resident 2 was not an abuse because Resident 2 had the intention to throw the cup back at Resident 1. The DSD stated that was her understanding about abuse incidents. During an interview on 5/3/2024 at 9:18 a.m., the Director of Nursing (DON) stated Resident 2 informed her that it was self-defense because Resident 1 was insulting him, and he got frustrated. The DON stated Resident 2 did not deny throwing the cup at Resident 1. The DON stated abuse is deliberate infliction of injury and altercation falls under abuse. During an interview on 5/3/2024 at 9:34 a.m., the Administrator (ADM) stated Resident 2 abused Resident 1. The ADM stated both residents denied, however, there was evidence that something took place because there was injury to Resident 1 and that was abuse. 2. During a review of Resident 3 ' s Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack) COPD, cognitive communication deficit and type 2 diabetes mellitus (high blood sugar levels). During a review of Resident 3 ' s H&P, dated 2/9/2024, the H&P indicated the resident could not make own decisions but could make needs known. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 3 was unable to walk and used a wheelchair for mobility. During a review of Resident 3 ' s COC, dated 4/19/2024, the COC indicated Resident 3 had a potential for pain and emotional distress when Resident 4 had a contact with Resident 3 ' s upper left shoulder. The COC indicated Resident 3 was sitting on her wheelchair when Resident 4 got out of her wheelchair, took two steps forward and made a physical contact with Resident 3 ' s left shoulder. During a review of Resident 3 ' s Progress Note, dated 4/19/2024, the Progress Note indicated Resident 3 notified Psychologist (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) through facetime that she was waiting in the hallway when Resident 4 came to her and hit her on the shoulder. During a review of Resident 3 ' s IDT ' s Care Conference notes, dated 4/19/2024, the IDT notes indicated LVN 2 witnessed the incident from the nurse ' s station but was not able to prevent it. The IDT notes indicated Resident 3 reported that she was just sitting when Resident 4 got up and swung at her. During a concurrent observation and interview on 5/3/2024 at 9:55 a.m., inside Resident 3 ' s room, Resident 3 was observed sitting on a wheelchair. Resident 3 stated she cannot forget when Resident 4 hit her so hard in between her left shoulder and left side of her head. Resident 3 stated she was hit so hard, and it was so painful. Resident 3 was observed started to cry and stated she felt so humiliated and embarrassed. Resident 3 stated what Resident 4 did was not acceptable and that she felt abused. Resident 3 stated she was hit twice on her left shoulder. During a review of Resident 4 ' s Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (is a problem in the brain, caused by a chemical imbalance in the blood), schizoaffective disorder (is a mental health problem where you experience psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality] as well as mood symptoms), and essential hypertension. During a review of Resident 4 ' s H&P, dated 4/18/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 4 ' s MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 4 was dependent on staff for standing and walking. During a review of Resident 4 ' s COC, dated 4/19/2024, the COC indicated at 8: 10 a.m., Resident 4 had increased confusion. The COC indicated Resident 4 walked out of the room without assistance. The COC indicated the staff attempted to redirect Resident 4 but was not successful and the resident continued walking in the hallway. During a review of Resident 4 ' s COC, dated 4/19/2024, the COC indicated Resident 4 swung at Resident 3 without provocation. The COC indicated doctor was notified and ordered to transfer Resident 3 to GACH 2. During a review of Resident 4 ' s IDT Care Conference notes dated 4/19/2024, the IDT Care Conference notes indicated Resident 4 had an increased confusion on 4/19/2024 at 8 a.m., and multiple staff attempted to redirect the resident, but the resident remained difficult to redirect during activities of daily living ([ADL]- personal hygiene, eating and walking). During a review of the facility ' s Witnesses Statement, dated 4/19/2024, the facility ' s Witnesses Statement indicated LVN 2 was at the nursing station when she saw Resident 4 got up from a wheelchair and swung at Resident 3. During an interview on 5/3/2024 at 8:18 a.m., the DSD stated LVN 2, who witnessed the incident between Resident 3 and Resident 4, no longer works at the facility. During an interview on 5/3/2024 at 8:25 a.m., LVN 3 stated on 4/19/2024 she was in another room when she came out, she saw Resident 4 was sitting on a wheelchair across the nursing station and Resident 3 was not there. LVN 3 stated LVN 2 notified her that Resident 4 got up from the wheelchair and punched Resident 3 ' s left shoulder. LVN 3 stated Resident 4 punched Resident 3 and that is an abuse. During an interview on 5/3/2024 at 8:44 a.m., Certified Nursing Assistant 1 (CNA 1) stated when she came in that morning of 4/19/2024 she was notified to be careful with Resident 4 because she could hit people. CNA 1 stated that morning when she went inside Resident 4 ' s room, Resident 4 told her to get out. CNA 1 stated an hour later she saw Resident 4 walking in the hallway with blanket tied to her waist and she was very fast. CNA 1 stated she took the wheelchair and followed Resident 4 and redirected the resident back to her room. During an interview on 5/3/2024 at 9:03 a.m., RN 2 stated that on 4/19/2024, LVN 2 notified her that Resident 4 hit Resident 3 in the shoulder. RN 2 stated she noticed Resident 3 was crying. RN 2 stated Resident 4 had increased confusion that morning and they were monitoring her. RN 2 stated monitoring was not done at the bedside of the resident the whole time, just visual checks. RN 2 stated Resident 4 abused Resident 3 when she hit her. During an interview on 5/3/2024 at 9:18 a.m., the Director of Nursing (DON) stated Resident 4 unintentionally abused Resident 3. During an interview on 5/3/2024 at 9:34 a.m., the ADM stated in the case of Resident 3 and Resident 4, it was a witnessed physical contact. The ADM stated any unwanted physical contact that has the potential to hurt the resident is abuse. A review of facility ' s policy and procedure (P&P) titled, Abuse-Prevention, Screening, and Training Program. dated 7/2018 and reviewed on 3/26/2024, indicated, abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint not required to treat symptoms and or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, ,mental anguish .It includes verbal abuse, sexual abuse, physical abuse, mental abuse or abuse facilitated or enabled by the use of technology that cause physical harm, pain or mental anguish. Physical abuse is defined as, but not limited to, hitting, slapping, punching, and or kicking. Mental Abuse, emotional abuse and psychological abuse are defined as, but is not limited to, verbal or nonverbal conduct that causes humiliation, intimidation, fear, shame, agitation, or degradation. A review of facility ' s P&P titled, Reporting Abuse, dated 1/8/2014 and reviewed on 3/26/2024, indicated the facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Based on interview and record review, the facility failed to prevent an accident and injury for one of three sampled residents (Resident 1), who was a high risk for falls and was on a low air loss mattress (LALM, a device that operates using a blower-based pump designed to circulate a constant flow of air; the air mattress is covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture as well as to relieve pressure). The facility failed to ensure Certified Nursing Assistant 1 (CNA 1) was trained on the changes in setting of the LALM during turning and cleaning Resident 1. As a result, on 11/10/2023, at around 10 p.m., while CNA 1 was turning Resident 1 in bed without the LALM adjusted to firm, Resident 1 fell out of bed hitting the back of the head. Resident 1 was immediately transferred to General Acute Care Hospital 1 (GACH 1) and required three staples (specialized surgical staples used to close wounds) to a laceration (cut) on the scalp at the back of the head. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted Resident 1 on 4/6/2021 with diagnoses including right hemiplegia (loss of strength on one side of the body) and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction (a disruption of blood supply and oxygen to the brain), muscle wasting (loss of muscle tissue and strength), and cognitive communication deficit (a person has difficulty communicating because of injury to the brain that controls the ability to think). A review of Resident 1 ' s Fall Risk Evaluation form, dated 6/25/2023, indicated Resident 1 scored 18. The assessment tool indicated that a score of ten (10) or higher meant high fall risk. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/5/2023, indicated Resident 1 had impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for care including bed mobility, transfers from or to bed, and showering or bathing. Resident 1 was assessed as incontinent (unable to control) of bowel and bladder functions. A review of the Physician ' s Order for Resident 1, dated 6/26/2023, indicated the use of a LALM for skin management due to skin fragility (skin easily breaks) with normal pressure and to set firmness at Resident 1 ' s current weight. A review of Resident 1 ' s Treatment Administration Record (TAR) indicated that from 11/1/2023 to 11/10/2023, Resident 1 was using the LALM. A review of Resident 1 ' s Change in Condition, dated 11/10/2023, indicated that approximately at 10 p.m. CNA 1 reported he needed assistance because Resident 1 had fallen out of bed. Upon entering Resident 1 ' s room, Charge Nurse found Resident 1 on the floor on lying on the left side of the bed. Charge Nurse noticed blood on the ground and asked CNA 1 to call Registered Nurse (RN) Supervisor. RN Supervisor, after assessing Resident 1, instructed staff (unspecified) to call 911 (emergency number to obtain help [paramedics, persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital]). Resident 1 was noted with blood on the back of the head, repeatedly calling out and crying, grimacing (expression of pain), and unable to be consoled or reassured. A review of the Physician ' s Order for Resident 1, dated 11/10/2023, indicated to transfer Resident 1 to a GACH via 911 related to falling. A review of Resident 1 ' s GACH 1 History and Physical Reports, dated 11/11/2023, indicated Resident 1 had a laceration (cut) on the scalp and three staples (specialized surgical staples used to close wounds). Resident 1 was admitted to GACH 1. On 12/7/2023 at 3:11 p.m., during an interview, the Treatment Nurse (TM) stated only licensed nurses (LNs, both Licensed Vocational Nurses [LVNs] and RNs) were allowed to change / adjust the LALM settings. TM stated the setting of the LALM is based on the resident ' s weight. If the mattress was placed on static or in paused mode before care was provided, the mattress would be same level of firmness; the resident would not be thrown off the mattress, the air inside would be static. The TN did not mention the use of the Max Inflate / Low Air Loss Button. On 12/7/2023 at 3:32 p.m., during an interview, the Director of Staff Development (DSD) stated he did not know about the settings for the LALM for care and turning in bed or the purpose of the Static button on the LALM pump. The DSD indicated he was responsible for providing training to staff but confirmed that training related to use of LALM was not provided. The DSD did not provide evidence that nursing staff reviewed the LALM manufacturer ' s recommendations and guidance on its use. On 12/7/2023 at 3:48 p.m., during an interview, the Quality Assurance (QA) Nurse stated that adjusting the LALM firmness for care was important when treatment or personal care was provided to the residents on the LALM so that the air pressure inside the mattress would equalize. The QA Nurse stated the LNs could stop the LALM air flowing by pressing the pause or the Static Button and this would keep the air inside the mattress even. The QA Nurse indicated that if the air inside the mattress was not even, the free-flowing air will not equalize the pressure inside the LALM, the weight of the resident on one side of the bed would flatten the mattress and cause the air to shift to the opposite side of the mattress and push the resident off. The QA Nurse added that the LALM material could be slippery. The QA Nurse did not mention the use of the Max Inflate / Low Air Loss Button. On 12/7/2023 at 4:08 p.m., during an interview, CNA 1 confirmed he took care of Resident 1 on 11/10/2023 when Resident 1 fell out of the bed. CNA 1 confirmed not calling a LN to pause or set the LALM to static before assisting Resident 1 with personal hygiene and incontinent care. CNA 1 stated he was at the right side of the bed when turning Resident 1 onto Resident 1 ' s left side and Resident 1 fell on the left side of the bed, the opposite side of the bed from where CNA 1 was standing. CNA 1 indicated seeing blood on the back area of Resident 1 ' s head. On 12/7/2023 at 5:11 p.m., during an interview, RN 2, when asked what the static button on an LALM was for, RN 2 stated, I don ' t know. I am not sure. I have not received in-service on use of LALM. On 12/7/2023 at 6:18 p.m., during an interview, the QA Nurse stated the vendor (provide the facility with the LALM) have not provided in-service training to the nursing staff on the use of the LALM. The QA Nurse did not provide evidence nursing staff reviewed and were familiar with the LALM manufacturer ' s recommendations and guidance on its use. On 12/7/2023 at 6:36 p.m., during interview, the Director of Nurses (DON) stated Resident 1 was at risk of infection on the scalp laceration. The DON was asked to provide a policy and procedure (P&P) on the use of the LALM including the settings and who was allowed to adjust the settings and when settings needed to be adjusted (i.e., providing personal care); however, none was provided. A review of the LAL Mattress Manufacturer ' s General Guidelines, page 5 of 33, indicated, Danger, Risk for Death, Injury or Damage: - If you are unable to understand the warnings, cautions or instructions, contact healthcare professional, dealer, or technical personnel before attempting to use this equipment. - Do not use this product or any available optional equipment without first completely reading and understanding these instructions and any additional instructional material such as user manuals or instruction sheets supplied with this product or optional equipment. The LAL Mattress Manufacturer ' s General Guidelines, page 21 of 33 indicated, Press the Static Button to enter Static mode and maintain all air cushions in the mattress at a constant pressure. The LAL Mattress Manufacturer ' s General Guidelines, page 22 of 33 indicated, Press the Max Inflate / Low Air Loss button to select the max inflate mode or the low air loss mode. Max Inflate Mode: in this mode the mattress inflates rapidly to maximum firmness. It is recommended that Max Inflate setting be used during turning or patient cleaning. A review of the facility ' s provided P&P titled, Fall Management Program last revised on 3/13/2021 indicated the purpose of the P&P was To provide residents a safe environment that minimizes complications associated with falls. A review of the facility ' s provided P&P titled, Safety of Residents revised on 1/1/2012 indicated the purpose of the P&P was To provide a safe environment for residents and Facility Staff. A review of the facility provided P&P titled, In-Service Training and Record Keeping last revised one 2/20/2020 stated the Training program shall address specific needs of the facility ' s resident population, address areas for improvement determined through annual nurse performance reviews, facility deficiencies and annual facility assessment.ased on interview and record review, the facility failed to prevent an accident for one of three sampled residents affecting Resident 1 by: 1) Failing to implement the correct use of a Low Air-loss (LAL) Mattress (a mattress designed to distribute a patient ' s body weight over a broad surface area and help with the prevention of skin breakdown). 2) Failing to provide training to staff on use of LAL mattress. While receiving care from staff, Resident 1 encountered a fall from the bed, which resulted in the need for hospitalization and treatment for injuries sustained related to the fall. This deficient practice increases the risks for injuries, pain, and or psychosocial despair to other residents within the facility who may also be dependent on staff care. Findings A record review of Resident 1 ' s Admission Record indicated an admitted [DATE] with diagnoses of Hemiplegia (severe or complete loss of strength to one side of the body) and Hemiparesis (mild loss of strength affecting one side of the body) following Cerebral Infarction (a disruption of blood supply and oxygen to the brain) affecting right side, muscle wasting (loss of muscle tissue and strength), and cognitive communication deficit (difficulty in thinking and how someone uses language). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 10/5/2023 indicated that Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making tasks were severely impaired. The MDS further indicated that Resident 1 was fully dependent (helper does all the effort to complete the activity) on staff for eating, oral hygiene, toileting hygiene (including adjusting of clothes before and after an episode of bowel and bladder incontinence), showering or bathing, dressing, and handling of personal hygiene needs. A review of Resident 1 ' s Fall Risk Evaluation dated 6/25/2023 indicated that Resident 1 scored a fall risk total score of eighteen (18). The assessment tool stated that a score of ten (10) or higher placed Resident 1 at high risk for falls. A review of Resident 1 ' s Physician ' s orders dated 6/26/2023 include an order for use of Low Air Loss Mattress for skin management due to skin fragility (easily broken or damaged skin). A record review of Resident 1 ' s Treatment Administration Record (TAR) indicated that on 11/10/2023, the day of encountering a fall incident, Resident 1 was using an LAL mattress. On 12/7/2023 at 3:11 p.m., during an interview with the Treatment Nurse (TM), TM indicated that only licensed nurses (Licensed Vocational Nurses or Registered Nurses) are allowed to touch the settings on an LAL mattress. TM stated, The purpose of having the LAL mattress is to help prevent pressure injuries (damage to skin or underlying tissue due to prolonged constant pressure placed on the area). The LAL mattress is based on a resident ' s weight. The air inside alternates and it reduces pressure points applying it to other parts of the body. Its purpose is to relieve pressure points to prevent skin breakdown and to manage circulation for tissue perfusion or skin circulation. If the machine is not deactivated, the air inside the mattress would freely move. The air would shift inside the mattress to the opposite side of where the resident is laying and throw the resident off the mattress. If the mattress was placed on static (lacking in movement) or paused mode before care was provided, the mattress would be same level of firmness and the resident would not be thrown off the mattress, the air inside would be static. TM indicated that an order for use of LAL mattress must be obtained from a physician and that was why Certified Nursing Assistants (CNA) are not allowed to touch the settings. A review of Resident 1 ' s Physician ' s orders dated 11/10/2023 indicated an order to transfer Resident 1 to a General Acute Care Hospital (GACH) via 911 (emergency response) related to status post fall. A review of Resident 1 ' s record titled Change in Condition dated 11/10/2023 at 11:06 p.m. indicated that Resident 1 encountered a fall. Resident 1 ' s functional status was described as In Pain and Contracted (stiffened parts of the body). Resident 1 was identified with Blood stain on back of the head. Resident 1 was also described as troubled with repeated calling out and crying, facial expressions with grimacing (expression of pain or strong dislike) and was unable to be consoled (to provide comfort) or be reassured. On 12/7/2023 at 3:32 p.m., during an interview with the Director of Staff Development (DSD), DSD was asked what the purpose of the Static button was on an LAL mattress machine. DSD was unable to answer the question. DSD indicated being responsible for providing training to staff but confirmed that training related to use of LAL mattress has not been provided. On 12/7/2023 at 3:48 p.m., during an interview with the Quality Assurance (QA) Nurse, QA indicated that for LAL mattresses, the static (lacking in movement) button is activated when treatment or Activities of Daily Living (ADL) is being provided to the resident so that the air pressure inside the mattress would equalize. QA stated that Licensed Nurses can stop the LAL mattress by pressing the pause or static button and it will keep the air inside the mattress even. QA indicated that if the air inside the mattress is not even, the free-flowing air will not equalize the pressure inside the mattress, the weight of the resident on one side of the bed would flatten the mattress and cause the air to shift to the opposite side of the mattress and push the resident off. QA added that the LAL mattress is made of a slippery material. On 12/7/2023 at 4:08 p.m., during an interview with Certified Nurse ' s Assistant 1 (CNA 1), CNA 1 described Resident 1 as not being alert and being fully dependent on staff for activities of daily living (ADL) hygiene needs. CNA 1 confirmed that Resident 1 was using an LAL mattress, but CNA 1 did not call any licensed nurse to deactivate the LAL mattress before working with Resident 1. CNA 1 stated being on the right side of Resident 1, then turning Resident 1 onto resident ' s left side, causing Resident 1 to have a fall on the opposite side of the bed from where CNA 1 was standing. CNA 1 indicated seeing blood on the back area of Resident 1 ' s head. On 12/7/2023 at 5:11 p.m., during an interview with Registered Nurse 2 (RN 2), when asked what the static button on an LAL mattress was for, RN 2 stated, I don ' t know. I am not sure. I have not received in-service on use of LAL mattresses. RN 2 indicated that it was important for staff to know how to properly use an LAL mattress so that it can be used correctly. RN 2 stated that staff need to know more about how the LAL mattress works to prevent incidents from happening again. On 12/7/2023 at 6:18 p.m., during an interview with QA, QA indicated that the facility staff have not been provided in-service training for use of LAL mattress by facility or from the vendor that delivers the LAL mattresses to the facility. On 12/7/2023 at 6:36 p.m., during interview with Director of Nurses (DON), DON indicated that Resident 1 was sent to GACH on 11/10/2023 after the fall encounter. During concurrent record review with DON of the GACH records, Resident 1 received three (3) staples (surgical staples to close skin) while in the emergency department due to a laceration (a deep cut or tear in the skin) on Resident 1 ' s scalp (skin covering the head). DON stated that a risk factor of Resident 1 ' s laceration to the head would include risk for infection. On 12/7/2023 at 6:32 p.m., during interview, Infection Prevention (IP) Nurse was asked what risk factors that Resident 1 was placed in after sustaining a fall and injury to the head. IP indicated that Resident 1 would be at risk for bleeding or excessive bleeding on the injury site, which could lead to death. On 12/7/2023 at 6:40 p.m., during interview with QA regarding Resident 1 ' s risk factors associated with the head injury from the fall, QA indicated that the injury could cause seizures which are abnormal electrical impulses to the brain, causing something serious like choking or airway obstruction to Resident 1, leading to death. A review of Resident 1 ' s Care plan (a form summarizing a resident ' s health condition, specific care needs, and current treatments) with revision date 9/17/2023 indicated the focus for Impaired Skin Integrity with interventions to include providing an air loss mattress for skin management, and to Provide education to resident, responsible party, and staff regarding special care needs. A review of the LAL Mattress Manufacturer ' s general guidelines page 5 of 33 indicated, Danger, Risk for Death, Injury or Damage stating: - If you are unable to understand the warnings, cautions or instructions, contact a healthcare professional, dealer, or technical personnel before attempting to use this equipment. - Do not use this product or any available optional equipment without first completely reading and understanding these instructions and any additional instructional material such as user manuals or instruction sheets supplied with this product or optional equipment. A review of the facility provided Policy and Procedure titled Fall Management Program with last revised date 3/13/2021 indicated the purpose, To provide residents a safe environment that minimizes complications associated with falls. A review of the facility provided Policy and Procedure titled Safety of Residents with last revision date 1/1/2012 indicated, To provide a safe environment for residents and Facility Staff. A review of the facility provided Policy and Procedure titled In-Service Training and Record Keeping with last revised date 2/20/2020 stated, To establish guidelines for facility staff to complete required in-service education in accordance with Federal and State regulations. The policy indicated, Training program shall address specific needs of the facility ' s resident population, address areas for improvement determined through annual nurse performance reviews, facility deficiencies and annual facility assessment.

Based on interview and record review, the facility failed to provide supervision and follow its policy and procedures titled, Wandering & Elopement, to ensure one of two sampled residents (Resident 1) would not elope (leaving facility without notice or permission) from the facility. The facility failed to: -Ensure Resident 1 received an accurate behavioral and mental evaluation after the attempted elopement on 8/1/2022, per the Change in Condition Evaluation. - Develop and implement a person-centered comprehensive elopement care plan for Resident 1, including supervision or a detailed monitoring plan and monitoring placement and functioning of the Wander Guard. As a result, on 12/2/2022, Resident 1 eloped from the facility and remains missing. Findings: A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 6/16/2022 with diagnoses including unspecified encephalopathy (disease of the brain manifested by an altered mental state sometimes accompanied by physical changes), uncomplicated psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), and hypertension (HTN - elevated blood pressure). A review of Resident 1's Elopement Evaluation, dated 8/1/2022 indicated the resident had a history of or attempted leaving the facility without informing staff, was a wanderer, and that Resident 1's wandering behavior was likely to affect the privacy of others. The Elopement Evaluation form indicated Resident 1 scored of 5 and was at risk of elopement, however the evaluation form did not indicate the score key to determine the score range for 'at risk.' A review of Resident 1's Change of Condition (COC) Evaluation form dated 8/1/2022, indicated Resident 1 had an episode of attempting to leave the facility. The COC form indicated Resident 1 was reoriented multiple times but failed to comprehend. The primary physician recommended to apply Wander Guard (a system to monitor resident safety to protect those at risk of elopement) and closely monitor the resident. The COC form indicated Resident 1 had an ability to pay attention and had no mental changes compared to baseline. The COC also indicated Resident 1's behavioral assessment was not relevant to the change in condition of attempting to elope from the facility and was not clinically applicable to the change in condition being reported. This indicated a discrepancy in the COC Evaluation for Resident 1. The COC form also indicated a neurological assessment for Resident 1 (including cognition; mood and affect; and thought content), was not clinically applicable to the change in condition being reported. According to a review of the Physician's Orders dated 8/1/2022, Resident 1 received a Wander Guard due to episodes of wandering out of the facility and to check wander guard using code alert every shift. A review of Resident 1's care plan for elopement or wandering, dated 8/1/2022 and updated 9/2/2022, indicated resident was a risk for wandering or elopement related to resident unaware of safety needs. The care plan interventions included application of wander guard, assess resident's elopement risk at the following intervals: admission, readmission, quarterly, and identification of significant change of condition. The care plan did not include interventions for Resident 1 to be placed closer to the nursing station or farther from the exit doors whichever was appropriate or safer for the resident's needs and did not indicate supervision or detailed monitoring plan. A review of Resident 1's Interdisciplinary Team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) Note, dated 9/19/2022 indicated on 8/1/2022 Resident 1 had an episode of attempt to leave facility, and to monitor resident closely with Wander Guard to prevent elopement. A review of the Minimum Data Set (MDS- an assessment and care screening tool), dated 9/21/2022, indicated Resident 1 was cognitively intact (decisions consistent / reasonable) and required supervision with set up help only for bed mobility, transfer, and locomotion on and off unit. A review of Resident 1's Change of Condition form, dated 12/2/2022 indicated the resident was ambulating the hallway in the morning. At 12 pm, Resident 1 was not found in the facility and had an episode of elopement. The COC indicated Resident 1 had no mental changes compared to baseline, and a behavioral assessment was not clinically applicable to Resident 1's change in condition. The COC form also indicated a neurological assessment (including cognition; mood and affect; and thought content), was not clinically applicable to Resident 1's change in condition. During an interview on 2/1/2023 at 3:24 PM, the Director of Nursing (DON) stated Licensed Vocational Nurse 1 (LVN 1) documented on the COC that Resident 1 was reoriented multiple times but failed to comprehend during the first attempt to elope. The DON stated if Resident 1 did not comprehend or was unable to be reoriented, either the behavioral evaluation section of the COC or mental status evaluation section should have been documented reflecting such. The DON stated the COC Evaluation indicated no changes observed in mental status evaluation and behavioral status evaluation not clinically applicable to the change in condition being reported. She stated this was not an appropriate assessment of Resident 1 after the attempted elopement on 8/1/2022. The DON stated the recommendation of the primary physician was to monitor closely and apply the Wander Guard. She stated the care plan for elopement risk included to apply the Wander Guard but did not indicate monitoring. The DON stated Resident 1's risk of elopement care plan did not include the monitoring and could potentially increase the elopement risk for Resident 1. The DON stated Resident 1 remains missing. During an interview on 2/1/2023 at 3:45 PM, Registered Nurse 1 (RN 1) stated Licensed Vocational Nurse 1 (LVN 1) documented that Resident 1 was reoriented multiple times but failed to comprehend during the first attempt to elope. RN 1 stated the COC indicated the mental or behavioral evaluation was not conducted and that LVN 1 should have completed a mental or behavioral evaluation after Resident 1's incident on 8/1/22. RN 1 stated the care plan for elopement risk did not include monitoring interventions for Resident 1. On 2/1/2023 at 3:55 PM, during an interview, the Administrator (ADM) stated the elopement care plan for Resident 1 did not indicate visual monitoring for elopement. The Administrator stated it was very unlikely that staff would monitor Resident 1 if not indicated in the care plan causing a potential for Resident 1 to elope from the facility unnoticed. During an interview on 2/2/2023 at 3:47 PM, Licensed Vocational Nurse 1 (LVN 1) stated she tried to reorient Resident 1 on 8/1/2022 when the resident tried to ambulate throughout the facility. She stated Resident 1 seemed to not understand and did not want to go back to his room. LVN 1 stated the resident was being difficult. LVN 1 stated there was potentially a change in either his behavior or mental status and that she failed to conduct a behavioral or mental evaluation on 8/1/2022. LVN 1 stated she called the physician who ordered the Wander Guard and to monitor closely, but the care plan for Resident 1's elopement risk did not include monitoring closely. A review of the facility's policy and procedure titled, Wandering & Elopement, revised 7/2017, indicated the facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT) will assess residents upon identification of significant change in condition. The policy indicated the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and would be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition. A review of the facility's policy and procedure titled, Care Planning, revised 11/2018, indicated the care plan will be completed within seven days after completion of the Comprehensive Admission Assessment, and periodically reviewed and revised by IDT at the following intervals: onset of new problems, change of condition, quarterly, annually, and in preparation for discharge. A review of the facility's policy and procedure titled, Change of Condition Notification, dated 4/1/2015, indicated the licensed nurse would assess the change in condition and determine which nursing interventions were appropriate. The licensed nurse must observe the resident and assess the overall condition utilizing a physical assessment and chart review. The policy indicated the licensed nurse would update the care plan to reflect the resident's current status.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had been identified as having behaviors of wandering (move about without a definite destination or purpose and can be dangerous when the person goes in areas with unsafe conditions) and identified at risk for elopement (the most dangerous form of wandering is elopement which is when a resident leaves the facility or safe area without authorization or necessary supervision) remained supervised while the assigned certified nursing assistant went on break and free from accidents by leaving an exit door propped open. These deficient practices resulted in Resident 1's elopement from the facility in his wheelchair, which rolled down the parking lot ramp to the street curb, causing Resident 1 to fall out of his wheelchair and hit his head on the street. Resident 1's injuries caused him to be transported to a general acute care hospital (GACH), where he was found to have a facial laceration (deep cut or tear in skin or flesh) that required staples and displaced fractures (break in the bone) of the sixth and seventh right ribs. Findings: A review of Resident 1's Admission Record (Face Sheet), indicated the resident was initially admitted to the facility on (MONTH) 2, 2013 and readmitted on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated (MONTH) 29, (YEAR), indicated the resident had severely impaired cognition (mental process of thinking and understanding). The MDS indicated Resident 1 was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing. A review of the plan of care titled, Dementia, initiated (MONTH) 29, (YEAR), indicated Resident 1 had dementia and Alzheimer's which was manifested by wandering. According to the care plan, the interventions included utilizing diversion, distraction or redirection to limit reoccurrence and providing education to resident, responsible party (RP) and staff regarding special care needs. The goal date for the care plan was (MONTH) 30, (YEAR) and there was no indication the care plan had been revised or reviewed since initiation. A review of the plan of care titled, Wandering/Elopement, dated (MONTH) 29, (YEAR), indicated Resident 1 was a risk for wandering or elopement related to cognitive status and the resident not being aware of safety needs. According to the care plan, the interventions included assessing the resident's elopement risk at the following intervals: Admission, Readmission, Quarterly, and Identification of Significant Change of Condition. The goal date for the care plan was (MONTH) 30, (YEAR). The care plan was updated after Resident 1's elopement on (MONTH) 3, (YEAR). A review of the Psychiatric Progress Notes dated (MONTH) 6, (YEAR), indicated Resident 1 was nonverbal, had impaired long-term and short-term memory, and had a psychiatric condition that was deteriorating. A review of Resident 1's Elopement Risk Assessments indicated the only date for the assessment was (MONTH) 3, (YEAR). Resident 1 had a score of eight (8) on 10/3/18. According to the assessment, if the total score is 8 or greater, the resident should be considered at risk for potential elopement from the facility. According to the assessments instructions, the Elopement Risk Assessment is to be done upon admission, readmission, quarterly and identification of significant change. A review of Resident 1's Licensed Personnel Weekly Progress Notes dated (MONTH) 3, (YEAR), indicated Resident 1 was observed wheeling by the station's hallway at 12:30 p.m. At 12:35 p.m., the notes indicated the charge nurse received a call about Resident 1 being found outside the facility. The notes further indicated Resident 1 was found on the ground in sitting position beside his wheelchair with a bystander, alert and responding to verbal commands, with a right temporal cut and skin tears to both hands. According to the notes, the 9-1-1 (emergency number) crew arrived at 12:42 p.m., took over the resident's care and transported him to the GACH. A review of Resident 1's GACH Emergency Documentation (MONTH) 3, (YEAR), indicated Resident 1 was brought in by ambulance after rolling down a steep driveway in wheelchair, falling out of wheelchair and striking head. The documentation indicated Resident 1 normally had a Glasgow Coma Scale of 14 (GCS - a neurological scale from 3 to 15, which aims to give a reliable and objective way of recording the conscious state of a person and is useful after head injury. A GCS of 8 or less indicates severe injury, one of 9-12 moderate injury, and a GCS score of 13-15 is obtained when the injury is minor.), but upon being brought to the GACH had a GCS of 10. According to the Emergency Documentation, Resident 1 had a five (5) centimeter laceration over his right brow that required four (4) staples. A review of Resident 1's computed tomography (CT, an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) result from the GACH dated (MONTH) 3, (YEAR) indicated Resident 1 had mildly displaced fractures of the lateral 6th and 7th right rib. A review of Resident 1's GACH Discharge Summary indicated Resident 1 had a hospital stay of eight (8) days, from (MONTH) 3, (YEAR) to (MONTH) 11, (YEAR). During the course of hospitalization , Resident 1 needed to be intubated (placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) while in the emergency department and was sent to the intensive care unit (ICU, a department of a hospital in which resident who are dangerously ill are kept under constant observation for monitoring) from (MONTH) 3, (YEAR) to (MONTH) 4, (YEAR). According to the discharge documentation, Resident 1 needed continued hospitalization from (MONTH) 4, (YEAR) to (MONTH) 11, (YEAR), on the medical floor for acute [MEDICAL CONDITION] (a disease in which the functioning of the brain is affected by some agent or condition) and decreased mental alertness likely secondary to concussion (an injury to the brain that results in temporary loss of normal brain function). During an interview with Certified Nursing Assistant 1 (CNA 1) on (MONTH) 30, (YEAR) at 9:20 a.m., CNA 1 stated that in order to prevent accident, injury or elopement, he makes rounds and checks residents frequently. CNA 1 stated that he was assigned to Resident 1 on the day of his elopement. CNA 1 stated before he went on his break, he got Resident 1 up to his wheelchair and brought him in front of the door and somebody was supposed to pick him up to bring him to the dining room. CNA 1 stated that when he goes on break, he tells the charge nurse and another staff covers his residents. CNA 1 stated that when he came back from break, he was informed that Resident 1 got out of the building and had an accident in the parking lot. During an interview with Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 30, (YEAR) at 9:40 a.m., LVN 1 stated that he was the one to find Resident 1 outside the facility. LVN 1 stated around 12:30 p.m., he was leaving the facility to pick up his food that he had ordered and was driving his car through the exit way of the facility parking lot. LVN 1 stated he saw someone on the floor next to a wheelchair at the exit way close to the sidewalk. LVN 1 stated he stopped to check the person and found that it was one of their residents, Resident 1. LVN 1 stated there was a bystander beside Resident 1 who had already called 9-1-1. LVN 1 stated Resident 1 was in sitting position, bleeding on the right temporal side. LVN 1 stated he called the facility right away and staff came out immediately. According to LVN 1, at baseline, Resident 1was non-verbal, with left sided weakness due to a stroke, alert but confused, his both arms with contractures, but was able to wheel himself using his feet. During an interview with the Administrator (ADM) on (MONTH) 19, (YEAR) at 12:15 p.m., the ADM stated there was nothing we could do to prevent that fall. The ADM stated he was not sure how Resident 1 got outside. When asked if Resident 1 had a wander guard in place, the ADM stated that he did not have a wander guard because the facility did not feel like he needed one at that time. During an interview and concurrent tour of the facility with the Director of Nursing (DON) on (MONTH) 19, (YEAR) at 3:35 p.m., the DON stated Resident 1 had wandering behavior but had never made an attempt to leave the facility before. The DON stated Resident 1 just wheels around the stations and hallways near his room. When asked why Resident 1 did not have a wander guard, the DON stated wander guards are only used on residents who have attempted to elope, so upon readmission, a wander guard would be applied on Resident 1. When asked about the interventions for his wandering behavior, the DON stated Resident 1 was always under close supervision of staff. During the tour of the facility, the DON pointed out all the exits; the main entrance which leads to the parking lot, the emergency exit in the Activities Room, the back exit which leads to the employee patio and an emergency exit located between the kitchen and rehabilitation room which leads to the steep parking lot driveway. The DON stated that since Resident 1 was found at the end of the driveway, the staff believe the resident eloped using the exit that was between the kitchen and the rehabilitation room. During the observation of the exit between the kitchen and the rehabilitation room, the exit door was found to be propped open with a piece of wood. The DON confirmed the door was propped open. The sign on the exit door stated to keep door closed at all times. During an interview with the Administrator (ADM) on (MONTH) 19, (YEAR) at 12:15 p.m., when asked about the propped exit door, the ADM stated that after the incident with Resident, 1 he made sure all staff was in-serviced about the importance of making sure all exit doors are secured and closed properly. The ADM stated that he made it very clear to all staff that all doors are to remain locked. The ADM stated that after the incident with Resident 1, he installed cameras at the exits. The ADM stated that he will look into the video footage and will have to let go of the staff member who propped the door open because that disregard for safety, will not be tolerated in the facility. A review of the facility's policy titled, Elopement Risk Reduction Approaches, revised (MONTH) 2012, indicated the facility will ensure that residents are monitored and remain safe. The policy also indicated the facility staff need to know the protocols to follow to minimize successful exiting.

Based on interview and record review, the facility failed to ensure Resident 1's environment was free of accident hazards during the distribution of snacks; and failed to provide supervision and assist Resident 1 in receiving her snacks from the nourishment cart. Resident 1, who had a history of [REDACTED]. When she let go of her FWW to grab snacks and put them in a plastic bag that was hanging from her FWW, she lost her balance, and fell backwards hitting her head on the floor. As a result, Resident 1 sustained a fatal blunt head injury from the fall. She was sent to the general acute care hospital (GACH) where she died on [DATE], the same date of her fall. Findings: On [DATE], the Department received a complaint (CA 541) that alleged Resident 1 had a fall on [DATE], between 6:30 p.m. and 7 p.m., while she was getting her snack from the food-cart. The resident fell and sustained an injury to her head, and was transferred to the general acute care hospital, where she died the same day. On [DATE], at 11:32 p.m., during a telephone interview Family Member 1 (FM 1) stated Resident 1 fell and hit her head. According to FM 1 the resident had previous fall without injury and she was under close supervision to prevent an injury from a fall. FM 1 stated this time she fell while she was getting snacks from the nourishment cart. On [DATE], at 1:40 p.m., during investigation of the above allegation, a review of Resident 1's admission record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].). A review of the current Minimum Data Set (MDS-a comprehensive assessment and care screening tool) dated February 12, 2014, indicated Resident 1 had moderately impaired cognitive skills for daily decision- making, had poor vision (unable to read regular prints) required supervision oversight, encouragement or cueing and support set up help only while walking with a FWW. Resident 1 required limited assistance in dressing, toilet use and personal hygiene, and needed physical help in part of bathing activity. The MDS indicated Resident 1 was not steady when walking or turning around, even with her assistive device (FWW), and had a history of [REDACTED]. A review of the Fall Risk Assessments dated [DATE], indicated Resident 1 was a high risk for falls. Resident 1 was also assessed as having poor safety awareness and judgement, unsteady gait, and received multiple medications including Vasotec and Clonidine (medication to treat high blood pressure) and Ultram (pain medication that may cause drowsiness, and dizziness, and increased the risk for falls). A review of the physician's orders [REDACTED]. 1. Clonidine 0.2 milligram (mg) one tablet by mouth two times a day for high blood pressure, dated [DATE]. The adverse reaction included drowsiness, dizziness, dry mouth, nausea and vomiting. 2. Vasotec 10 mg at 9 a.m. every day, dated on [DATE]. The adverse side effects of these blood pressure medications included orthostatic hypotension (is a condition in which your blood pressure falls when you stand up quickly, leaving you feeling dizzy or lightheaded). 3. Ultram 50 mg one cap by mouth one time a day for pain, dated [DATE]. The adverse effects of Ultram included drowsiness and dizziness. 4. Monitor orthostatic hypotension (blood pressure while lying, sitting and standing. A review of the medication administration record (MAR) indicated Resident 1 had received the above medications as ordered. There was no documented evidence that indicated the adverse effects of the above three medications were monitored on the date Resident 1 fell and sustained a head injury. The resident's orthostatic hypotension blood pressure was not monitored on the date she had the fall. There was a care plan developed with a goal date of [DATE], for the potential for recurrent falls/injury related to the presence of fall risk factors: history of falls, visually impaired, poor safety awareness, problems of impaired decision making, impaired judgement, predisposing disease or injury, heart medications, advanced age, osteoporosis and unsteady balance. The interventions to prevent falls and injury included to escort Resident 1 to activity programs for safety; keep the resident in frequently monitored areas; remind Resident 1 to use her ambulation device (FWW), and to keep her environment safe from safety hazards/clutter. On [DATE], at 3:35 p.m., an interview was conducted with Certified Nursing Assistant 1 (CNA 1), who was assigned on the 3 p.m. to 11 p.m. shift, to pass nourishments on the day of Resident 1's fall incident. CNA 1 stated at approximately 6:45 p.m., while she was passing nourishments, Resident 1 was ambulating in the hallway with her FWW. Resident 1 started to pick multiple nourishments directly from the cart, and put them inside a plastic bag that was hanging on her walker, as she always did. While doing so, Resident 1 had to take her hands off of her FWW to place the items into her bag. Resident 1 then lost her balance and fell backwards, hitting the back of her on the floor. CNA 1 stated she attempted to grab Resident 1 before she landed on the floor but she did not succeed. CNA 1 stated she summoned for help, and staff members rushed to the location. Vital signs were done, but Resident 1 was unresponsive, and the paramedics were called via 911. On [DATE], at 4: 05 p.m., during an interview CNA 2 stated the charge nurse would announce when the nourishments were to be passed to the residents. CNA 2 stated ambulatory residents came all at once to the nourishment cart. Resident 1 walked with her FWW to the nourishment cart, took multiple items to place inside a plastic bag hanging on her walker. In doing so, when she took her hands off the walker, she lost her balance and fell backwards, hitting the back of her head on the floor. On [DATE], at 4:45 p.m., during an interview Licensed Vocational Nurses 1 (LVN 1) stated in the past, he had observed Resident 1 take snacks directly from the cart because she did not have the patience to wait until the staff members served her snack. LVN 1 stated in the past, he had attempted to stop Resident 1 from taking snacks from the cart, but Resident 1 became upset and angry. On [DATE], at 5:15 p.m., during an interview, the director of Nurses (DON) stated CNA 1 had witnessed Resident 1's fall at the nourishment cart. The DON stated this was not an isolated incident with Resident 1, because she always picked up her snacks by herself from the nourishment cart. If the staff handed her the snacks, Resident 1 became angry and upset. There was no documented evidence provided to indicate the facility had addressed this potential safety problem in Resident 1's plan of care. A review of the facility's Investigation Record dated [DATE], at 9 a.m., indicated CNA 1 saw Resident 1 walking with her walker to the nourishment cart in the hallway. Resident 1 began picking up multiple food items from the cart and placed them into a plastic bag. CNA 1 was standing on the opposite side of the nourishment cart facing Resident 1, when the resident suddenly fell backwards hitting the back of her head. The Charge Nurse Narrative Notes regarding the incident dated [DATE], indicated at 6:30 p.m., Resident 1 was seen ambulating with her walker heading towards the nourishment cart near Room 123. Resident 1 approached the cart on the opposite side, started picking up multiple items from the cart to place into a plastic bag hanging on her FWW. Resident 1 let go of the walker in order to place the items into her bag. While doing so she lost her balance and fell backwards hitting the back of her head on the floor. CNA 1 ran to the other side of the cart, and the resident was unresponsive for approximately two minutes. Nursing staff were notified and responded immediately. Vital signs were checked and 911 called. At 6: 35 p.m., the paramedics arrived, assessed the resident who remained unmoved, awake but altered in mental status. Resident was not able to answer any questions, and had an episode of vomiting. The paramedics transferred Resident 1 to the GACH. A review of the GACH emergency room Report dated [DATE], indicated Resident 1 arrived at the emergency room at 7:11 p.m. Resident 1 was assessed in emergency with an altered level of consciousness with an acute brain injury. Resident 1 was intubated (the process of inserting a tube through the mouth and into the airway to enable the use of a breathing machine to assist with breathing when a a patient is unable to breath independently). Resident 1 had an elevated systolic blood pressure of 260 (reference range 120), no movement to all extremities. A brain scan revealed a large left subdural hematoma (is a collection of blood outside the brain. Subdural hematoma is usually caused by severe head bleeding and increased pressure on the brain and can be life-threatening) with midline shift, mass effect and evidence of herniation (a potentially deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across the brain structures). The ER report indicated the resident had extremely poor prognosis (outcome) consistent with brain death at 8:27 p.m., and there was no further interventions needed to preserve the neurological functions. Resident 1 died at the GACH on [DATE], at 10:27 p.m, the same date she was admitted to the GACH. A review of the literature indicates that .in the older adult, traumatic brain injuries are typically more severe than a younger patient's prospects for survival less certain. Recovery takes longer and the threat of complications looms larger (Stamatos, Christine A. RN, MS, CCRN and Co. American Journal of Nursing: [DATE]- Volume 96-Issue 5-Pages ,[DATE]). A review of the Certificate of Death dated [DATE], indicated the following: 1. Immediate Cause of Death: (a) Subdural Hematoma (is a collection of blood is a collection of blood between the covering of the brain (dura) and the surface of the brain, usually caused by severe head injuries) (b) Blunt Force Head Injury. 2. Other Significant conditions contributing to death but not resulting in the underlying cause: Hypertension, Cerebral Vascular Accident.