Every finding on record at Maclay Healthcare Center

Based on interview and record review, the facility failed to prevent a fall and injury for one of three residents (Resident 1) who had severely impaired cognition (resident had lost the ability to think, learn, remember, or make decisions to the point that resident cannot live independently and require full-time supervision or help with daily tasks like eating and dressing). The facility failed to ensure two or more nursing staff assisted Resident 1 when Certified Nursing Assistant (CNA) 1 repositioned (turned or moved a resident to a new position in bed) Resident 1 while providing bed bath (a care method used to clean a person who is unable to leave the bed), with no assistance from another staff, on 6/27/2026 at around 9:35 a.m. As a result, on 6/27/2026 around 9:35 a.m., Resident 1 rolled off the bed on the floor, face down, and sustained an abrasion (a superficial skin injury caused by the skin rubbing or scraping against a rough surface) with bleeding on the back of the head, a bump on the right eye, and laceration (a rough, jagged tear or cut in the skin and underlying soft tissue) on the left big toe. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 6/27/2026 at 10:20 a.m. where Resident 1 was diagnosed with right supraorbital soft tissue hematoma (a collection of blood pools in the soft tissue just above the right eye, typically along the eyebrow arch [curved part of the eyebrow] or lower forehead) measuring 2.1 centimeters (cm - a unit of measurement) in length x (by) 2.7 cm in width x 4 cm in depth and Resident 1's lacerations were repaired with nine staples (sterile metal clips doctors used to quickly hold the cut edges of skin together so the wound can heal). During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 1/26/2021 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (the body's inability to process sugar), atelectasis (the complete or partial collapse of a lung [an organ responsible for breathing]), chronic myeloproliferative disease (a group of rare blood cancers [occurs when abnormal cells grow uncontrollably and spread to other parts of the body] where the bone marrow [the soft, spongy tissue found inside the center of large bones] produces too many red blood cells [a type of blood cell in the body]), hemiplegia (a form of paralysis [the loss of voluntary muscle function in one or more parts of the body] that affects one side of the body) and hemiparesis (weakness or partial paralysis) following cerebral infarction (when blood flow to an area of the brain is blocked), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/25/2026, the MDS indicated Resident 1 had severe impaired cognitive skills (a profound and persistent decline in memory, reasoning, language, and judgment that makes it impossible for a person to manage daily life without substantial help) for daily decision making and was dependent (helper does all of the effort and resident does none of the efforts to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) with staff with oral hygiene, toileting hygiene, shower and bathing, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 1 was dependent on staff with rolling left to right (the ability to roll from lying on back to left and right side, and return lying on back on the bed).During a review of Resident 1's Care Plan (CP - a comprehensive health document that outlines resident's specific medical needs, treatments, and goals) Report titled, The resident (Resident 1) has an ADL (Activities of Daily Living - activities such as bathing, dressing and toileting a person performs daily) self-care performance deficit related to confusion, hemiplegia, impaired balance (a loss of control over your body's stability), limited mobility (movement), . cognitive deficit (trouble with mental skills like memory, attention, and problem-solving), initiated on 2/10/2021 and revised on 4/2/2025, indicated Resident 1 was At risk for falls/injuries, skin breakdown (damage or injury to the skin and tissue underneath). The CP Interventions indicated that for shower/bathe Resident 1 required dependent assistance with staff and for bed mobility Resident 1 required dependent assistance with staff to turn and reposition in bed (roll left and right). During a review of Resident 1's Interdisciplinary Team (IDT - a coordinated group of health professionals who work together to plan, deliver, and evaluate resident care) Note, dated 6/17/2026 at 11:10 a.m., the IDT Note indicated . the resident demonstrates generalized muscle weakness and decreased endurance, which increases the likelihood of instability and falls during movement or repositioning. The IDT Note indicated Resident 1 was prescribed with Eliquis (an anticoagulant medicine [blood thinner] that prevents harmful blood clots from forming or growing and Apixaban is the generic name), which places the resident at increased risk for bleeding complications in the event of a fall. The IDT Note indicated Resident 1 demonstrates limited tolerance to activity and positional transitions (movement from one physical place, posture, or structural location to another) due to muscle weakness, deconditioning (the loss of physical fitness, muscle strength, and body function), and overall frailty (a medical state of increased vulnerability and reduced physical reserve that makes it hard for the body to recover from minor illnesses, injuries, or everyday stress). The IDT Note indicated Resident 1's Fall prevention measures will remain in place, including . gradual repositioning techniques. During a review of Resident 1's Change in Condition (CIC - when there is a sudden change in a resident's condition that requires assessment, often prompting a revision of the care plan) Evaluation, dated 6/27/2026 at 10 a.m., the CIC indicated on 6/27/2026 at 9:56 a.m., Resident 1 was observed on the floor lying on her right side. Registered Nurse (RN - licensed nurse, not specified) Supervisor 1 assessed Resident 1 and was noted with open skin on the back of the head with bleeding and right eye bump. The CIC indicated the facility (did not specify the staff) applied ice to head and right side of the face and gently placed a pillow behind Resident 1's back and under the legs for resident comfort. The CIC indicated the facility called 911 (a universal emergency number) and sent Resident 1 to GACH 1 for further evaluation on 6/27/2026 at around 10:20 a.m. During a review of Resident 1's GACH 1 History and Physical (H&P) Note, dated 6/27/2026, the H&P Note indicated Resident 1 had a fall from bed and the head strike (a clinical protocol used by emergency and trauma centers for patients who hit their head) performed indicated Resident 1 was with frontal (front part) and occipital (back part) lacerations (tears or rips on or inside the body). The H&P Note indicated Resident 1's lacerations were repaired with nine staples. During a review of Resident 1's GACH 1's Computed Tomography Scan (CT scan - a scan imaging test that helps healthcare providers detect disease and injuries) of maxillofacial (refers to the area of face and jaw) without contrast (a specialized substance given to a patient to highlight the details), dated 6/27/2026, the CT scan indicated Resident 1 had right supraorbital soft tissue hematoma measuring 2.1 cm in length x 2.7 cm in width x 4 cm in depth. During a review of Resident 1's Nursing Progress Note, dated 6/27/2026 at 10:23 a.m., the Nursing Progress Note indicated Resident 1 had lacerations to the back of the head, right eyebrow, and left big toe (did not specify size of laceration). The Nursing Progress Note indicated the facility sent Resident 1 to GACH 1. During a review of Resident 1's GACH 1's CT Scan of the Head without contrast, dated 6/27/2026, the CT scan indicated Resident 1 had right frontal parietal encephalomalacia (the localized death and degradation of brain tissue following an injury), prominent soft tissue hematoma (a localized collection of clotted or pooling blood that forms outside a blood vessel, usually caused by trauma or injury) near the right orbit (right eye socket) and zygoma (the cheekbone). During a review of Resident 1's IDT Note, dated 7/6/2026 at 11:26 a.m., the IDT Note indicated, The resident is totally dependent and requires two-person assistance (a care and safety method where two trained helpers work together to move, lift, or walk a patient who cannot safely move alone) for all activities of daily living, including transfers, turning, and repositioning. The resident receives Aspirin (an antiplatelet drug [a medicine that stops blood cells called platelets from clumping together) used to reduce pain, fever, swelling, and also stops the blood from clotting) and Eliquis, placing her at increased risk for bleeding following trauma. The IDT Note indicated that On the date of the incident (6/27/2026), the resident was found on the floor beside her bed at approximately 9:56 a.m. after falling from her low air loss mattress (a specialized type of mattress designed to prevent and treat pressure injuries [bedsores]) during provision of morning ADL care. While providing incontinent care at approximately 9:30 a.m., the resident was turned (by CNA 1) toward the wall onto her left side. According to the CNA (CNA 1), the resident unexpectedly rolled rapidly across the low air loss mattress and over the opposite edge of the bed, landing on the floor. The CNA (CNA 1) immediately called for assistance, Registered Nurse (RN Supervisor 1) arrived at approximately 9:58 a.m. to assess the resident. The resident remained awake with no observed change in level of consciousness (the state of being awake and actively aware of one's surroundings, own thoughts, and own existence). Bleeding was noted from the posterior aspect (back part) of the head, although the exact source could not be fully visualized due to the resident remaining in place to prevent potential further injury. Emergency Medical Services (is an organized system that provides rapid pre-hospital medical care and safe transport for people with sudden serious illnesses or injuries) was activated, and the resident was transferred to the acute care hospital (a medical facility that provides short-term, active treatment for people with severe injuries, sudden illnesses, or urgent medical conditions) for further evaluation and treatment. The IDT Note indicated the facility's Root Cause Analysis that The immediate cause of the fall was the resident (Resident 1) rolling unexpectedly across the Low Air Loss mattress while being turned during incontinent care (the support and management provided to residents who cannot control their bladder or bowel functions), resulting in the resident crossing the bed surface and falling from the opposite side of the bed. Contributing factors include: Requirements for complete dependence with all mobility and repositioning activities. Significant muscle weakness and left-sided hemiplegia. Cognitive impairment., limiting the resident's ability to understand or assist with repositioning. Reduced friction created by the therapeutic Low Air Loss mattress, allowing more rapid body movement during turning. Multiple chronic (lasting for a long time) medical conditions contributing to frailty and impaired body control. Anticoagulant (Eliquis) and antiplatelet (Aspirin) therapy, which increased the severity of bleeding after the fall. During an interview with CNA 1 on 7/21/2026 at 1:20 p.m., CNA 1 stated she was providing a bed bath to Resident 1 on 6/27/2026 around 9:35 a.m. CNA 1 stated she turned Resident 1 to the left and proceeded to clean her (Resident 1's) back. CNA 1 stated when she (CNA1) went to open the incontinence pad (a highly absorbent pad designed to catch urine leaks and bowel movement), Resident 1 rolled off the bed, and it happened so fast that she (CNA 1) could not prevent the fall. CNA 1 stated that Resident 1 fell face down on the floor and she (CNA1) immediately went to get help from Licensed Vocational Nurse (LVN) 1. CNA 1 stated that Resident 1 was on an air loss mattress and required two-person assist for transfers and repositioning, however, on 6/27/2026, she (CNA1) provided bed bath to Resident 1 by herself. CNA 1 stated that she was very sorry. During an interview with LVN 1 on 7/21/2026 at 1:30 p.m., LVN 1 stated that on 6/27/2026 she (LVN 1) was done passing (distributing) medications when CNA 2 called her (LVN 1) and reported that Resident 1 fell on the floor. LVN 1 stated she went inside Resident 1's room and noted Resident 1 on the floor on the left side of the bed. LVN 1 stated that Resident 1 was verbally responsive, and she (LVN 1) noted blood in the back of Resident 1's head and a bump with an abrasion on the right side of the face. LVN 1 stated that she called RN Supervisor 1, they did not move Resident 1, and called 911. LVN 1 stated that CNA 1 needed another CNA to help her (CNA1) provide ADL care to Resident 1. During an interview with the Director of Nurses (DON) on 7/21/2026 at 2:15 p.m., the DON stated that Resident 1 fell from bed while CNA 1 was providing care. The DON stated that Resident 1 had to be transferred to the hospital for further evaluation and treatment. The DON stated that the facility replaced Resident 1's low air loss mattress and provided in services to the staff that Resident 1 always needed two person-assist while providing care. The DON stated that the facility obtained the low air loss mattress with raised air bolsters (act as safety barriers to stop residents from rolling out of bed) designed to stop accidental resident rollouts. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, with review date of 4/16/2026, the P&P indicated the facility is committed to minimizing the risk of resident falls through a structured Fall Management Program that includes prevention, monitoring and post-fall evaluation. Purpose. To provide a systematic approach to: Prevent falls, Assess residents after a fall, Implement individualized interventions, (and) Monitor outcomes and reduce fall related injuries. Policy Guidelines. 1. Fall Prevention Strategies. Implement individualized interventions based on risk level, which may include . mobility assistance.

Based on observation, interview and record review, the facility failed to ensure medications were properly labeled and dated in accordance with facility policy in one of two inspected treatment carts (Station 2) when Treatment Nurse (TXN) 1 failed to: Label one tube of Ketoconazole cream with resident identification.Label three opened bottles of nystatin powder with resident identification and the date opened.Label container of silver sulfadiazine cream with resident identification and was labeled with an open date of [DATE]. These failures had the potential to result in medication errors, administration of medications to the wrong residents, and improper use of the medications. Findings: During a concurrent observation and interview on [DATE] at 10:36 a.m. of Station 2 Treatment Cart with the TXN 1, TXN 1 stated that the three bottles of nystatin powder observed in Station 2 Treatment Cart should have been labeled with resident identification and should have had an open date label. TXN 1 stated that the three bottles needed to be discarded because it did not have a label, we would not know who it belongs to and one of the bottles caps is missing from the nystatin powder. TXN 1 stated that ketoconazole cream observed was not labeled with resident name or had an open date and medication was opened. TXN stated that it was important to ensure that topical medications are stored properly and labeled with resident name to ensure we are administering to the right resident. During an observation on [DATE] at 10:59 a.m. in the treatment supply room in station 2, silver sulfadiazine cream container was on the shelf with no resident identification and with an open date of [DATE]. During an interview on [DATE] at 12:45 p.m. with Assistant Director of Nursing (ADON), the ADON stated that Silver Sulfadiazine is a topical antibiotic medication and it should have been discarded after being discontinued by the physician. ADON stated that TXN is responsible for discarding topical medications and ensuring that all topical medications are labeled with correct resident name. During a review of the facility's policy and procedure (P&P) titled, Medication Storage and Disposal, revised [DATE], the P&P indicated All medication will be stored, secured, temperature-controlled, properly labeled, and separated according to manufacturer's recommendations and facility protocol. All expired, discontinued, wasted, or contaminated medication will be removed and disposed of properly per facility process and applicable regulations.

Based on observation, interview and record review, the facility failed to ensure Certified Nurse assistant (CNA) 1 was wearing personal protective equipment {(PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission)} on enhanced barrier precautions (EBP- infection control measures for high-risk residents, to reduce the spread of multidrug-resistant organism or MDRO due to open wounds) room for one of three sample residents (Resident 1). This deficient practice placed the staff and all residents in the facility at risk for the spread of infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/31/2018 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set [MDS)] resident assessment tool), dated 5/14/2026, the MDS indicated Resident 1 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and needed maximal assistance (helper does more than half of the efforts) for toileting hygiene, showers, upper body dressing, and personal hygiene. 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 3/30/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a record review of Resident 1's Order summary Report (OSR), dated 6/08/2026, the OSR indicated Enhanced barrier Precautions-staff to utilize gowns and gloves for high-contact resident care activities due to wound sacrococcyx (sacrum-the triangular base of the spine connects to the coccyx -the tailbone) stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). During an observation on 6/08/2026 at 10:51 a.m. outside of Resident 1's room, CNA 1 entered Resident 1's room without wearing a gown and repositioned Resident 1 by pulling on the bed linens. During an interview on 6/08/2026 at 1:31 a.m. with CNA 1, CNA 1 stated that she was assigned to Resident 1. CNA 1 reported that she was unaware that Resident 1 was on EBP due to stage 2 pressure injury and stated this was the reason she did not wear a gown while providing care and repositioning Resident 1. During an interview on 6/8/2026 at 2:01 p.m. with Infection Preventionist (IP) nurse, the IP nurse stated that Resident 1 was on EBP due to a pressure ulcer. IP nurse stated that staff were to wear PPE while performing all patient care and if they were not wearing proper PPE, they were putting all the other residents at risk for spread of infection. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, revised 4/16/2026, indicated Staff must wear gloves, gowns, mask and eye protection as indicated when providing direct care. PPE is donned before entering the resident area and removed before leaving.

Based on observation, interview, and record review, the facility failed to place one of three sampled residents (Resident 1) in a low air loss (LAL- a specialized medical-grade mattress used to prevent and treat bedsores) mattress in accordance with the physician order and care plan when the facility maintained Resident 1 on a standard mattress on 6/8/2026 who had a stage 2 pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential to result in worsening of Resident 1's stage 2 pressure injury and increase the risk for further pressure related skin deterioration.Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set [MDS)] resident assessment tool), dated 5/14/2026, the MDS indicated Resident 1 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and needed maximal assistance (helper does more than half of the efforts) for toileting hygiene, showers, upper body dressing, and personal hygiene. 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 3/30/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Order summary Report (OSR), dated 6/07/2026, the OSR indicated LAL mattress for wound management to be set per resident comfort every shift. During a review of Resident 1's care plan titled, LAL mattress for wound management, initiated 6/07/2026, the care plan goal indicated Resident will experience comfort and pressure relief while on low air mattress, as evidence by relaxed posture and absence of pressure related skin deterioration. The care plan intervention indicated maintain resident on LAL set per resident comfort to promote pressure redistribution and skin integrity. During an observation on 6/08/2026 at 10:51 a.m. inside Resident 1's room, Resident 1 was lying in bed on a standard mattress rather than the ordered LAL mattress. During a concurrent observation and interview on 6/08/2026 at 10:57 a.m. with Treatment Nurse (TXN) 2 in Resident 1's room. TXN 2 stated Resident 1 remained on a standard mattress and stated that staff should have placed Resident 1 on a LAL mattress following the 6/07/2026 order. TXN 2 further stated that Resident 1 had developed a stage 2 pressure injury to the sacrococcyx area, and the LAL mattress had been ordered to provide pressure injury treatment and prevention. During an interview on 6/09/2026 at 12:03 p.m. with Maintenance Assistant 1, Maintenance Asstistant 1 stated that a nurse (unknown name) informed him on 6/07/2026 that Resident 1 required a LAL mattress due to a wound infection. Maintenance Assistant 1 stated that he attempted to locate and inflate an LAL, however, the mattress was not functioning properly. As a result, he did not replace Resident 1's mattress. Maintenance Assistant 1 further stated that he notified his supervisor of the issue, and the supervisor indicated to him that they were going to purchase a new LAL mattress. During an interview on 6/09/2026 at 12:45 p.m. with Assistant, Director of Nursing (ADON), the ADON stated that staff should have implemented the physician's order for a LAL mattress to relieve pressure, promote wound healing, and prevent further deterioration of Resident 1's wound. The ADON stated that staff failed to follow Resident 1's care plan and physician order because Resident 1 was never placed on a LAL after the order was issued on 6/07/2026. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer Management, Treatment, and Prevention, revised 4/16/2026, indicated, The facility implements evidence-based practices, individualized care plans, and ongoing staff education to minimize risk and promote skin integrity in compliance with CMA requirements. Use pressure-relieving devices such as specialty mattresses, cushions, or heal protectors.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and had documented history of falls, (as indicated in Resident 1's admission Record), was free from preventable falls and injury, by failing to: a. Monitor Resident 1's orthostatic blood pressure (a change in blood pressure that occurs when a person stands up from a sitting or lying position) in accordance with physician orders. b. Ensure Resident 1 wore nonskid (slip-resistant) footwear while ambulating (walking). c. Ensure Resident 1 used the assistive device (a tool or equipment that helps a person with a disability or medical condition maintain or improve their independence, safety, and ability to perform daily tasks such as walking) while ambulating. As a result, on 4/25/2026 at 1:55 a.m., Resident 1 fell to the ground while ambulating in the hallway without the assistive device and while wearing personal slip-on slippers (a comfortable, indoor shoe designed to be easily put on and taken off but lacks the support, stability, and secure fit leading to potential risks of falls, tripping, and foot pain). Following the fall, Resident 1 reported severe pain (pain not measured in numerical value) to the left shoulder and entire left arm and was subsequently diagnosed with a closed displaced fracture of the proximal end of the left humerus (a common serious type of broken shoulder where the top part of the left upper arm bone is broken into two or more pieces that moved out of their normal position, but had not broken through the skin), and a closed displaced fracture of the left great toe proximal phalanx (broken big toe bone on the left foot but had not broken through the skin). Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 4/25/2026 for further evaluation and treatment.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 2/10/2026 with diagnoses including orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from sitting or lying position and may cause lightheadedness, dizziness or fainting), difficulty walking, muscle weakness, history of falling, and restless leg syndrome (RLS - a nervous system disorder that creates an irresistible urge to move your legs, usually accompanied by uncomfortable sensations like crawling, itching, or pulling). 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 2/11/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Physician Order, dated 2/13/2026, the Physician Order indicated to monitor for side effects of mirtazapine (a medication used to treat depression [a mental health condition causing persistent sadness, loss of interest, and decreased energy that interferes with daily life] and frequently used for its sedative [medication that calms the mind and body] and appetite-stimulating effects) such as postural hypotension (also known as orthostatic hypotension, a sudden drop in blood pressure that occurs when standing up from a sitting or lying position). The Physician Order indicated for nursing staff to document observations using tally marks or hash marks (a system used for counting or keeping track of ongoing results with each mark representing one unit) on the Medication Administration Record (MAR - a legal document used by healthcare professionals to track and record every dose of medication given to a resident) every shift. During a review of Resident 1's Physician Order, dated 2/13/2026, the Physician Order indicated to monitor for side effects of anti-psychotic medications (used to manage symptoms of psychosis [a set of symptoms indicating a loss of contact with reality, where a person has trouble distinguishing what is real from what is not]), including drowsiness (a state of strong desire for sleep or extended, inappropriate sleeping during the day) and postural hypotension. The Physician Order indicated for nursing staff to document these side effects using tally marks on Resident 1's MAR every shift. During a review of Resident 1's Fall Risk Evaluation, dated 2/26/2026, the Fall Risk Evaluation indicated Resident 1 had a total score of ten (score breakdown not indicated) and indicated Resident 1 was a high risk for falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/8/2026, the MDS indicated Resident 1's cognitive (refers to the mental processes involved in gaining knowledge, understanding, and thinking) skills for daily decision making were moderately impaired. The MDS further indicated that Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for mobility (movement) activities, including sit-to-stand (the ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed) transfers and walking 150 feet (ft - unit of measurement). The MDS indicated Resident 1 required set-up assistance (helper assists the resident prior to or following the activity) for walking 50 ft with two turns (once standing, the ability to walk at least 50 ft and make two turns). During a review of Resident 1's Change in Condition (COC - when there is a sudden change in a resident's condition) Evaluation, dated 4/25/2026, the COC Evaluation indicated on 4/25/2026 at 1:55 a.m., Registered Nurse 1 (RN 1) was notified of Resident 1's fall. The COC Evaluation indicated Resident 1 complained of severe pain in the left shoulder and entire left arm and did not tolerate the range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) on the left upper arm. The COC Evaluation indicated Resident 1 was left on the floor until the paramedics (are highly trained healthcare professional who provide advanced medical care to individuals outside of a hospital setting) arrived. During a review of Resident 1's Physician Order, dated 4/25/2026, the Physician Order indicated the facility transferred Resident 1 to GACH 1 via ambulance (a specially equipped vehicle used to transport sick or injured people to a hospital, usually for emergency medical care) due to the fall. During a review of Resident 1's GACH 1 Emergency Department (ED) Provider Notes, dated 4/25/2026, the ED Provider Notes indicated that x-rays (medical imaging test that uses a small amount of radiation through the body to create pictures of bones and organs) were performed on Resident 1's left humerus (the long bone located in the upper arm, extending from the shoulder to the elbow) and left foot. The ED Provider Notes indicated Resident 1 sustained a closed displaced fracture of the proximal end of the left humerus and a closed displaced fracture of the proximal phalanx of the left great toe. The ED Provider Notes further indicated that Resident 1's left arm required the use of a shoulder immobilizer (medical sling with extra straps that securely holds the arm against the chest to stop the shoulder from moving) and Resident 1's left big toe required a buddy tape (a method that wraps an injured finger or toe together with an adjacent healthy one that acts as a splint). During a concurrent observation and interview on 4/28/2026 at 9:03 a.m., with Resident 1, Resident 1 stated that on 4/25/206, at around 1:55 a.m., she (Resident 1) walked to the restroom and then to the sink (both located inside the resident's room) without using her front-wheeled walker (FWW - a mobility aid with wheels on the front two legs, designed to help a person walk with improved stability and easier maneuvering) or a wheelchair. Resident 1 stated she returned to sit on her bed, stood up again, and proceeded to walk outside of her room without an assistive device. Resident 1 stated she did not recall why she left her room or where she intended to go. Resident 1 stated the next thing she remembered was being on the floor in front of Nurse Station 4, experiencing severe pain in her left arm. Resident 1 stated she was wearing her personal purple slip-on slippers on 4/25/2026, the day of the fall. During an observation, Resident 1's purple open-toed and open-back slippers were observed in Resident 1's room. During an interview on 4/28/2026 at 1:54 p.m., and a concurrent record review of Resident 1's MAR dated 4/1/2026 to 4/30/2026, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there was no documented evidence Resident 1's orthostatic blood pressure was monitored. LVN 1 stated Resident 1 was prescribed anti-psychotic medications that required orthostatic blood pressure monitoring in accordance with the physician's order. LVN 1 stated that orthostatic blood pressure is assessed by obtaining blood pressure readings while the resident is lying, sitting, and standing. A review of Resident 1's vital signs (essential objective measurements of basic body functions such as body temperature, heart rate, respiration rate, and blood pressure) logs, dated 2/10/2026 to 4/28/2026, was conducted during the interview. LVN 1 stated that there was no documented evidence indicating that blood pressure readings were obtained while standing. LVN 1 further stated that she was not checking Resident 1's orthostatic blood pressures. LVN 1 stated that failure to monitor Resident 1's orthostatic blood pressure could result in an undetected episode of orthostatic hypotension, which may increase the risk for falls. During an interview on 4/29/2026 at 6:30 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 1 walks in the hallway while pushing a wheelchair as a walker for support but would occasionally refuse to use the wheelchair. CNA 2 stated on 4/25/2026, she (CNA 2) observed Resident 1 walking from her (Resident 1) room towards Nurse Station 4. CNA 2 stated Resident 1 was wearing purple rubber slippers, one to two inches (in- unit of measurement) thick and was not using an assistive device at the time. CNA 2 further stated that Resident 1 fell forward and subsequently complained of left shoulder pain. During an interview on 4/29/2026 at 6:59 a.m. and a concurrent record review of Resident 1's admission Record, Progress Notes dated 4/1/2026 to 4/28/2026, Vital Signs Log dated 2/10/2026 to 4/28/2026, and Care Plan (document that outlines the specific healthcare and support needs of a resident, along with strategies and interventions to address those needs) initiated on 2/10/2026, the records were reviewed with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated Resident 1's diagnoses included orthostatic hypotension, muscle weakness, and difficulty walking. LVN 2 stated Resident 1 refused to wear nonskid socks and preferred to wear personal purple rubber slippers approximately one to one and a half inches thick. LVN 2 further stated Resident 1 occasionally refused to use the assistive device while ambulating. LVN 2 stated orthostatic blood pressure should be obtained by first measuring blood pressure while the resident is in lying and sitting positions using a battery-operated blood pressure machine, followed by repeat measurements after 15 to 30 minutes using a manual blood pressure machine. LVN 2 stated she did not obtain Resident 1's standing blood pressure due to LVN 2's fear that the resident might fall if the blood pressure decreased or dropped. LVN 2 stated on 4/25/2026 she (LVN 2) observed Resident 1 walking in the hallway in front of Nurse Station 4 from the resident's room without an assistive device. LVN 2 stated Resident 1 appeared groggy (a state of being weak, dizzy, and unable to think clearly or move properly). LVN 2 stated she did not witness Resident 1's actual fall but observed Resident 1 lying in a prone (lying flat, specifically face down) position on the floor with both arms positioned under the resident's body. LVN 2 further stated Resident 1 complained of left arm pain and was observed wearing purple rubber slippers at the time of the incident. LVN 2 reviewed Resident 1's care plan for falls, initiated on 2/10/2026, which identified Resident 1 as high risk for falls due to impaired balance, decreased or poor safety awareness, orthostatic hypotension, history of repeated falls, and possible medication side effects. LVN 2 stated Resident 1's care plan interventions did not indicate the resident's orthostatic blood pressure monitoring, use of personal rubber slippers, and Resident 1's refusal to use assistive device while ambulating. LVN 2 stated that the use of slippers and refusal to use an assistive device while ambulating may have contributed to Resident 1's fall. During a concurrent observation and interview on 4/29/2026 at 8:15 a.m., with the Maintenance Director (MDtr), the MDtr measured the distance from Resident 1's bed to Nurse Station 4, where Resident 1 had walked without an assistive device prior to the fall on 4/25/2026. The MDtr stated that the total distance measured was 71 ft. During an interview on 4/29/2026 at 9:30 a.m. and concurrent record review of Resident 1's Physical Therapy (healthcare specialty focused on treating injuries, illnesses or conditions that limit mobility and physical function) Treatment Encounter Notes, dated 3/31/2026, with Physical Therapist 1 (PT 1 - a licensed healthcare professional who diagnoses and treats patients of all ages with conditions limiting their ability to move and function), PT 1 stated Resident 1's vital signs were monitored due to the resident's history of syncope (temporary loss of consciousness [is the state of being aware of one's surroundings, sensations, thoughts, and existence] and muscle strength caused by a sudden drop in blood flow to the brain, usually lasting only a few seconds to minutes). PT 1 stated Resident 1 was able to ambulate 150 feet within the facility by using the handle of the resident's wheelchair for support. PT 1 further stated Resident 1 was not trained to ambulate more than ten feet without the use of an assistive device. During an interview on 4/29/2026 at 10:04 a.m., and a concurrent record review of Resident 1's Physical Therapy Discharge summary, dated [DATE], with the Director of Rehabilitation (DOR), the DOR stated Resident 1's Physical Therapy Discharge Summary indicated the resident's treatment diagnosis as difficulty walking. The Discharge Recommendation and Status section indicated that Resident 1 may ambulate as desired within the facility using a FWW with staff supervision. The DOR stated she was not aware that Resident 1 refused to use an assistive device or that the resident preferred to wear slippers while ambulating. The DOR further stated that the physical therapy department did not recommend the use of slippers for Resident 1 due to the resident's increased risk for falls. During an interview on 4/29/2026 at 1:26 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was at high risk for falls and had diagnoses that included orthostatic hypotension. The DON stated Resident 1's orthostatic blood pressure should be obtained while the resident is in lying, sitting, and standing positions. The DON further stated that obtaining Resident 1's standing blood pressure reading is crucial in identifying orthostatic hypotension and monitoring the resident's condition. The DON stated Resident 1's orthostatic blood pressure should have been monitored in accordance with the physician's orders and documented in Resident 1's medical records. The DON stated there was no documented evidence that Resident 1's orthostatic blood pressure was monitored. The DON stated Resident 1's use of slippers while ambulating and refusal to use an assistive device placed the resident at increased risk for falls and injury. The DON acknowledged and stated the facility failed to monitor Resident 1's orthostatic blood pressure in accordance with the physician order. The DON further stated the facility failed to identify Resident 1's risks for falls and failed to implement interventions to prevent a fall with injury. The DON stated that the facility failed to identify the use of open-toed and open back slippers while ambulating and the resident's refusal to use an assistive device as risks for falls. The DON stated the facility failed to create a care plan and implement the appropriate interventions to prevent Resident 1 from falling and sustaining an injury. During a review of the facility's policy and procedure (PnP) titled, Fall Management Program, last reviewed on 4/16/2026, the PnP indicated the facility is committed to minimizing the risk of resident falls through a structured Fall Management Program that includes prevention, monitoring, and post-fall evaluation. The Fall Prevention Strategies section indicated . implement individualized interventions based on risk level, which may include environmental modifications, mobility assistance and physical therapy. The PnP indicated all post-fall assessments, interdisciplinary team (IDT - a collaborative group of professionals from different disciplines - such as physicians, nurses, therapists, and social workers - who work together to create and implement a single, unified care plan for a resident) recommendations, and care plan updates must be documented in the Electronic Health Record (HER - a secure, digital, and real-time version of a resident's paper chart, containing comprehensive medical history, diagnostics [tests, methods, or procedures used to identify the cause, nature, and severity of a disease, injury, or technical problem], medications, and treatment plans). During a review of the facility's PnP titled, Nursing Assessment, last reviewed on 4/16/2026, the PnP indicated, all residents will receive timely, comprehensive, and ongoing nursing assessments to identify clinical needs, detect changes in condition, and ensure appropriate interventions are implemented in accordance with physician orders and professional standards. The PnP indicated the purpose is to ensure early detection of changes in condition, timely intervention and physician notification, prevention of avoidable decline, accurate and complete clinical documentation. During a review of the facility's PnP titled, Orthostatic Blood Pressure Monitoring, last reviewed on 4/16/2026, the PnP indicated the purpose to identify and manage residents at risk for orthostatic hypotension to prevent falls and injury. The PnP indicated the facility will monitor orthostatic blood pressure (BP) for residents at risk and ensure timely intervention, documentation, and physician notification. During a review of the facility's PnP titled, Care Planning, last reviewed on 4/16/2026, the PnP indicated, each resident will have an individualized, person-centered care plan developed and implemented by the Interdisciplinary Team (IDT) that reflects the resident's needs, preferences, goals, and clinical conditions.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to:Ensure licensed nurses monitored Resident 1's orthostatic blood pressure related to the resident's orthostatic hypotension. Resident 1's orthostatic blood pressure was not taken from 2/13/2026 to 4/28/2026.Ensure licensed nurses appropriately assessed Resident 1's risk for falls following the resident's fall on 2/26/2026. Ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's Change of Condition (COC - when there is a sudden change in a resident's condition) on 4/25/2026 related to the resident's fall. These deficient practices had the potential to result in the failure to identify continued or worsening clinical deterioration and increase risk for falls, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted the resident on 2/10/2026 with diagnoses including orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from sitting or lying position and may cause lightheadedness, dizziness or fainting), difficulty walking, muscle weakness, history of falling, and restless leg syndrome (RLS - a nervous system disorder that creates an irresistible urge to move your legs, usually accompanied by uncomfortable sensations like crawling, itching, or pulling). During a review of Resident 1's Physician Order, dated 2/13/2026, the Physician Order indicated to monitor for side effects of anti-psychotic medications (used to manage symptoms of psychosis [a set of symptoms indicating a loss of contact with reality, where a person has trouble distinguishing what is real from what is not]), including drowsiness (a state of strong desire for sleep or extended, inappropriate sleeping during the day) and postural hypotension (also known as orthostatic hypotension, a sudden drop in blood pressure that occurs when standing up from a sitting or lying position). The Physician Order indicated for nursing staff to document these side effects using tally marks on Resident 1's Medication Administration Record (MAR - a legal document used by healthcare professionals to track and record every dose of medication given to a resident) every shift. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/8/2026, the MDS indicated Resident 1's cognitive (refers to the mental processes involved in gaining knowledge, understanding, and thinking) skills for daily decision making were moderately impaired. The MDS further indicated that Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for mobility (movement) activities, including sit-to-stand (the ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed) transfers and walking 150 feet (ft - unit of measurement). The MDS indicated Resident 1 required set-up assistance (helper assists the resident prior to or following the activity) for walking 50 ft with two turns (once standing, the ability to walk at least 50 ft and make two turns). During a review of Resident 1's Change in Condition (COC - when there is a sudden change in a resident's condition) Evaluation, dated 4/25/2026, the COC Evaluation indicated on 4/25/2026 at 1:55 a.m., Registered Nurse 1 (RN 1) was notified of Resident 1's fall. The COC Evaluation indicated Resident 1 complained of severe pain in the left shoulder and entire left arm and did not tolerate the range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) on the left upper arm. The COC Evaluation indicated Resident 1 was left on the floor until the paramedics (are highly trained healthcare professional who provide advanced medical care to individuals outside of a hospital setting) arrived. The Functional Status Evaluation section indicated Resident 1 did not have orthostatic hypotension but there was no documented evidence that orthostatic blood pressure was taken. During an interview on 4/28/2026 at 1:54 p.m., and a concurrent record review of Resident 1's MAR dated 4/1/2026 to 4/30/2026, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there was no documented evidence Resident 1's orthostatic blood pressure was monitored. LVN 1 stated Resident 1 was prescribed anti-psychotic medications that required orthostatic blood pressure monitoring in accordance with the physician's order. LVN 1 stated that orthostatic blood pressure is assessed by obtaining blood pressure readings while the resident is lying, sitting, and standing. A review of Resident 1's vital signs (essential objective measurements of basic body functions such as body temperature, heart rate, respiration rate, and blood pressure) logs, dated 2/10/2026 to 4/28/2026, was conducted during the interview. LVN 1 stated that there was no documented evidence indicating that blood pressure readings were obtained while standing. LVN 1 further stated that she was not checking Resident 1's orthostatic blood pressures. LVN 1 stated that failure to monitor Resident 1's orthostatic blood pressure could result in an undetected episode of orthostatic hypotension, which may increase the risk for falls. LVN 1 stated Resident 1 had a fall on 4/25/2026. LVN 1 stated Resident 1 should be monitored every shift for 72 hours. LVN 1 stated Resident 1's Progress Notes, dated 4/25/2026 to 4/28/2026, indicated there was no documented evidence that the resident was monitored on the following shifts: a. On 4/26/2026 (3 p.m. to 11 p.m. shift and 11 p.m. to 7 a.m. shift) and b. On 4/27/2026 (7 a.m. to 3 p.m. shift). LVN 1 stated that failure to document Resident 1's medical status monitoring following a change of condition related to a fall could put Resident 1's safety at risk. During an interview on 4/29/2026 at 1:26 p.m. and a concurrent record review of Resident 1's Fall Risk Evaluation, dated 2/26/2026, with the Director of Nursing (DON), the DON stated Resident 1 had a total score of ten representing high risk for falls. The DON stated Resident 1 had history of multiple falls. The DON stated the Fall Risk Evaluation indicated Resident 1 had no falls in the past 90 days, the Gait Evaluation section was not completed and indicated there was no drop in orthostatic blood pressure between lying and standing. The DON stated there was no documented evidence of Resident 1's orthostatic blood pressure was taken. The Diagnosis Review section indicated Resident 1 had one to two present diseases and diagnoses that could contribute to falls. The DON stated Resident 1 had more than two diseases and diagnoses that could contribute to falls. The DON stated failure to accurately evaluate Resident 1's risk for falls could cause inadequate interventions required to prevent falls and injuries. The DON stated there was no documented evidence of monitoring on the identified shifts and Resident 1's orthostatic blood pressures. The DON stated care not documented was considered not provided. The DON stated failure to monitor Resident 1 every shift after a COC could result to the resident's missed signs of orthostatic hypotension that could lead to falls and injury. The DON stated the facility failed to identify, document, and monitor Resident 1's risk for falls. The DON further stated the facility failed to follow the physician orders to monitor Resident 1 for orthostatic hypotension. During a review of the facility's policy and procedures (PnP) titled, Nursing Assessment, last reviewed on 4/16/2026, the PnP indicated all residents will receive timely, comprehensive, and ongoing nursing assessments to identify clinical needs, detect changes in condition, and ensure appropriate interventions are implemented in accordance with physician orders and professional standards. The PnP indicated the purpose to ensure early detection of changes in condition, timely intervention and physician notification, prevention of avoidable decline, accurate and complete clinical documentation. During a review of the facility's PnP titled, Orthostatic Blood Pressure Monitoring, last reviewed on 4/16/2026, the PnP indicated the purpose is to identify and manage residents at risk for orthostatic hypotension to prevent falls and injury. The PnP indicated the facility will monitor orthostatic blood pressure (BP) for residents at risk and ensure timely intervention, documentation, and physician notification. During a review of the facility's PnP titled, Change in Condition, last reviewed on 4/16/2026, the PnP indicated, the facility will promptly recognize, assess, and respond to any changes in a resident's physical, cognitive, or emotional condition to ensure timely medical intervention and maintain resident safety. The Follow-up section indicated to monitor the resident until the condition stabilizes and adjust care plans and interventions as recommended by physician or Interdisciplinary Team (IDT).

Based on interview and record review, the facility failed to ensure the medical records of three of three sampled residents (Resident 1, Resident 2, and Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:a. Ensure certified nursing assistants (CNAs) documented Residents 1, 2, and 3's percentage (% - per one hundred) of food eaten at the correct time. b. Ensure licensed nurses documented the accurate time Resident 1 arrived back at the facility from General Acute Care Hospital (GACH) 1 on 4/25/2026. These deficient practices resulted in inaccurate information on Residents 1, 2, and 3's medical records and had the potential for delayed and inaccurate medical interventions.Findings:During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted the resident on 2/10/2026 with diagnoses including orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from sitting or lying position and may cause lightheadedness, dizziness or fainting), difficulty walking, muscle weakness, history of falling, and restless leg syndrome (RLS - a nervous system disorder that creates an irresistible urge to move your legs, usually accompanied by uncomfortable sensations like crawling, itching, or pulling). During a review of Resident 1's Physician Order, dated 2/10/2026, the Physician Order indicated the resident had consistent carbohydrate diet (CCHO - a meal plan that limits carbohydrates to a specific, steady amount at each meal and snack to manage blood sugar levels).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/8/2026, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was moderately impaired.During an interview on 4/29/2026 at 12:32 p.m. and concurrent record review of Resident 1's Progress Notes, dated 4/25/2026, reviewed with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on 4/25/2026 at 9: 30 a.m., Resident 1 returned to the facility from GACH 1. LVN 3 stated Resident 1's Progress Notes indicated the Assistant Director of Nursing (ADON) documented at 10:56 p.m. that Resident 1 returned to the facility at 9:30 p.m. on 4/25/2026. During an interview on 4/29/2026 at 11:58 a.m. and concurrent record review of Resident 1's Nutritional Task, dated 4/1/2026 to 4/28/2026, reviewed with CNA 3, CNA 3 stated the Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake amount the resident had eaten in percentage. Resident 1's Nutritional Task indicated the following:On 4/1/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 2:37 p.m.On 4/2/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 2:06 p.m.On 4/5/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 2:38 p.m.On 4/12/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 2:41 p.m.On 4/13/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 1:41 p.m.On 4/16/2026, Resident 1's documented breakfast meal intake was at 2:06 p.m. and lunch meal intake at 2:08 p.m., both at 76% to 100%.On 4/20/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 12:51 p.m.On 4/21/2026, Resident 1's documented breakfast meal intake was 0% to 25% at 2:19 p.m. and lunch meal intake was 26% to 50% at 2:20 p.m.On 4/22/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 1:39 p.m.On 4/23/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 12:53 p.m.On 4/24/2026, Resident 1's documented breakfast and lunch meal intake was 76% to 100%, both at 1 p.m.CNA 3 stated the documented times of Resident 1's percentages of meal intakes were inaccurate. CNA 3 stated Resident 1's meal intake should be documented after the meal had been consumed.During a review of Resident 2's undated admission Record, the admission Record indicated on the facility admitted the resident on 3/13/2025 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities but doctors cannot yet determine the exact underlying cause), muscle weakness, and essential hypertension (abnormally high blood pressure that was not the result of a medical condition).During a review of Resident 2's Physician Order, dated 7/29/2025, the Physician Order indicated the resident had regular diet (a balanced, everyday eating plan for healthy individuals with no restrictions).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were intact.During an interview on 4/29/2026 at 11:58 a.m. and concurrent record review of Resident 2's Nutritional Task, dated 4/1/2026 to 4/28/2026, reviewed with CNA 3, CNA 3 stated the Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake amount the resident had eaten in percentage. Resident 2's Nutritional Task indicated the following:On 4/1/2026, Resident 2's documented breakfast meal intake was at 12:30 p.m. and lunch meal intake at 12:31 p.m., both at 76% to 100%.On 4/2/2026, Resident 2's documented breakfast meal intake was at 12:14 p.m. and lunch meal intake at 12:15 p.m., both at 76% to 100%.On 4/5/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 1:43 p.m.On 4/6/2026, Resident 2's documented breakfast meal intake was 76% to 100% and lunch meal intake was 51% to 75%, both at 1:46 p.m.On 4/7/2026 and 4/8/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 1:11 p.m.On 4/9/2026, Resident 2's documented breakfast meal intake at 1:18 p.m. and lunch meal intake at 1:19 p.m., both were 76% to 100%.On 4/12/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 1:41 p.m.On 4/13/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 12:53 p.m.On 4/14/2026, Resident 2's documented breakfast meal intake was 51% to 75% and lunch meal intake was 76% to 100%, both at 1:05 p.m.On 4/15/2026, Resident 2's documented breakfast meal intake at 12:59 p.m. and lunch meal intake at 1 p.m., both were 76% to 100%.On 4/17/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 12:07 p.m.On 4/19/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 1:06 p.m.On 4/20/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 1:11 p.m.On 4/22/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 1:46 p.m.On 4/23/2026, Resident 2's documented breakfast and lunch meal intake was 76% to 100%, both at 12:21 p.m.CNA 3 stated the documented times of Resident 2's percentages of meal intakes were inaccurate. CNA 3 stated Resident 2's meal intake should be documented after the meal had been consumed.During a review of Resident 3's undated admission Record, the admission Record indicated on the facility admitted the resident on 11/12/2025 with diagnoses including unspecified dementia, muscle weakness, and displaced intertrochanteric fracture of right femur (a broken bone between the two bony bumps at the top of the thigh bone that moved out of place).During a review of Resident 3's Physician Order, dated 1/22/2026, the Physician Order indicated the resident had regular diet.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were severely impaired.During an interview on 4/29/2026 at 11:58 a.m. and concurrent record review of Resident 3's Nutritional Task, dated 4/1/2026 to 4/28/2026, reviewed with CNA 3, CNA 3 stated the Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake amount the resident had eaten in percentage. Resident 3's Nutritional Task indicated the following:On 4/11/2026, Resident 3's documented breakfast meal intake was 0% to 25% and lunch meal intake was 26% to 50%, both at 12:53 p.m.On 4/20/2026, Resident 3's documented breakfast and lunch meal intake was 76% to 100%, both at 1:43 p.m.On 4/23/2026, Resident 3's documented breakfast and lunch meal intake was 76% to 100%, both at 1:42 p.m.On 4/24/2026, Resident 3's documented breakfast and lunch meal intake was 76% to 100%, both at 12:30 p.m.On 4/25/2026, Resident 3's documented breakfast meal intake was 76% to 100% at 2:32 p.m. and lunch meal intake was 26% to 50% at 12:33 p.m.On 4/28/2026, Resident 3's documented breakfast meal intake at 1:10 p.m. and lunch meal intake at 1:11 p.m., both were 76% to 100%.CNA 3 stated the documented times of Resident 3's percentages of meal intakes were inaccurate. CNA 3 stated Resident 3's meal intake should be documented after the meal had been consumed.During an interview on 4/29/2026 at 1:26 p.m. with the Director of Nursing (DON), the DON stated CNAs should document the residents' (Residents 1, 2, and 3) amount of meal intake after the residents (Residents 1, 2, and 3) consumed their meals (breakfast, lunch, or dinner). The DON stated inaccurate documentation had the potential for inaccurate assessment that may lead to unidentified weight changes. The DON further stated the documentation in the resident's medical records should indicate the accurate date and time. The DON acknowledged and stated the facility failed to ensure the residents' (Residents 1, 2, and 3) medical records were complete and accurate.During a review of the facility's policy and procedure (PnP) titled, Charting and Documentation Policy, last reviewed on 4/16/2026, the PnP indicated all resident care, assessments, medications, treatments, and changes in condition must be documented in the medical record promptly, accurately, and according to facility and regulatory requirements. The PnP indicated to document care at the time it is provided of immediately afterward, use clear, legible, and factual entries.

Based on interview and record review, the facility failed to create and implement a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1). The facility failed to develop and implement an individualized care plan with interventions addressing the following: Resident 1's orthostatic blood pressure monitoring.Resident 1's preference in using a slip-on rubber slipper while ambulating (walking).Resident 1's refusal in using an assistive device while ambulating. These deficient practices placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury and serious condition such as worsening of Resident 1's orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from sitting or lying position and may cause lightheadedness, dizziness or fainting), falls, and fractures (broken bones).Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted the resident on 2/10/2026 with diagnoses including orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from sitting or lying position and may cause lightheadedness, dizziness or fainting), difficulty walking, muscle weakness, history of falling, and restless leg syndrome (RLS - a nervous system disorder that creates an irresistible urge to move your legs, usually accompanied by uncomfortable sensations like crawling, itching, or pulling). During a review of Resident 1's Fall Risk Evaluation, dated 2/10/2026, the Fall Risk Evaluation indicated Resident 1 had a total score of 15. A total score of ten and above represented high risk for falls. During a review of Resident 1's Physician Order, dated 2/13/2026, the Physician Order indicated to monitor for side effects of mirtazapine (a medication used to treat depression [a mental health condition causing persistent sadness, loss of interest, and decreased energy that interferes with daily life] and frequently used for its sedative [medication that calms the mind and body] and appetite-stimulating effects) such as postural hypotension (also known as orthostatic hypotension, a sudden drop in blood pressure that occurs when standing up from a sitting or lying position). The Physician Order indicated for nursing staff to document observations using tally marks or hash marks (a system used for counting or keeping track of ongoing results with each mark representing one unit) on the Medication Administration Record (MAR - a legal document used by healthcare professionals to track and record every dose of medication given to a resident) every shift. During a review of Resident 1's Physician Order, dated 2/13/2026, the Physician Order indicated to monitor for side effects of anti-psychotic medications (used to manage symptoms of psychosis [a set of symptoms indicating a loss of contact with reality, where a person has trouble distinguishing what is real from what is not]), including drowsiness (a state of strong desire for sleep or extended, inappropriate sleeping during the day) and postural hypotension. The Physician Order indicated for nursing staff to document these side effects using tally marks on Resident 1's MAR every shift. During a review of Resident 1's Change in Condition (COC - when there is a sudden change in a resident's condition) Evaluation, dated 2/26/2026, the COC Evaluation indicated on 2/26/2026 at 4:30 a.m., Resident 1 was found sitting on the floor beside the resident's bed. The Functional Status Evaluation section that will indicate if Resident 1 had an orthostatic hypotension was not completed. During a review of Resident 1's Fall Risk Evaluation, dated 2/26/2026, the Fall Risk Evaluation indicated Resident 1 had a total score of ten. A total score of ten and above represented high risk for falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/8/2026, the MDS indicated Resident 1's cognitive (refers to the mental processes involved in gaining knowledge, understanding, and thinking) skills for daily decision making were moderately impaired. The MDS further indicated that Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for mobility (movement) activities, including sit-to-stand (the ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed) transfers and walking 150 feet (ft - unit of measurement). The MDS indicated Resident 1 required set-up assistance (helper assists the resident prior to or following the activity) for walking 50 ft with two turns (once standing, the ability to walk at least 50 ft and make two turns). During a review of Resident 1's Change in Condition (COC) Evaluation, dated 4/25/2026, the COC Evaluation indicated on 4/25/2026 at 1:55 a.m., Resident 1 had a fall while ambulating in the hallway. The COC Evaluation indicated Resident 1 complained of severe pain in the left shoulder and entire left arm and did not tolerate the range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) on the left upper arm. The Functional Status Evaluation section indicated Resident 1 did not have orthostatic hypotension but there was no documented evidence that orthostatic blood pressure was taken. During an interview on 4/29/2026 at 6:30 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 wore a purple rubber slipper, one to two inches thick, and occasionally refused to use the wheelchair while ambulating. During a concurrent interview and record review on 4/29/2026 at 6:59 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's admission Record, Progress Notes dated 4/1/2026 to 4/28/2026, Vital Signs Log dated 2/10/2026 to 4/28/2026, and Care Plan (document that outlines the specific healthcare and support needs of a resident, along with strategies and interventions to address those needs) initiated on 2/10/2026, were reviewed. LVN 2 stated Resident 1 refused to wear nonskid socks and preferred to wear personal purple rubber slippers approximately one to one and a half inches thick. LVN 2 further stated Resident 1 occasionally refused to use the assistive device while ambulating. LVN 2 stated there was no documented evidence in Resident 1's medical records that indicated Resident 1 was monitored for orthostatic hypotension. LVN 2 reviewed Resident 1's care plan for falls, initiated on 2/10/2026, which identified Resident 1 as high risk for falls due to impaired balance, decreased or poor safety awareness, orthostatic hypotension, history of repeated falls, and possible medication side effects. LVN 2 stated Resident 1's care plan interventions did not indicate the resident's orthostatic blood pressure monitoring, use of personal rubber slippers, and Resident 1's refusal to use assistive device while ambulating. LVN 2 stated that the use of slippers and refusal to use an assistive device while ambulating may have contributed to Resident 1's fall. LVN 2 stated Resident 1's care plan was incomplete. During an interview on 4/29/2026 at 1:26 p.m. with the Director of Nursing (DON), the DON stated Resident 1's preference to use a personal slipper and the resident's refusal to use assistive devices while ambulating should have been addressed and reflected in the resident's care plan. The DON stated Resident 1's care plan did not have interventions that included orthostatic blood pressure monitoring. The DON stated Resident 1's care plans were not complete. The DON stated that the facility failed to identify the use of open-toed and open back slippers while ambulating and the resident's refusal to use an assistive device as risks for falls. The DON stated the facility failed to create a care plan and implement the appropriate interventions to prevent Resident 1 from falling and sustaining injuries. During a review of the facility's policy and procedure (PnP) titled, Care Planning, last reviewed on 4/16/2026, the PnP indicated each resident will have an individualized, person-centered care plan developed and implemented by the Interdisciplinary Team (IDT - a collaborative group of professionals from different disciplines - such as physicians, nurses, therapists, and social workers - who work together to create and implement a single, unified care plan for a resident) that reflects the resident's needs, preferences, goals, and clinical conditions. During a review of the facility's PnP titled, Nursing Assessment, last reviewed on 4/16/2026, the PnP indicated all residents will receive timely, comprehensive, and ongoing nursing assessments to identify clinical needs, detect changes in condition, and ensure appropriate interventions are implemented in accordance with physician orders and professional standards. The PnP indicated nursing assessments must be communicated to the Interdisciplinary Team (IDT), reflected in the care plan updates.

Based on observation, 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 (Resident 3) by failing to:1. Implement Resident 3's care plan on monitoring for anticoagulant therapy (often called blood thinners, medication used to reduce the risk of dangerous blood clots forming in blood vessels or the heart) side effects (an unintended, often unpleasant reaction to medication, treatment, or procedure that occurs alongside its intended purpose).2. Implement Resident 3's care plan for constipation (a condition in which stool becomes hard, dry, and difficult to pass, and bowel movements do not happen very often).3. Develop a care plan for Resident 3 that indicates use of bilateral landing mat (a thick, cushioned, foldable gym mat designed to safely absorb the impact of landing) as ordered by the physician.These failures had the potential for delays in the delivery of necessary care and services and could place Resident 3 at risk for bleeding, constipation and injury.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 2/10/2026, with diagnoses that included other acute kidney failure (often called Acute Kidney Injury [AKI], is a sudden, temporary loss of kidney function, often within hours or days), other pulmonary embolism (a medical emergency caused by a blood clot getting stuck in a lung artery [thick, muscular blood vessels that carry oxygen-rich blood away from the heart to the rest of the body] blocking blood flow) with acute cor pulmonale (the sudden, rapid failure of the right side of the heart caused by a severe lung issue, such as a large blood clot) and history of fall.During a review of Resident 3'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 2/11/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 2/17/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 3 needed maximum assistance from staff for toileting, showering, dressing and personal hygiene. The MDS indicated Resident 3 was always incontinent (unable to control) of bowel functions.a. During a review of Resident 3's Physician Order, dated 2/10/2026, the Physician Order indicated apixaban (blood thinner/anticoagulant medication used to prevent and treat dangerous blood clots) oral tablet five milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for pulmonary embolism/deep vein thrombosis (DVT- a blood clot that forms in a deep vein, usually in the leg or arm).During a review of Resident 3's Care Plan dated 2/16/2026, on anticoagulant therapy, the Care Plan indicated the following interventions:1. Monitor for side effects and effectiveness.2. Monitor/document/report adverse reactions (an unexpected, harmful, or unpleasant response to a medication or treatment, occurring even at normal doses) of anticoagulant therapy: blood tinged (a small amount of blood mixed in) or red blood in urine, black tarry stools (indicate bleeding in the upper digestive tract, such as the stomach or esophagus) dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (a state of having very little energy, feeling sluggish, tired, or unmotivated), bruising.During a review of Resident 3's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 4/2026, the MAR indicated Resident 3 received apixaban two times a day at 9 a.m., and 5 p.m. from 4/1/2026, to 4/13/2026.During a concurrent interview and record review on 4/14/2026, at 7:01 a.m., with the Director of Nursing (DON), Resident 3's Physician Order, dated 2/10/2026, and MAR, dated 4/2026, were reviewed. The DON stated apixaban is an anticoagulant that had a side effect of bleeding and bruising. The DON stated Resident 3 who was on apixaban should be monitored for bleeding every shift and monitoring should be documented in Resident 3's MAR. The DON stated there was no documented monitoring for the side effect of apixaban.During a concurrent interview and record review on 4/14/2026, at 7:10 a.m., with the DON, Resident 3's Care Plan, dated 2/16/2026, was reviewed. The DON stated Resident 3's Care Plan indicated an intervention to monitor side effects of apixaban. The DON stated the Care Plan for anticoagulant therapy monitoring was not followed.b. During a review of Resident 3's Physician Order, dated 2/10/2026, the Physician Order indicated the following:1. Naloxegol oxalate (medication used to treat opioid-induced constipation [OIC] in adults with chronic, non-cancer pain) oral tablet 25 mg, give one tablet by mouth daily for constipation.2. Polyethylene Glycol (medication used to treat constipation and for bowel preparation) 3350 powder, give 17 grams by mouth daily for constipation. During a review of Resident 3's Care Plan, dated 2/16/2026, for risk of constipation, the Care Plan indicated the following interventions:1. Medications as ordered.2. Monitor for effectiveness and report concerns to the physician for evaluation and review.During a review of Resident 3's MAR, dated 4/2026, the MAR indicated nurses administered naloxegol and polyethylene glycol to Resident 3 daily.During an interview on 4/13/2026, at 9:17 a.m., with Resident 3, Resident 3 stated she (Resident 3) had not had a bowel movement for 13 days. Resident 3 stated she (Resident 3) had notified the nurses, but no new medication was administered.During a review of Resident 3's Bowel Elimination Task dated 3/15/2026, to 4/13/2026, the Bowel Elimination Task indicated Resident 3 did not have bowel movement on the following dates: 3/15/2026, 3/19/2026, 4/2/2026, 4/6/2026, 4/9/2026, 4/12/2026, and 4/13/2026. During an interview on 4/13/2026, at 1:48 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 3 complaints of constipation all the time. LVN 1 stated the last time Resident 3 verbalized constipation was last week (LVN 1 unable to remember exact date), and she (LVN 1) had notified her (Resident 3) that she (Resident 3) was already on naloxegol and polyethylene glycol daily for constipation.During an observation on 4/14/2026, at 5:15 a.m., inside Resident 3's room, Observed Registered Nurse 2 (RN 2) talked to Resident 3 and heard Resident 3 asked RN 2 for enema (a medical procedure used to treat constipation, fecal impaction, [a severe form of constipation where a large, hard mass of stool gets stuck in the rectum or lower colon] or prepare the bowels for medical examination by injecting (introducing) liquid directly into the rectum.During an interview on 4/14/2026, at 5:16 a.m., with Resident 3, Resident 3 stated she (Resident 3) had requested enema a week ago, but it was not administered.During an interview on 4/14/2026, at 5:29 a.m., with LVN 2, LVN 2 stated Resident 3's last bowel movement was on 4/11/2026, and Resident 3 gets her (Resident 3) routine naloxegol and polyethylene daily for constipation. LVN 2 stated Resident 3 did not have any other medication ordered for constipation. LVN 2 stated Resident 3 informed her (LVN 2) that she (Resident 3) had an order for enema but there was no order on Resident 3's medical record. LVN 2 stated she (LVN 2) had reported to RN 2 of Resident 3's request for enema.During an interview on 4/14/2026, at 5:49 a.m., with RN 2, RN 2 stated LVN 2 reported that Resident 3 needed something to relieve her (Resident 3) constipation but there was no as needed (PRN) medication. RN 2 stated if there was no PRN medication she (RN 2) should have notified the physician. RN 2 stated there was no documented evidence that she (RN 2) had notified the physician of Resident 3's concern on constipation.During a concurrent interview and record review on 4/14/2026, at 7:10 a.m., with the DON, Resident 3's Care Plan, dated 2/16/2026, on at risk for constipation was reviewed. The DON stated Care Plan was not followed since the nurses did not notify the physician of Resident 3's constipation.c. During a review of Resident 3's Change in Condition (CIC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status) Evaluation, dated 2/26/2026, timed at 4:30 a.m., the CIC indicated Resident 3 slid of the bed in an attempt to go to the bathroom and found sitting on the floor. The CIC indicated the physician was notified at 4:45 a.m., and ordered bilateral landing pads, bed and wheelchair alarm (designed to prevent falls and wandering [to walk around slowly in a relaxed way or without any clear purpose or direction] by alerting caregivers when a high-risk patient attempts to leave their bed or chair).During a review of Resident 3's Care Plan, dated 2/26/2026, on at risk for fall and history of fall, the Care Plan indicated no bilateral landing pads.During a concurrent interview and record review on 4/14/2026, at 6:19 a.m. with RN 2, Resident 3's CIC, dated 2/26/2026, and Care Plans for fall were reviewed. RN 2 stated Resident 3 had a fall incident on 2/26/2026, and the physician ordered bilateral landing pads. RN 2 stated there were no bilateral landing pads in Resident 3's care plans. RN 2 stated since the physician ordered the bilateral landing pads, it should be in Resident 3's care plan to prevent fall. RN 2 stated care plans are list of care provided to resident to address problems like fall.During an interview on 4/14/2026, at 7:10 a.m. with the DON, the DON stated Resident 3's care plan for fall was not complete since the bilateral landing pads were not in the intervention to prevent fall. The DON stated care plans are the summary of care to be provided to the residents and care plans should be complete with interventions and care plans should be followed. During a review of facility's policy and procedure (P&P) titled, Comprehensive Care Plan, undated and last reviewed on 4/24/2025, the P&P indicated, The facility developed a Comprehensive Care Plan (CCP) for each resident to ensure individualized, resident-centered care that addresses medical, psychosocial, functional, and safety needs. To provide a structured framework for delivery, coordination, and evaluation of resident care, ensuring compliance. The CCP must include, but is not limited to:a. Resident identifiers, preferences, and goals,b. Medical diagnoses and treatment orders,c. Medication management.Implementation: All staff must follow the care plan to deliver resident-specific care.Review and revision: CCP must be reviewed at least quarterly and updated:a. After significant change in resident condition,b. Following hospitalization or major incident,c. When new interventions or goals are identified.

Based on interview and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 1) by failing to:1. Call the Wound Provider (WP) to obtain a physician wound care order and provide wound care treatment on 3/9/2026, to Resident 1's stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) from sacrococcyx (tailbone) extending to bilateral buttocks.2. Follow the WP order for wound treatment to right and left heel unstageable pressure ulcer (a severe wound where the true depth cannot be determined because it is completely covered by dead tissue) from 3/26/2026, to 3/31/2026.These failures had the potential for the development and worsening of Resident 1's pressure ulcers.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/2/2026, with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), generalized muscle weakness and essential HTN (high blood pressure).During a review of Resident 1'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 2/4/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Physician Order, dated 2/6/2026, the Physician Order indicated clean sacrococcyx extending to bilateral buttocks with normal saline (prepared mixture of salt and sterile water), pat dry and apply Santyl (a prescription medication that removes dead tissue from chronic skin ulcers and severe burns to promote healing), calcium alginate (highly absorbent wound dressing), barrier cream (a protective shield for your skin) to periwound (skin area immediately surrounding a wound), cover with dry dressing daily and as needed for 30 days and reevaluate on 3/9/2026.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 1's Wound Assessment, dated 3/4/2026, the Wound Assessment indicated Resident 1 had stage 4 pressure ulcer on sacrococcyx extending to bilateral buttocks measuring 13.5 centimeter (cm-a metric unit of length) long, 11 cm wide and 3 cm deep. The Wound Assessment indicated the Wound Provider (WP) performed a debridement (surgical procedure to remove non-viable tissue) and ordered Santyl with calcium alginate daily and as needed.During a review of Resident 1's Physician Order, dated 3/10/2026, the Physician Order indicated clean sacrococcyx extending to bilateral buttocks with normal saline, pat dry and apply Santyl, calcium alginate, cover with dry dressing daily and as needed for 30 days and reevaluate on 4/9/2026.During a review of Resident 1's Treatment Administration Record (TAR- flowsheet that indicates treatment given to a resident), dated 3/2026, the MAR indicated no wound treatment administered to Resident 1's sacrococcyx pressure ulcer.During a concurrent interview and record review on 4/13/2026, at 12:06 p.m., with the Director of Nursing (DON), Resident 1's Physician Order, dated 2/6/2026, 3/10/2026, TAR, dated 3/2026, were reviewed. The DON stated there was no documented treatment provided to Resident 1's sacrococcyx stage 4 pressure ulcer on 3/9/2026. The DON stated Resident 1's pressure ulcer could worsen because treatment was not provided.During an interview on 4/14/2026, at 11:28 a.m. with Treatment Nurse 1 (TN 1), TN 1 stated the TN assigned on 3/9/2026, should have called the WP to renew order for stage 4 sacrococcyx pressure ulcer. TN 1 stated on 3/10/2026, she (TN 1) the order was not renewed so she (TN 1) called the WP and obtained an order for sacrococcyx pressure ulcer wound treatment. TN 1 stated if there was no documented treatment done on 3/9/2026, it means treatment not provided to Resident 1. TN 1 stated not providing wound treatment can delay Resident 1's wound healing.b. During a review of Resident 1's Physician Order, dated 3/4/2026, the Physician order indicated the following: 1. left heel unstageable pressure ulcer-cleans with normal saline, pat dry, apply iodosorb (topical [applied directly to a specific surface of the body] antiseptic [a germ-killing substance that you apply to your skin to prevent infection] gel/powder used to treat chronic [persisting for a long time], exuding [a fluid released through pores or a wound], and infected wounds), cover with dry dressing daily for 30 days. 2. right heel unstageable pressure ulcer-cleans with normal saline, pat dry, apply iodosorb, cover with dry dressing daily for 30 days.During a review of Resident 1's Wound Assessment, dated 3/25/2026, the Wound Assessment indicated the WP ordered betadine (used on the skin to treat or prevent skin infection) and dry dressing daily to bilateral heels. During a review of Resident 1's Physician Order, dated 3/25/2026, the Physician order indicated the following: 1. left heel unstageable pressure ulcer-cleans with normal saline, pat dry, apply betadine, cover with dry dressing daily for 30 days. 2. right heel unstageable pressure ulcer-cleans with normal saline, pat dry, apply betadine, cover with dry dressing daily for 30 days.During a review of Resident 1's Care Plan, dated 2/3/2026, on left and right heel unstageable pressure ulcer, the Care Plan indicated a new intervention dated 3/25/2026, to clean left heel unstageable pressure ulcer with normal saline, apply betadine, cover with dry dressing daily for 30 days.During a review of Resident 1's Treatment Administration Record (TAR-), dated 3/2026, the TAR indicated from 3/26/2026, to 3/31/2026, nurses administered betadine and iodosorb daily to Resident 1's heels with unstageable pressure ulcer.During a concurrent interview and record review on 4/13/2026, at 12:06 p.m., with the DON, Resident 1's Physician Order, dated 3/25/2026 and TAR, dated 32026, were reviewed. The DON stated TNs should have called the WP and clarified which order to continue since there was a prior order of iodosorb on 3/4/2026, and on 3/25/2026, a new order was added for betadine to bilateral heels. The DON stated there could be a possible drug interaction (a situation where a substance, another drug, food, beverage, or supplement alters the effectiveness or safety of a medication) between betadine and iodosorb and could be too overpowering (too strong) for Resident 1's skin.During an interview on 4/14/2026, at 11:28 a.m., with TN 1, TN 1 stated Resident 1 had betadine and iodosorb applied to bilateral heels from 3/26/2026, to 3/31/2026. TN 1 stated the order was clarified on 4/1/2026, and the WP only ordered the betadine and discontinued the iodosorb. TN 1 stated wound care order should have been clarified on 3/25/2026, when the WP was at the facility. TN 1 stated multiple wound treatment might not be effective and can delay wound healing.During a review of facility's policy and procedure (P&P) titled, Pressure Ulcer Management, Treatment and Prevention, undated and last reviewed on 4/24/2025, the P&P indicated, The facility is committed to the prevention, early identification, and effective treatment of 1nessure ulcers (pressure injuries) in all residents.Treatment and Care: .1. Develop an individualized care plan for each resident with pressure ulcers.2. Clean wounds using appropriate solutions and techniques per facility and providerguidelines.3. Apply dressings as ordered, ensuring correct type and frequency of change.4. Monitor for signs of infection, necrosis, or delayed healing.5. Consult wound care specialists, physician, or dermatologist as needed.During a review of facility's policy and procedure (P&P) titled, Wound Documentation Policy, undated and last reviewed on 4/24/2025, the P&P indicated, Ongoing Wound Documentation:Licensed nurse to document: 1. At each treatment and dressing change. 3. Ensure documentation matches Treatment Administration Record (TAR).Care Plan: Interventions must reflect: 1. Pressure relief/offloading 2. Nutrition/hydration support 3. Wound treatment orders.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 1) by failing to follow physician's order to administer hydralazine (medication used to treat high blood pressure [HTN]) for systolic blood pressure (sbp-measures the pressure the blood is pushing against the artery walls when the heart beats) above 110 millimeter mercury (mmHg- the standard unit of measurement used to record blood pressure, indicating how much force the blood exerts against artery walls).This failure had the potential to result in medication errors and could cause to Resident 1's uncontrolled hypotension (low blood pressure).Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/2/2026, with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), generalized muscle weakness and essential HTN.During a review of Resident 1's Physician Order, dated 2/2/2026, the Physician Order indicated hydralazine hydrochloride oral tablet 25 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give 50 mg by mouth three times a day for HTN, hold for sbp less than 110 mmHg.During a review of Resident 1'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 2/4/2026, 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 2/9/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 4/2026, the MAR indicated the following on 4/10/2026:1. Licensed Vocational Nurse 3 (LVN 3) administered hydralazine to Resident 1 with a blood pressure of 107/68 mmHg at 1 p.m.2. LVN 4 administered hydralazine to Resident 1 with a blood pressure of 105/67 mmHg at 5 p.m.During a concurrent interview and record review on 4/13/2026, at 12:06 p.m., with the Director of Nursing (DON), Resident 1's Physician Order, dated 2/2/2026, and MAR dated 4/2026, were reviewed. The DON stated the Physician Order for hydralazine was to hold (temporarily stop) the medication if Resident 1's sbp was below 110 mmHg. The DON stated on 4/10/2026, at 1 p.m. Resident 1's bp was 107/68 mmHg and at 5 p.m., Resident 1's bp was 105/67 mmHg. The DON stated hydralazine should have been held on 4/10/2026, at 1 p.m. and at 5 p.m. following the physician order. The DON stated Resident 1's could develop uncontrolled hypotension (low blood pressure) because hydralazine was administered.During a review of facility's policy and procedure (P&P) titled, Medication Administration Procedure, undated and last reviewed on 4/24/2025, the P&P indicated, All medications shall be administered in accordance with the prescribers' orders.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3), who was receiving apixaban (an anticoagulant medication that helps prevent the formation of blood clots) was monitored for its side effects of bleeding.This deficient practice had the potential to place Resident 3 at increased risk for side effects including bleeding.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 2/10/2026, with diagnoses that included other acute kidney failure (often called Acute Kidney Injury [AKI]- is a sudden, temporary loss of kidney function, often within hours or days), other pulmonary embolism (a medical emergency caused by a blood clot getting stuck in a lung artery [thick, muscular blood vessels that carry oxygen-rich blood away from the heart to the rest of the body] blocking blood flow) with acute cor pulmonale (the sudden, rapid failure of the right side of the heart caused by a severe lung issue, such as a large blood clot) and history of fall.During a review of Resident 3's Physician Order, dated 2/10/2026, the Physician Order indicated apixaban oral tablet five milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for pulmonary embolism/deep vein thrombosis (DVT- a blood clot that forms in a deep vein, usually in the leg or arm).During a review of Resident 3'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 2/11/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Care Plan dated 2/16/2026, on anticoagulant therapy, the Care Plan indicated the following interventions:1. Monitor for side effects and effectiveness.2. Monitor/document/report adverse reactions (an unexpected, harmful, or unpleasant response to a medication or treatment, occurring even at normal doses) of anticoagulant therapy: blood tinged (a small amount of blood mixed in) or red blood in urine, black tarry stools (indicate bleeding in the upper digestive tract, such as the stomach or esophagus) dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (a state of having very little energy, feeling sluggish, tired, or unmotivated), bruising.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 2/17/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 3 needed maximum assistance from staff for toileting, showering, dressing and personal hygiene.During a review of Resident 3's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 4/2026, the MAR indicated Resident 3 received apixaban two times a day at 9 a.m., and 5 p.m. from 4/1/2026, to 4/13/2026.During a concurrent interview and record review on 4/14/2026, at 7:01 a.m., with the Director of Nursing (DON), Resident 3's Physician Order, dated 2/10/2026, and MAR, dated 4/2026, were reviewed. The DON stated apixaban is an anticoagulant that had a side effect of bleeding and bruising. The DON stated Resident 3 who was on apixaban should be monitored for bleeding every shift and monitoring should be documented in Resident 3's MAR. The DON stated there was no documented monitoring for the side effect of apixaban. The DON stated since Resident 3 was not monitored for the side effects of apixaban, it could possibly cause further bleeding.During a review of facility's policy and procedure (P&P) titled, Anticoagulation-Clinical Protocol, undated and last reviewed on 4/24/2025, the P&P indicated, a. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications.Monitoring and Follow-up: .5. The staff and physicians will monitor for possible complications in individuals who are being anticoagulated and will manage related problems.a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on interview and record review, the facility failed to notify the physician promptly (acting immediately, without delay, or exactly at a scheduled time) for one of three sampled residents (Resident 3) when Resident 3 had reported that she (Resident 3) had constipation (when the bowel movements become less frequent and stools become difficult to pass).This failure had potential for delay in the delivery of necessary care and services and had the potential for increased risk of abdominal discomfort and pain to Resident 3.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 2/10/2026, with diagnoses that included other acute kidney failure (often called Acute Kidney Injury [AKI], is a sudden, temporary loss of kidney function, often within hours or days), other pulmonary embolism (a medical emergency caused by a blood clot getting stuck in a lung artery [thick, muscular blood vessels that carry oxygen-rich blood away from the heart to the rest of the body] blocking blood flow) with acute cor pulmonale (the sudden, rapid failure of the right side of the heart caused by a severe lung issue, such as a large blood clot) and history of fall.During a review of Resident 3's Physician Order, dated 2/10/2026, the Physician Order indicated the following:1. Naloxegol oxalate (medication used to treat opioid-induced constipation [OIC] in adults with chronic, non-cancer pain) oral tablet 25 mg, give one tablet by mouth daily for constipation.2. Polyethylene Glycol (medication used to treat constipation and for bowel preparation) 3350 powder, give 17 grams by mouth daily for constipation. During a review of Resident 3'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 2/11/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 2/17/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 3 needed maximum assistance from staff for toileting, showering, dressing and personal hygiene. The MDS indicated Resident 3 was always incontinent (unable to control) of bowel functions.During a review of Resident 3's MAR, dated 4/2026, the MAR indicated nurses administered naloxegol and polyethylene glycol to Resident 3 daily.During an interview on 4/13/2026, at 9:17 a.m., with Resident 3, Resident 3 stated she (Resident 3) had constipation and had not had a bowel movement for 13 days. Resident 3 stated she (Resident 3) had notified the nurses, but no new medication was administered.During a review of Resident 3's Bowel Elimination Task dated 3/15/2026, to 4/13/2026, the Bowel Elimination Task indicated Resident 3 did not have bowel movement on the following dates: 3/15/2026, 3/19/2026, 4/2/2026, 4/6/2026, 4/9/2026, 4/12/2026, and 4/13/2026. During an interview on 4/13/2026, at 1:48 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 3 complained of constipation all the time. LVN 1 stated the last time Resident 3 verbalized constipation was last week (LVN 1 unable to remember exact date), and she (LVN 1) had notified her (Resident 3) that she (Resident 3) was already on naloxegol and polyethylene glycol daily for constipation. LVN 1 stated she (LVN 1) did not report to the Registered Nurse Supervisor (RNS) and did not call and notify the physician. LVN 1 stated she should have reported to the RNS and should have called the physician to obtain an additional medication to relieve constipation. LVN 1 stated Resident 3'c constipation can worsen and could affect her (Resident 3)'s mood.During an observation on 4/14/2026, at 5:15 a.m., inside Resident 3's room, Observed Registered Nurse 2 (RN 2) talked to Resident 3 and heard Resident 3 asked RN 2 for enema (a medical procedure used to treat constipation, fecal impaction, [a severe form of constipation where a large, hard mass of stool gets stuck in the rectum or lower colon] or prepare the bowels for medical examination by injecting (introducing) liquid directly into the rectum.During an interview on 4/14/2026, at 5:16 a.m., with Resident 3, Resident 3 stated she (Resident 3) had requested enema a week ago, but it was not administered.During an interview on 4/14/2026, at 5:29 a.m., with LVN 2, LVN 2 stated Resident 3's last bowel movement was on 4/11/2026, and Resident 3 gets her (Resident 3) routine naloxegol and polyethylene daily for constipation. LVN 2 stated Resident 3 did not have any other medication ordered for constipation. LVN 2 stated Resident 3 informed her (LVN 2) that she (Resident 3) had an order for enema but there was no order on Resident 3's medical record. LVN 2 stated she (LVN 2) had reported to RN 2 of Resident 3's request for enema. LVN 2 stated Resident 3's could have pain and get uncomfortable due to constipation.During an interview on 4/14/2026, at 5:49 a.m., with RN 2, RN 2 stated she (RN 2) was informed of Resident 3's not having a bowel movement for 13 days. RN 2 stated LVN 2 reported that Resident 3 needed something to relieve her (Resident 3) constipation but there was no as needed (PRN) medication. RN 2 stated if there was no PRN medication she (RN 2) should have notified the physician. RN 2 stated she (RN 2) had texted (the act or activity of sending text messages from one cell phone to another) the physician on 4/14/2026, at 1:30 a.m., using the RN phone and the physician had not replied. RN 2 stated today 4/14/2026, at 5:20 a.m., Resident 3 spoke to her (RN 2) and requested enema. RN 2 stated she (RN 2) had not yet documented that she (RN 2) had texted the physician. RN 2 stated Resident 3 can get moody, upset, frustrated and get abdominal pain and discomfort from constipation.During a concurrent interview and record review on 4/14/2026 at 6:19 a.m., with RN 2, RN cellphone text messages dated 4/14/2026, were reviewed. The text message indicated the following:1. on 4/14/2026, at 6:04 a.m. RN 2 send a text message to Physician's first number.2. On 4/14/2026, at 6:05 a.m., RN 2 send a text message to Physician's alternate second number.RN 2 stated the facility only has one RN cordless phone. RN 2 stated there was no documented evidence that she (RN 2) had notified the physician of Resident 3's concern on constipation on 4/14/2026, at 1:30 a.m. RN 2 stated that delay in physician notification can delay treatment. RN 2 stated there was no CIC documented for Resident 3's constipation. RN 2 stated she (RN 2) did not create a CIC for Resident 3's constipation.During an interview on 4/14/2026, at 7:01 a.m., with the DON, the DON stated when Resident 3 mentioned that she (Resident 3) had not had a bowel movement for 13 days, a CIC should have been created, physician should have been notified and obtain order for PRN medication for constipation, whether Resident 3's complaint was through or not. The DON stated RN 2 should have created the CIC for constipation. The DON stated not notifying the physician delayed the care needed by Resident 3. The DON stated delay in medication to relieve constipation could result in abdominal discomfort, nausea and affect Resident 3's sleep.During a review of facility's policy and procedure (P&P) titled, Change in Condition, undated and last reviewed on 4/24/2025, the P&P indicated, The facility will promptly recognize, assess, and respond to any change in a resident's physical, cognitive, or emotional condition to ensure timely medical intervention and maintain resident safety.1. Recognition a. All staff must observe and report any changes in resident status, including but not limited to: i. Vital signs ii. Mental status or behavior iii. Skin changes, wounds, or pressure injuries iv. Appetite, hydration, or intake changes v. Mobility or functional ability.2. Immediate Action a. Licensed nursing staff shall assess the resident promptly. b. Notify the physician or authorized practitioner according to seve1ity and facility protocol. c. Implement immediate interventions as needed to stabilize the residents.3. Documentation a. Document the change, assessment, interventions, and provider notifications in the electronic health record or medical record. b. Include date, time, and staff signature.

Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to completely investigate two resident-to-resident allegations of physical abuse for four of five sampled residents (Residents 1, 2, 3 and 4) by: 1. Failing to interview or obtain a written witness statement from Licensed Vocational Nurse 2 (LVN 2) and Certified Nursing Assistant 2 (CNA 2) who were assigned to Resident 1.2. Failing to interview or obtain a written witness statement from LVN 1 and CNA 5 who were assigned to Resident 2.3. Failing to interview or obtain a written witness statement from CNA 4 who was assigned to Resident 3.4. Failing to interview or obtain a written witness statement from LVN 4 and CNA 3 who were assigned to Resident 4.These failures resulted in incomplete investigation and had the potential to result in unidentified abuse in the facility and had the potential failure to protect residents from abuse.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/19/2016, with diagnoses that included other encephalopathy (a disturbance of brain function), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and generalized muscle weakness.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.During a review of Resident 1's Change of Condition Evaluation (CIC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 2/15/2026, the CIC indicated Resident 1 received physical contact from Resident 2. The CIC indicated Registered Nurse 1 (RN 1) witnessed and separated Resident 1 from Resident 2 and performed head-to-toe assessment with no pain and injuries.During an interview on 3/3/2026, at 12:41 p.m., with the Director of Staff Development (DSD), the DSD stated on 2/15/2026, RN 1, LVN 2 and CNA 2 were assigned to Resident 1.During a concurrent interview and record review on 3/3/2026, at 12:59 p.m., with the Director of Nursing (DON), of facility's submitted untitled document (Staff Interview), dated 2/15/2026, was reviewed. The DON stated the untitled document were the staff interviews. The DON stated when they investigate allegations of abuse, the facility interviews the staff and documents it or the staff write their own statements. The DON stated the Staff Interviews indicated statements from RN 1, two clinical students and one clinical instructor. The DON stated there were no staff statements from LVN 2 and CNA 2 who were assigned to Resident 1.b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/27/2025, with diagnoses that included end stage renal disease (ESRD- -irreversible kidney failure), unspecified chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and essential hypertension (HTN-high blood pressure).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were intact.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 1/28/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's CIC, dated 2/15/2026, the CIC indicated RN 1 witnessed Resident 2 made physical contact with Resident 1 and separated Residents 1 and Resident 2 and assessed Resident 2 with no pain and injury.During a review of facility's Five-Day Investigation Summary, dated 2/19/2026, the Five-Day Investigation Summary indicated staff witnessed statements were reviewed.During an interview on 3/3/2026, at 12:41 p.m., with the DSD, the DSD stated on 2/15/2026, RN 1, LVN 1 and CNA 5 were assigned to Resident 2.During a concurrent interview, and record review on 3/3/2026, at 12:59 p.m., with the DON, the facility's submitted untitled document (Staff Interview), dated 2/15/2026, was reviewed. The DON stated the untitled document were the staff interviews. The DON stated the Staff Interviews indicated statements from RN 1, two clinical students and one clinical instructor. The DON stated there were no staff statements from LVN 1 and CNA 5 who were assigned to Resident 2.c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/6/2020, with diagnoses that included other acute kidney failure (a sudden, often reversible, loss of kidney function occurring within hours or days), difficulty in walking and generalized weakness.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions were intact.During a review of Resident 3's H&P, dated 1/21/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions.During a review of Resident 3's CIC, dated 2/16/2026, the CIC indicated on 2/16/2026, at 2:15 p.m., Resident 3 maneuvered his electric motorized wheelchair (battery-powered mobility devices steered via a joystick, designed for individuals with limited strength or endurance) in the activity room and Resident 3's wheelchair made contact with Resident 4's wheelchair. The CIC indicated Resident 4 turned, extended his (Resident 4) arm toward Resident 3 and made physical contact. The CIC indicated staff intervened and separated the two residents, body assessment was done with no visible injury and denied pain. During an interview on 3/3/2026, at 10:14 a.m., with CNA 4, CNA 4 stated on 2/16/2025, she (CNA 4) was assigned to Resident 3. CNA 4 stated the incident happened in the activity room and she (CNA 4) was with another resident when the incident happened between Resident 3 and Resident 4.During an interview on 3/3/2026, at 10:39 a.m., with LVN 3, LVN 3 stated on 2/16/2026, at 2:15 p.m., she (LVN 3) was at Station 200 when she (LVN 3) was informed that her (LVN 3) resident (Resident 3) hit Resident 4 in the right shoulder. During an interview on 3/3/2026, at 12:41 p.m., with the DSD, the DSD stated on 2/16/2026, RN 1, LVN 3 and CNA 4 were assigned to Resident 3. During a concurrent interview and record review on 3/3/2026, at 12:59 p.m., with the DON, of facility's submitted untitled document (Staff Interview), dated 2/15/2026, was reviewed. The DON stated the untitled document were the staff interviews. The DON stated the Staff Interviews indicated statement from LVN 3. The DON stated there were no staff statement from CNA 4 who were assigned to Resident 3.d. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 6/2/2025, with diagnoses that included acute embolism (a life-threatening, sudden blockage in a lung artery, usually caused by a blood clot) and thrombosis (the dangerous formation of a blood clot inside a vein or artery, obstructing blood flow) of unspecified deep vein of the left lower extremity and essential hypertension.During a review of Resident 4's H&P, dated 6/6/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's CIC, dated 2/16/2026, the CIC indicated on 2/16/2026, at 2:15 p.m., Resident 4 extended his (Resident 4) arm toward Resident 3 and made physical contact. The CIC indicated staff intervened and separated the two residents. The CIC indicated Resident 3 hit Resident 4's left knee on the table. The CIC indicated RN 1offered pain medication but Resident 4 refused. The CIC indicated RN 1 assessed Resident 4 and had no visible injuries present.During an interview on 3/3/2026, at 10:23 a.m. with LVN 4. LVN 4 stated he (LVN 4) was assigned to Resident 4 but was not in the activity room when it happened. LVN 4 stated RN 1 just informed him (LVN 4) of the incident. LVN 4 stated he (LVN 4) had checked Resident 4 and had no pain and injury.During an interview on 3/3/202,6 at 10:52 a.m. with the Activity Director (AD), the AD stated on 2/16/2026, Activity Staff 1 (AS 1) reported that Resident 4's wheelchair bumped into Resident 3's wheelchair while in the activity room. The AD stated that was all AS 1 had witnessed.During an interview on 3/3/2026, at 12:41 p.m., with the DSD, the DSD stated on 2/16/2026, RN 1, LVN 4 and CNA 3 were assigned to Resident 4.During a concurrent interview, and record review on 3/3/2026, at 12:59 p.m., with the DON, of facility's submitted untitled document (Staff Interview), dated 2/15/2026, was reviewed. The DON stated the untitled document were the staff interviews. The DON stated the Staff Interviews indicated no staff statements were documented. The DON stated there were no staff statements from LVN 4 and CNA 3 who were assigned to Resident 4.During a concurrent interview and record review on 3/3/2026, at 1:10 p.m., with the DON, facility's policy and procedure titled, Abuse Investigation and Reporting, undated and last reviewed on 4/2025, the P&P indicated, The individual conducting the investigation as a minimum: .h. interviews staff members (on all shifts) who have had contact with the residents during the period of the alleged incident;i. interviews the resident's roommate, family members, and visitors; .k. reviews all events leading up to the alleged incident; [NAME]. documents the investigation completely and thoroughly.9. The following guidelines are used when conducting interviews: . d. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement. The DON stated based on the facility's policy, the investigation was not complete.During an interview on 3/3/2026, at 1:18 p.m., with the Administrator (ADM), the ADM stated the allegation of abuse on 2/15/2026, and 2/16/2026, the ADM had interviewed RN 1 and AS 1. The ADM stated she (ADM) did not interview the assigned staff for Residents 1, 2, 3, and 4. The ADM stated she (ADM) should have interviewed the assigned staff to make sure all information was obtained and to verify information was all correct and not to miss any details of the incident. The ADM stated Residents 1, 2, 3 and 4 had incomplete investigation.

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of five sampled residents (Resident 1) by failing to accurately document medication administrations. Licensed Vocational Nurse 6 (LVN 6) and LVN 7 documented administration of medication in Resident 1's Medication Administration Record (MAR), from 2/17/2026, to 2/19/2026, even when Resident 1 was in General Acute Care Hospital (GACH) from 2/15/2026, at 7:20 p.m., to 2/19/2026, at 3:02 p.m.These failures had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/19/2016, with diagnoses that included other encephalopathy (a disturbance of brain function), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and generalized muscle weakness.During a review of Resident 1's Physician Order, dated 6/6/2025, the Physician Order indicated the following:1. Atorvastatin calcium (medication used to lower bad cholesterol) oral tablet 40 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth at bedtime for hyperlipidemia (an excess of lipids or fats in the blood).2. Levothyroxine sodium (replacement therapy for underactive thyroid to normalize low hormone levels) oral tablet 25 micrograms (mcg- unit of measurement for weigh), give one tablet by mouth in the morning for hypothyroidism (the thyroid gland, located in the neck, is underactive and does not produce enough thyroid hormones).3. Docusate sodium capsule (stool softener used to relieve occasional constipation) 100 mg, give one capsule by mouth two times a day for bowel management, hold for loose (watery) stools.4. Ferrous Sulfate (supplement used to treat and prevent iron deficiency anemia by replenishing iron levels required for red blood cell production) oral tablet, 325 mg, give one tablet by mouth two times a day for supplement.5. Lubiprostone (medication used to treat chronic idiopathic constipation [a persistent, functional gastrointestinal disorder defined by, or more, difficult, or incomplete bowel movements for at least three months without an underlying organic cause]), oral capsule 24 mcg, give one capsule by mouth two times a day for constipation, hold for loose stools.6. Pantoprazole sodium (medication used to treat certain conditions in which there is too much acid in the stomach) oral tablet delayed released 40 mg, give one tablet by mouth two times a day for gastritis (inflammation of the stomach lining).During a review of Resident 1's Physician Order, dated 1/14/2026, the Physician Order indicated quetiapine fumarate (medication used to treat insomnia (common, persistent sleep disorder characterized by difficulty falling asleep, staying asleep, or waking too early, resulting in poor sleep quality) tablet 25 mg, give one tablet by mouth at bedtime for mood stabilizer manifested by verbalization feelings of highs and lows.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.During a review of Resident 1's Physician Order, dated 2/19/2026, the Physician Order indicated senna (medication used to relieve occasional constipation in adults and children) oral tablet 8.6 milligram, give two tablets by mouth at bedtime for bowel management, hold if loose stool.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 2/2026, the MAR indicated LVN 6 administered the following medications on the following dates and times:1. Atorvastatin on 2/17/2026, at 9 p.m.2. Quetiapine on 2/17/2026, at 9 p.m.3. Senna on 2/17/2026, at 9 p.m.4. Docusate on 2/17/2026, and 2/18/2026, at 5 p.m.5. Ferrous on 2/17/2026, and 2/18/2026, at 5 p.m.6. Pantoprazole on 2/17/2026, at 5 p.m.7. Lubiprostone on 2/18/2026, at 6 p.m.During a review of Resident 1's MAR, dated 2/2026, the MAR indicated LVN 7 administered the following medications on the following dates and times:1. Levothyroxine on 2/18/2026, and 2/19/2026, at 6:30 a.m.2. Pantoprazole on 2/18/2026, and 2/19/2026, at 6:30 a.m.During a review of Resident 1's Change of Condition Evaluation (CIC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 2/15/2026, the CIC indicated Resident 1 received physical contact from Resident 2. The CIC indicated Registered Nurse 1 (RN 1) witnessed and separated Resident 1 from Resident 2 and performed head to toe assessment with no pain and injuries. The CIC indicated the physician ordered to transfer Resident 1 to GACH for further evaluation.During a review of Resident 1's Progress Notes, dated 2/15/2026, timed at 7:25 p.m., the Progress Notes indicated on 2/15/2026 at 7:20 p.m., the facility transferred Resident 1 to GACH.During a review of Resident 1's Progress Notes, dated 2/19/2026, timed at 3:02 p.m., the Progress Notes indicated the facility readmitted Resident 1 from GACH.During a concurrent interview, and record review on 3/3/2026, at 10:59 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Physician Orders, dated 6/6/2025, 1/14/2026, and 2/19/2026, MAR, dated 2/2026, Progress Notes, dated 2/15/2026 to 2/19/2026, were reviewed. The ADON stated Resident 1 was at GACH from 2/15/2026, to 2/19/2026. The ADON stated while Resident 1 was at GACH, LVN 6 documented administration of the following medications on the following dates and times:1. Atorvastatin on 2/17/2026, at 9 p.m.2. Quetiapine on 2/17/2026, at 9 p.m.3. Senna on 2/17/2026, at 9 p.m.4. Docusate on 2/17/2026, and 2/18/2026, at 5 p.m.5. Ferrous on 2/17/2026, and 2/18/2026, at 5 p.m.6. Pantoprazole on 2/17/2026, at 5 p.m.7. Lubiprostone on 2/18/2026, at 6 p.m.During a concurrent interview and record review on 3/3/2026, at 11:15 a.m., with the ADON, Resident 1's Physician Orders, dated 6/6/2025, MAR, dated 2/2026, Progress Notes, dated 2/15/2026 to 2/19/2026, were reviewed. The ADON stated Resident 1 was at GACH from 2/15/2026 to 2/19/2026. The ADON stated while Resident 1 was at GACH, LVN 7 documented administration of levothyroxine and pantoprazole on 2/18/2026, and 2/19/2026, at 6:30 a.m. The ADON stated LVN 6 and LVN 7 should check Resident 1's name identifier to make sure they are administering medication to the right resident. The ADON stated LVN 6 and LVN 7 should make sure Resident 1 was at the facility before medication administration. The ADON stated Resident 1's medical record was inaccurate.During an interview on 3/3/2026, at 11:54 a.m., with the Director of Nursing DON, the DON stated LVN 6 and LVN 7 should not document administration of medication when Resident 1 was at GACH. The DON stated nurses should be paying attention to prevent inaccurate documentation. The DON stated nurses should have documented medication not given since Resident 1 was not at the facility. The DON stated Resident 1's medical record was inaccurate and could cause confusion in care.During a review of facility's policy and procedure (P&P), titled, Charting and Documentation Policy, undated and last reviewed on 4/2025, the P&P indicated, All resident care, assessments, medications, treatments, and changes in condition must be documented in the medical record promptly, accurately, and according to facility and regulatory requirements. Document care at the time it is provided or immediately afterward.

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 (Resident 2) by failing to develop a care plan on Resident 2's refusal for medication. This failure had the potential for delays in the delivery of necessary care and services to Resident 2.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/27/2025, with diagnoses that included end stage renal disease (ESRD -irreversible kidney failure), unspecified chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and essential hypertension (HTN-high blood pressure).During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 1/2/2026, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 2's Physician Order, dated 1/23/2026, the Physician Order indicated Lokelma (medication used to treat high potassium levels) oral packet 10 grams, give one packet by mouth daily every Wednesday, Friday and Sunday for hyperkalemia (a serious condition characterized by elevated potassium levels in the blood, it can cause muscle weakness, numbness, tingling, nausea, and life-threatening heart arrhythmias [irregular heart beat]).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 1/28/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Medication Administration Record (MAR), dated 2/2026, the MAR indicated on 2/1/2026, Resident 2 refused the medication.During a concurrent interview, and record review on 3/3/2026, at 10:59 a.m., with the Assistant Director of Nursing (ADON), Resident 2's Physician Order, dated 1/23/2026, MAR, dated 2/1/2026, and Care Plans, were reviewed. The ADON stated there was no care plan developed for Resident 2's refusal of Lokelma. The ADON stated Licensed Vocational Nurse 5 (LVN 5) should have notified the physician of resident 2's refusal and document Resident 2's refusal. The ADON stated Lokelma is to use for hyperkalemia. The ADON stated if there were no care plan for Resident 2's refusal of Lokelma, there would be no intervention to correct the hyperkalemia and could potentially cause further increase in Resident 2's potassium level.During an interview on 3/2/2026, at 11:54 a.m., with the DON, the DON stated care plan should have been developed for Resident 2's refusal of medication. The DON stated care plan should have been developed to create a new treatment plan to prevent further elevation of potassium. The DON stated without a care plan Resident 2's hyperkalemia might not be corrected.During a review of facility's policy and procedure (P&P), titled, Comprehensive Care Plan, undated and last reviewed on 4/2025, the P&P indicated, The facility develops a Comprehensive Care Plan (CCP) for each resident to ensure individualized, resident-centered care that addresses medical, psychosocial, functional, and safety needs. The CCP is developed by the Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) and updated regularly based on resident conditions and preferences.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs (requirements for a person's well-being, such as food) for:1. Three (3) of eight (8) sampled residents (Resident 14, Resident 96, and Resident 24) on pureed diet (a texture modified diet that consist of smooth, pudding-like consistencies that are easy to swallow) by not following the recipe for puree oatmeal and in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks) when on 1/13/2026, Resident 14, Resident 96, and Resident 24 were served regular oatmeal with lumps, grains, and was not pureed.2. Sixteen (16) of 16 residents on soft bite sized (SB6 - soft, tender foods that are appropriate for oral processing skills with no more than 15 millimeters [mm - a unit of length], for adults) were given pork mushroom and carrots that were finely chopped and minced.3. Eight (8) of 8 residents on puree diet were given puree pancakes that left a thick film during a spoon tilt test (method used to check the texture, stickiness, and ability to hold shape of foods for individuals with swallowing difficulties) and puree sausages that were flat and did not hold its shape on the plate on 1/13/2026.These deficient practices had potential to cause Resident 14, Resident 96, and Resident 24 to not be able to eat their food and/or choke (when food gets stuck in your airway, blocking the flow of the air to the lungs) and aspirate (when food or liquid enters your airway and lungs instead of your stomach) on their food. On 1/14/2026 at 9:10 a.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON), due to the facility's failure to provide food and drink prepared in a form designed to meet individual needs in accordance with S483.60(d)(3) by failing to ensure the facility staff followed the recipe for pureed diet and served pureed food to Resident 14, Resident 96, and Resident 24.On 1/16/2026 at 3:20 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted in IJ situation) which included the following summarized actions:1. On 1/14/2026, Resident 14, Resident 96, and Resident 24 were assessed by the Registered Nurse (RN) Supervisor. The residents showed no signs of respiratory distress (difficulty breathing where the body cannot get enough oxygen). The RN Supervisor notified each resident's primary care physician (PCP) and ordered a stat (immediate) chest x-radiation (x-ray - medical imaging test that uses a tiny amount of high-energy radiation to take pictures of the inside of the body) for each resident. Resident 14, Resident 96, and Resident 24's chest x-ray results showed the residents' lungs were clear.2. On 1/14/2026, the Registered Dietitian (RD) conducted a one-to-one (1:1) in-service (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) and competency validation (the structured process of verifying that an individual possesses the required knowledge, skills, and behaviors to perform specific tasks or job roles to a defined standard) with [NAME] 1 regarding IDDSI Level 4 Standards, food preparation techniques, spoon-tilt test (a test used to check foods are not too sticky or runny), fork drip test (a test used to check the correct thickness and cohesiveness of food) and fork pressure test (a test used to check if food is soft enough by pressing the food with a fork to ensure it mashes and hold its shape), proper use of blender, and following approved recipes and spreadsheets. [NAME] 1 successfully demonstrated competency in all areas.3. On 1/14/2026, the RD conducted a 1:1 in-service and competency validation with Dietary Assistant 1 (DA 1) regarding tray accuracy according to physician's orders, reviewing and following the diet slip, and performing the spoon tilt test, fork drip test and fork pressure test. DA 1 successfully demonstrated competency in all areas. 4. On 1/14/2026, the Speech Therapist (ST - a person qualified to treat people with conditions that affect the production of speech, communication and swallowing problems) conducted a 1:1 in-service and competency validation with Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 2 (LVN 2) on meal tray verification including visual checks of all foods, verification of diet slip against the meals served and resident care plans, and the spoon tilt test, fork drip test and fork pressure test. Both LVNs (LVN 1 and LVN 2) successfully demonstrated competency in all areas.5. On 1/14/2026, the Director of Staff Development (DSD) Mentor provided an in-service on choking (a life-threatening event where food, liquid or another object becomes lodged in a resident's airway obstructing their ability to breathe) signs and symptoms, and prevention to LVN 1 and LVN 2. LVN 1 and LVN 2 successfully demonstrated competency through verbal return demonstration. 6. On 1/14/2026, the ST conducted a 1:1 in-service and competency validation with Certified Nursing Assistant 1 (CNA 1) and Certified Nursing Assistant 2 (CNA 2) regarding identification of correct pureed foods prior to serving, visual check of all foods, desserts and fluids and demonstrations on spoon tilt test, fork drip test, and fork pressure test to ensure adherence to pureed diet. CNA 1 and CNA 2 successfully demonstrated competency in all areas. The DSD Mentor provided in-service training on choking signs and symptoms, and prevention to CNA 1 and CNA 2. Both CNAs (CNA 1 and CNA 2) successfully demonstrated competency through verbal return demonstration.7. On 1/14/2026 at 10:05 a.m., the DON and Assistant Director of Nursing (ADON) completed a facility-wide audit using the diet list to identify all residents on IDDSI Level 4 (pureed) diets. Five (5) additional residents (Resident 39, Resident 46, Resident 3, Resident 66, and Resident 121) were identified as being on the IDDSI Level 4 diet. None of the additional residents showed signs and symptoms of aspiration (the accidental breathing of food and fluid into the lungs).8. On 1/14/2026, the facility implemented a three-step check tray accuracy (a quality assurance process designed to ensure therapeutic diet compliance) verification process outlining staff responsibilities:- Dietary Aide Responsibilities: Verify each tray prior to placing it on the delivery cart, comparing the diet list against the meal ticket and actual food to be conducted for all meals and snacks everyday including weekends and holidays. - Licensed Nursing (LN) Responsibilities: Two (2) LN staff members verify meal trays prior to serving the residents by lifting plate covers, checking side dishes and desserts, comparing the food on the tray to the diet order and tray card, and confirming the correct IDDSI Level 4 texture. LNs would return any tray with discrepancies for correction and replacement to the kitchen before serving.9. On 1/14/2026 at 10 a.m. and ongoing, the RD, Regional RD, DSD Mentor, and ST conducted immediate in-service trainings for CNAs and LNs for following physician diet orders, IDDSI Level 4 (Pureed) diet standards, recognition of choking/aspiration signs and symptoms and prevention strategies, LN responsibilities for diet texture verification prior to feeding and serving the residents. Thirty-six (36) of 80 (45%) CNAs, 17 of 32 (53%) LVNs and 4 of 12 (33%) RNs demonstrated competency on the topics. The DSD and DON will ensure that all remaining staff complete the IDDSI training prior to their scheduled shift.10. On 1/14/2026 at 10 a.m., the RD conducted in-service training for dietary staff on following physician diet orders, IDDSI level 4 diet standards, spoon tilt test, fork drip test, and fork pressure test, accuracy of meal preparation and distribution, and correct procedure for modifying foods including proper blender techniques to achieve puree consistency. Fourteen (14) of 14 (100%) dietary staff members completed the training and demonstrated competency. 11. On 1/15/2026, the DSD Mentor created an educational resource in the SNF Clinic Portal regarding the following topics:a. Pureed Diet and IDDSI Level 4 guidelines b. Following physician diet orders and the care planc. Recognition and prevention of choking signs and symptomsd. IDDSI Level 4 competency.12. On 1/16/2026, two licensed nurses conducted a tray audit using the diet list by checking each tray on the delivery carts, lifting lids and comparing the food to the diet list and tray card. Audit results were reported to the DON. 13. On 1/14/2026, the facility implemented the following monitoring systems:a. Starting 1/14/2026, the Dietary Supervisor (DS) or designee along with the tray line (an area where foods are assembled from the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving]) staff, will perform checks of all meal trays, including snacks on the tray line seven (7) days a week, including weekends and holidays, for a period of 3 months. The DS will report any deviations to the Quality Assessment and Assurance (QAA- a continuous process used in healthcare to evaluate and improve the quality of care and services provided to the residents) Committee for further evaluation. Goal 100% compliance. Tool: Meal and snacks tray audit logs.b. The DS or designee will review all residents' diet orders daily for accuracy for the next 3 months. Any changes to diet orders or texture modifications will be transcribed to the individual meal tray cards. The DS will report any deviations from the established practice to the QAA Committee for further evaluation. Goal: 100% compliance. Tool: Meal and Snacks Tray Audit Log will be used to document findings. c. Effective 1/14/2026, LN staff will report any discrepancies related to served pureed meals to the DON or designee daily for the next 3 months, or until 100% compliance is achieved. Audit findings will be reported to Quality Assurance and Performance Improvement (QAPI - a comprehensive, data-driven system used to ensure high-quality resident care and life by merging traditional quality assurance with proactive performance improvement), and corrected actions will be initiated immediately for any identified variances.d. The ADM will provide monthly reports on QAPI progress. Any deviations from established practice will be reviewed and addressed with further evaluation and corrective action as needed. 14. Effective 1/14/2026, an RD or Qualified Dietary Service Manager will provide oversight of all meals and snacks for 30 consecutive days to ensure residents receive accurate, safe, and diet-complaint meals and snacks in accordance with physician orders, care plans, and IDDSI Level 4 pureed standards during the IJ monitoring period.On 1/16/2026, at 5:33 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined that the IJ situation related to the facility's failure to provide food and drink prepared in a form designed to meet individual needs was no longer present. The SSA removed the IJ situation, while onsite, on 1/16/2026, at 5:33 p.m., in the presence of the ADM and DON.Findings: 1A. During a review of the facility's menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, Fall 2025, dated 1/13/2026, the spreadsheet indicated that residents on a pureed diet in accordance with IDDSI Level 4 were to receive the following on the meal tray: Apple juice 4 ounces (oz - a unit of measure for volume) Puree oatmeal 4 oz Puree sausage patty 1/3 cup (c - a unit of measure for volume) Puree pancakes 1/2 c Milk 2% 8 oz Coffee 8 oz Margarine 1 each Syrup 1 ozDuring an observation on 1/13/2026 at 6:50 a.m. of the food at the steamtable, observed no pureed oatmeal on the steamtable.During an interview on 1/13/2026 at 7:16 a.m. with the DS, the DS stated that no food substitutions (replacing one food ingredient or item with another to accommodate dietary restrictions and adjust nutritional intake) were made for the breakfast prepared on 1/13/2026.During a subsequent observation on 1/13/2026 at 7:22 a.m., at the start of breakfast meal service, observed no separate pureed oatmeal on the steamtable. During an interview on 1/13/2026 at 7:35 a.m., with [NAME] 1, [NAME] 1 stated she (Cook 1) prepared regular oatmeal, but stated it could not be served to all residents because residents on pureed diets required pureed oatmeal, and residents on fortified diets (adding additional high calorie [a unit of measurement for energy], high protein [essential nutrients that aid for building and repairing body tissue] food to the meal) required oatmeal prepared with added butter as an ingredient to increase calorie and protein content.During an observation on 1/13/2026 at 7:41 a.m., of Resident 24's breakfast meal tray on the meal cart, observed that Resident 24's meal tray contained regular oatmeal with visible chunks of oats. 1B. During a review of Resident 14's admission Record, the admission Record indicated the facility originally admitted Resident 14 on 4/18/2023 and readmitted the resident on 12/22/2025 with diagnoses including dysphagia (difficulty swallowing) oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and adult failure to thrive (syndrome [a group of symptoms which consistently occur together] of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration [when body loses more water than it takes in and could disrupt normal bodily function]).During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 10/31/2025, the MDS indicated Resident 14 usually made self-understood and understood others. The MDS indicated Resident 14 required supervision and touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes the activity). The MDS further indicated Resident 14 had mechanically altered diet (food texture that is intended to be safe and easy to swallow) within the last 7 days as a resident in the facility. During a review of Resident 14's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 11/20/2025, the H&P indicated Resident 14 was able to understand and make decisions. During a review of Resident 14's Care Plan titled, [Resident 14] has a swallowing problem, initiated on 12/22/2025, the Care Plan indicated goals for the resident's risk for injury related to aspiration will be minimized through the review date with the interventions including diet to be followed as ordered and monitor, document and report as needed for any signs and symptoms of dysphagia: pocketing (holding food in the cheeks), choking, coughing, drooling, holding food in mouth, several attempts at swallowing and refusing to eat.During a review of Resident 14's Speech Therapy Evaluation and Plan of treatment, dated 1/9/2025, the Speech Therapy Evaluation and Plan of Treatment indicated Resident 14 presented with moderate oropharyngeal phase dysphagia (difficulty moving food and liquids from the mouth into the throat and towards the esophagus [the food pipe connecting the throat to the stomach]). The Speech Therapy Evaluation and Plan of Treatment also indicated for Resident 14 to be on pureed diet texture and consistency with thin liquids.During a review of Resident 14's Food and Nutrition- IDDSI Nutritional Assessment and Care Area Assessment (CAA) dated 1/6/2026, the Food and Nutrition-IDDSI Nutritional Assessment and CAA review indicated Resident 14 had chewing and swallowing problems and a pureed texture diet was ordered. During a review of Resident 14's Order Summary Report dated 12/22/2025, the Order Summary Report indicated a physician's order for Consistent Carbohydrate Diet (CCHO - a diet with the same amount of carbohydrate in each meal for blood sugar management), No Added Salt (NAS - no salt packet on the tray), Pureed Level 4, and thin liquid consistency with no restrictions. During an observation on 1/13/2026 at 8:19 a.m. of the breakfast meal service in Station 4 observed LVN 1 and LVN 2 checked meal cart 2 trays against the diet list and opened the cover of the plate but did not open the lid of the oatmeal to verify its consistency.During an observation on 1/13/2026 at 8:21 a.m. of the meal cart checking process at Station 4, observed LVN 1 and LVN 2 complete the tray-checking process, after which the Certified Nursing Assistants (CNA) began delivering breakfast trays to the residents. LVN 1 and LVN 2 did not open the oatmeal lids verify its consistency.During an observation on 1/13/2026 at 8:26 a.m. of passing of trays, observed CNA 2 delivering Resident 14's tray to the resident's bed side (place next to a resident's bed). During a concurrent observation and interview on 1/13/2026 at 8:38 a.m. of Resident 14's breakfast meal, with CNA 2, observed CNA 2 assisting Resident 14 with breakfast and feeding Resident 14 five (5) teaspoons (tsp - a household measurement) of regular oatmeal. CNA 2 stated that Resident 14's tray contained regular oatmeal, even though Resident 14 was ordered to have a pureed diet. CNA 2 stated Resident 14's oatmeal was lumpy, which is not appropriate for a pureed diet. During an interview on 1/13/2025 at 10:44 a.m., with CNA 2, CNA 2 stated she (CNA 2) checks the ticket on residents' trays however, the LVNs already check the trays to ensure the trays are safe to pass and deliver to the residents for consumption. CNA 2 stated that other residents received oatmeal that appeared more solid, while Resident 14 received watery oatmeal. CNA 2 stated the pureed oatmeal could be slightly watery but should not be overly thin and should be blended without specks (tiny spots). CNA 2 further stated she (CNA 2) did not identify any issues with Resident 14's tray because the LVNs had already checked the trays and Resident 14 would always receive watery oatmeal with specks. CNA 2 stated she fed Resident 14 the regular oatmeal on the tray.During a concurrent interview and record review on 1/13/2026 at 1:58 p.m. with the ST, Resident 14's Speech Therapy Evaluation and Plan of Treatment, dated 1/9/2026, was reviewed. The Speech Therapy Evaluation and Plan of Treatment indicated Resident 14 presented with moderate oropharyngeal phase dysphagia. The ST stated Resident 14 has a complex medical history with frequent hospitalizations and is currently on pureed diet due to impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses). The ST stated that upgrading Resident 14's diet would not be safe and that Resident 14 requires feeding assistance. The ST stated Resident 14 cannot tolerate any foods other than pureed and thin liquids because Resident 14 has some level of oropharyngeal dysfunction, as well as weakened and delayed swallowing. During an interview on 1/13/2026 at 2:35 p.m., with the ST, the ST stated serving regular oatmeal to Resident 14 was not appropriate because regular oatmeal does not meet IDDSI standards for a smooth, pudding-like consistency. The ST further stated that consuming regular oatmeal could place the residents at risk for aspiration or chokingDuring an interview on 1/13/2026 at 3 p.m., with CNA 3, CNA 3 stated she (CNA 3) saw Resident 14 was served oatmeal that was not pureed. CNA 3 stated she did not stop Resident 14 from eating because Resident 14 stated she (Resident 14) eats regular oatmeal at home. During an interview on 1/13/2026 at 3:06 p.m., with the RD, the RD stated that he (RD) assessed Resident 14 on 1/6/2026 and that Resident 14 was ordered CCHO, NAS, Pureed Diet, and thin liquid consistency due to a medical diagnosis of dysphagia. The RD stated that continuing the pureed diet for Resident 14 was appropriate. 1C. During a review of Resident 96's admission Record, the admission Record indicated the facility originally admitted Resident 96 on 4/27/2023 and readmitted the resident on 11/11/2025 with diagnoses including dysphagia, essential hypertension (HTN - high blood pressure) and hyperlipidemia (increase fats in the blood). During a review of Resident 96's MDS, dated [DATE], the MDS indicated Resident 96 made self-understood and understand others. The MDS indicated Resident 96 required supervision and touching assistance. The MDS further indicated Resident 96 had a mechanically altered diet within the last 7 days as a resident in the facility. During a review of Resident 96's H&P, dated 1/2/2026, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 96's Care Plan titled, [Resident 96] has a swallowing problem. initiated on 10/24/2025, the Care Plan indicated goals for the resident's risk for choking episodes when eating and drinking and at risk for signs and symptoms of aspiration will be minimized through the review date. The Care Plan indicated interventions including diet to be followed as ordered. During a review of Resident 96's Care Plan titled, [Resident 96] has a nutritional problem: Fortified Pureed texture level 4 with moderately thick level 3 liquid consistency (liquid can be drunk from a cup with moderate effort required to suck through a bore or wide bore straw), last revised on 12/10/2025, the Care Plan indicated interventions to monitor, document and report as needed for any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing and refusing to eat.During a review of Resident 96's Speech Therapy Evaluation and Plan of treatment, dated 10/20/2025, the Speech Therapy Evaluation and Plan of Treatment indicated Resident 96 presented with severe oropharyngeal dysphagia characterized by poor bolus control (refers to the tongue's ability to form, manipulate, and propel a food or liquid mass through the oral cavity), tongue pumping (refers to a repetitive, involuntary, forward-and-backward movement of the tongue) and unproductive cough yielding wet vocal quality post (after) swallow. The Speech Therapy Evaluation and Plan of Treatment also indicated for Resident 96 to be on pureed diet texture and consistency with thin liquids.During a review of Resident 96's Food and Nutrition-IDDSI Nutritional Assessment and CAA dated 11/18/2025, the Food and Nutrition-IDDSI Nutritional Assessment and CAA review indicated Resident 96 had chewing and swallowing problems and a pureed texture diet was ordered. The document further indicated Resident 96 has inadequate oral intake related to dysphagia. During a review of Resident 96's Order Summary Report, dated 12/10/2025, the Order Summary Report indicated a physician's order for Fortified Pureed Level 4, and moderately thick liquid level 3 consistency. During an observation on 1/13/2026 at 8:20 a.m. of Resident 96's breakfast tray in Resident 96's bedside, observed regular oatmeal with oatmeal particles and lumps on the tray. Observed CNA 1 fed Resident 96 with regular oatmeal. Resident 96 consumed 3 tsp of regular oatmeal.During an interview on 1/13/2026 at 11:59 a.m. with CNA 1, CNA 1 stated she (CNA 1) did not notice that the oatmeal served that morning was not pureed. CNA 1 stated that she (CNA 1) served regular oatmeal to Resident 96, however, Resident 96 did not consume all of it, stating she (Resident 96) did not like it. CNA 1 stated that had she (CNA 1) noticed that the oatmeal was not pureed, she (CNA 1) would have returned it to the kitchen to request cream of wheat or another appropriate substitute. CNA 1 stated she (CNA 1) was aware that Resident 96 is on a pureed diet and the oatmeal that Resident 96 consumed was clumpy and Resident 96 could choke on the oatmeal. During a concurrent interview and record review on 1/13/2026 at 2:13 p.m., with the ST, Resident 96's Speech Therapy Evaluation and Plan of Treatment, dated 10/20/2025, was reviewed. The Speech Therapy Evaluation and Plan of Treatment indicated Resident 96 presented with severe oropharyngeal dysphagia. The ST stated she (ST) evaluated Resident 96 on 10/20/2025 and observed that Resident 96 was not managing her (Resident 96) saliva secretions (useful fluids, chemicals, or substances produced and released by cells, glands, or organs in the body) well. The ST stated Resident 96 was ordered a Puree Level 4 diet with mildly thick liquids, which ST stated was an appropriate diet order for Resident 96. The ST further stated Resident 96 has cognitive impairment and inattention when swallowing, as she does not remember to swallow her own secretions. The ST stated Resident 96 has oropharyngeal dysphagia and that a puree diet would be the safest at this time, as Resident 96 is able to tolerate pureed foods. During an interview on 1/13/2026 at 2:35 p.m., with the ST, the ST stated serving regular oatmeal to Resident 96 was not appropriate because regular oatmeal does not meet IDDSI standards for a smooth, pudding-like consistency. The ST further stated that consuming regular oatmeal could place the residents at risk for aspiration or chokingDuring an interview on 1/13/2026 at 3:10 p.m., with the RD, the RD stated he (RD) assessed Resident 96 on 12/10/2025 and that Resident 96 was ordered fortified Pureed diet, and moderately thick liquid consistency level 3. The RD stated that continuing the pureed diet for Resident 96 was appropriate because of the dysphagia diagnosis. 1D. During a review of Resident 24's admission Record, the admission Record indicated the facility admitted Resident 24 on 6/9/2023 with diagnoses including oropharyngeal phase dysphagia, type 2 DM, and essential hypertension. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 made self-understood and understood others. The MDS indicated Resident 24 required setup and clean-up assistance with meals. The MDS further indicated Resident 24 had a mechanically altered diet within the last 7 days as a resident in the facility. During a review of Resident 24's H&P, dated 5/4/2026, the H&P indicated the resident was able to understand and can make medical decisions. During a review of Resident 24's Care Plan titled [Resident 24] presents with a mild oropharyngeal dysphagia and is on modified diet, initiated on 9/3/2025, the Care Plan indicated interventions including for Resident 24 to get skilled ST services everyday three times a week for four weeks for oropharyngeal dysphagia and the services included oral motor exercises (activities that strengthen and improve the coordination of the lips, tongue, jaw, and cheeks, essential for speech clarity, chewing, and swallowing), diet texture analysis and modification as needed. During a review of Resident 24's Care Plan titled, [Resident 24] has a nutritional problem or potential nutritional problem [related to] . dysphagia, oropharyngeal phase., last revised on 12/23/2025, the Care Plan indicated Resident 24 has goals to remain free from signs and symptoms of aspiration and to avoid difficulty with chewing and swallowing throughout the review period. The Care Plan interventions included explaining and reinforcing to the resident the importance of maintaining the prescribed diet, as well as monitoring, documenting, and reporting as needed any signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing and refusing to eat.During a review of Resident 24's, Speech Therapy Treatment Encounter Note, dated 1/2/2026, the Speech Therapy Treatment Encounter Note indicated Resident 24 to be on pureed diet texture consistency with thin liquids.During a review of Resident 24's Mini Nutritional Assessment, dated 12/26/2025, the Mini Nutritional Assessment indicated Resident 24 has a diet order of pureed thin liquid consistency.During a review of Resident 24's Order Summary Report, dated 11/3/2025, the Order Summary Report indicated a physician's order for CCHO diet, Pureed level 4 texture, with thin level consistency. During an observation on 1/13/2026 at 8 a.m. of Resident 24 and Resident 24's tray at bedside, observed CNA 3 arrange the breakfast tray on Resident 24's table. Resident 24 was then observed eating regular oatmeal. During a concurrent observation and interview on 1/13/2026 at 8:02 a.m., with CNA 3, observed Resident 24 eating regular oatmeal with CNA 3 at bedside and observed Resident 24 consumed 100% of the regular oatmeal. CNA 3 stated Resident 24's meal ticket indicated pureed pancakes, pureed meat, and pureed oatmeal. CNA 3 stated that the pancakes and meat served to Resident 24 were pureed however Resident 24's oatmeal was not pureed. CNA 3 stated the oatmeal that was served to Resident 24 contained liquid consistency, but the oatmeal was not pureed, as it was not smooth in consistency. During an interview on 1/13/2026 at 8:39 a.m., with the DS, the DS stated the oatmeal deliveries come every Thursday, but she (DS) did not order oatmeal and did not forecast the oatmeal usage well. The DS stated [NAME] 1 cooked the regular oatmeal on 1/13/2026, at around 6:30 a.m. and informed her (DS) that the facility had run out of oatmeal. The DS stated she (DS) instructed [NAME] 1 to substitute oatmeal with cream of wheat instead. The DS stated that the RD did not approve substituting oatmeal with cream of wheat. The DS stated that regular oatmeal needed to be pureed for residents on a pureed diet because pureed oatmeal was included in the residents' diet orders, and residents receiving regular oatmeal instead of pureed oatmeal could experience difficulty swallowing, resulting in choking.During an interview on 1/13/2026 at 10:11 a.m., with [NAME] 1, [NAME] 1 stated she (Cook 1) cooked the breakfast today and made a big pan of regular oatmeal. [NAME] 1 stated she (Cook 1) needed to separate oatmeal for residents on pureed diets, however, she (Cook 1) did not separate and puree the oatmeal because there was no oatmeal remaining. [NAME] 1 further stated that she (Cook 1) cooked cream of wheat.During an interview on 1/13/2026 at 10:20 a.m., with DA 1, DA 1 stated she (DA 1) was responsible for checking the meal trays prior to placing the trays in the carts. DA 1 stated that her responsibilities included verifying residents' allergies (a condition that causes illness when someone eats certain food), diet orders, likes and dislikes, tray accuracy, and tray completeness. DA 1 stated that if [NAME] 1 placed incorrect food items on a tray, she (DA 1) would return the tray to be corrected. DA 1 stated that residents on puree diet should have received cream of wheat for today's (1/13/2026) breakfast. DA 1 stated regular oatmeal is not appropriate for a pureed diet because regular oatmeal contains large particles that could become lodged in a resident's throat. DA 1 further stated that residents on a puree diet could potentially choke if served regular oatmeal. DA 1 stated that she does not give regular oatmeal to residents on a puree diet, as they usually blend the oatmeal, but sometimes, she (DA 1) makes mistakes. DA 1 stated she (DA 1) made a mistake today by placing regular oatmeal on trays designated for residents on a pureed diet. DA 1 also stated that there have been instances when nurses came to the kitchen and requested regular oatmeal instead of pureed oatmeal for residents (did not specify) on puree diets. During an interview on 1/13/2026 at 10:39 a.m., with LVN 1, LVN 1 stated she (LVN 1) checked the meal trays today (1/13/2026) before the meal trays were distributed to the residents. LVN 1 stated the process involves reading the diet list while another LN checks the trays for allergies, resident's likes and dislikes, diet texture and consistency, and tray accuracy. LVN 1 stated the other LN checks the trays by opening the lids of the food items. LVN 1 stated that if a meal tray

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one (1) of 1 sampled resident (Resident 57) reviewed for physical restraints by failing to obtain a physician's order, informed consent, and complete a restraint assessment prior to placement of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). These deficient practices had the potential to result in the restriction of Resident 57's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and possibly death. Findings: During a review of Resident 57's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 57 on 11/18/2025 and readmitted in the facility on 11/21/2025 with diagnoses hemiplegia (total paralysis [the loss of muscle function in a part of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis of the arm, leg, and trunk on one side of the body) following cerebral infarction (also known as stroke, loss of blood flow to a part of the brain) affecting right non-dominant side, congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and cognitive communication deficit (difficulty in talking, listening, or understanding, and participating in conversations). During a review of Resident 57's History and Physical (H&P), dated 11/19/2025, the H&P indicated Resident 57 did not have the capacity to understand and make decisions. During a review of Resident 57's Minimum Data Set (MDS - a resident assessment tool), dated 11/27/2025, the MDS indicated Resident 57 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and able to make his needs known. The MDS further indicated Resident 57 required partial or moderate assistance with eating, oral hygiene, and upper body dressing; total assistance with toileting hygiene, bathing, and lower body dressing; substantial or maximal assistance from staff with all other activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 57 had a fall incident prior to admission to the facility. During a review of Resident 57's Order Summary Report, dated 1/16/2026, the Order Summary Report did not indicate a physician's order for the use of bed pad alarm. During a review of Resident 57's paper and electronic health records, dated as of 1/16/2026, the paper and electronic health records did not indicate a consent was obtained from the resident or responsible party for the use of the bed pad alarm. During a review of Resident 57's fall risk evaluation forms, dated 11/18/2025, 11/20/2025, 12/4/2025, and 12/9/2025, the fall risk evaluations indicated that Resident 57 was at a high risk for falls. During a review of Resident 57's care plan (CP) on risk for falls, initiated on 11/18/2025 and actual fall incidents on 12/4/2025 and 12/9/2025, the CP indicated interventions including bed alarm in place and continue with fall precautions such as nonskid socks and bed in lowest position so the resident will remain free from falls and complications from falls. During a concurrent observation and interview on 1/12/2026 at 11:14 a.m. inside Resident 57's room with Licensed Vocational Nurse (LVN) 10, observed Resident 57 sitting at the edge of the bed. LVN 10 stated Resident 57's bed alarm box was hanging on the wall with the cord wrapped around the bed control cord closest to the plug and was not functioning properly. LVN 10 stated Resident 57 was at a high risk for falls and one of the interventions to prevent falls or injury is the bed alarm due to multiple fall incidents since admission. During a concurrent interview and record review on 1/16/2026 at 9:36 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 57's physician's order, CPs, fall risk evaluations, and paper and electronic health records were reviewed. The MDSC stated there was no physician's order, informed consent obtained, and a restraint assessment completed prior to application of the bed alarm. The MDSC stated if Resident 57 had a bed alarm as part of the fall management program, the staff should have obtained a physician's order, obtained a signed informed consent, and completed a restraint assessment prior to the application of a bed alarm to Resident 57. The MDSC stated that restraint assessments are completed prior to application of the restraint, quarterly, and as needed with any significant change in condition. The MDSC stated the bed alarm is considered a restraint as it restricts the resident from getting up and moving freely and should have a physician's order so the physician would be aware of the proper device Resident 57 needed for his safety. The MDSC stated an informed consent should have been obtained to ensure the resident and/or resident representative understands the risks and consequences of having the bed alarm and gives them the opportunity to decline or accept the treatment. The MDSC stated a restraint or device use assessment should have been completed prior to use of the bed alarm to ensure the use of bed alarm is appropriate. During a review of the facility's policy and procedure (P&P) titled, Bed and Chair Alarm Monitoring Policy, last reviewed on 4/24/2025, the P&P indicated the facility utilizes bed and chair alarm monitoring systems as part of a comprehensive fall prevention and resident safety program. Bed and chair alarms are implemented based on individual residents' assessment, clinical need, and interdisciplinary care planning. The P&P further indicated: - Bed/chair alarms are monitoring device designed to alert staff when a resident attempts to rise from a bed or wheelchair. - Residents are assessed for fall risk on admission, quarterly, after a fall, and with any significant change in condition. - Resident and/or responsible representative shall be informed of alarm use as appropriate. During a review of the facility's P&P titled, Restraint-Free environment, last reviewed on 4/24/2025, the P&P indicated the facility is committed to maintaining a restraint free environment for all residents. Physical or chemical restraints are used only when medically necessary to protect the resident or others and only after all alternatives have been attempted. The P&P further indicated: - Residents are assessed for risk of harm to self or others upon admission and continuously thereafter. - Restraint use is documented and justified only when alternatives fail. - Restraints are used only with a physician's order specifying the type of restraint, reason for use, and duration and monitoring requirements. - Residents and/or responsible parties are informed about restraint use, alternatives, and potential risks. - Consent must be documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (meal tickets) containing protected information (PHI - any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 127 of 127 residents' rights for privacy and confidentiality of personal and medical records. Findings: During an observation on 1/14/2026 at 12:59 p.m., observed meal tickets in the trash by the dishwashing machine area. During an interview on 1/14/2026 at 1 p.m. with the Dietary Supervisor (DS), the DS stated the meal tickets come back to the kitchen after each meal and the meal tickets would be thrown out in the trash. The DS stated the meal tickets contained residents' name, diet, and room number and these are all protected information. The DS stated it was not appropriate for the staff to throw the meal tickets in the trash because it's a violation of Health Insurance Portability and Accountability Act (HIPPA - a law that sets national standard to protect sensitive health information, making sure it stays private and secure) law. The DS stated other people could get the residents' information and use it and they are not protecting the privacy rights of the residents. During a review of the facility's policies and procedures (P&P) titled, Meal Ticket Policy, dated 4/24/2025, the P&P indicated Meal ticket shall be generated based on the resident's current diet orders documented in the EHR. During a review of the facility's P&P titled, Resident Privacy and Confidentiality Policy, dated 4/24/2025, the P&P indicated Our facility will safeguard the confidentiality of all resident personal and medical records. Access to these records is limited to authorized staff members and approved business associates.

Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for five (5) of five (5) sampled residents (Residents 65, 55, 33, 39 and 72) by failing to: 1. Maintain the cleanliness of Resident 65's electric stand fan. 2. Ensure Resident 55`s electric fan was free from dust buildup on the fan blades and the front and back safety enclosure grill of the fan. These deficient practices had the potential to negatively affect Resident 65 and Resident 55's quality of life and had violated the residents' right to a safe, clean, comfortable and homelike environment. 3. Provide Residents 33, 39, and 72 with a homelike environment when their room was damaged due to water leaks. This deficient practice had the potential to prevent residents from enjoying the right to a clean dry and homelike environment free from water damaged floors and closet space. Cross-reference F880 and F921. Findings: 1) During a review of Resident 65's admission Record, the admission Record indicated the facility originally admitted the resident on 10/8/2012, and readmitted in the facility on 6/9/2025, with diagnoses including dependence on supplemental oxygen, pneumonitis (swelling of the lung tissue), pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart), and generalized muscle weakness. During a review of Resident 65's History and Physical (H&P) dated 6/19/2025, the H&P indicated that Resident 65 had the capacity to understand and make decisions. During a review of Resident 65's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/26/2025, the MDS indicated Resident 65 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial or moderate assistance with oral and personal hygiene; substantial/maximal assistance with upper body dressing and rolling to left and right; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 1/12/2026 at 10:31 a.m., inside Resident 65's room, observed an electric stand fan facing the resident and was turned on had strips of gray powder like material lining the outward front and back panel and the blades. During a concurrent observation and interview on 1/12/2026 at 10:40 a.m. inside Resident 65's room with Certified Nursing Assistant (CNA) 8, CNA 8 stated Resident 65's electric stand fan had a lot of gray colored dusts in the front and back panel. CNA 8 stated she (CNA 8) is not sure who is responsible on cleaning the electric fans. CNA 8 stated if the electric fan was blowing and full of dusts, Resident 65 can inhale the dust particles and the resident can get sick. Resident 65's electric fan should have been cleaned regularly as it does not provide a homelike environment to the resident as the facility is already their home. During a concurrent observation and interview on 1/12/2026 at 10:45 a.m. inside Resident 65's room with Licensed Vocational Nurse (LVN) 10, LVN 10 states Resident 65's electric stand fan that was blowing and facing the resident had a lot of gray colored dusts in the front and back. LVN 10 stated the maintenance department was responsible in making sure the electric fans or any resident equipment is clean to provide a homelike environment to the residents. LVN 10 stated the maintenance department should have been notified by the staff that Resident 65's electric fan had a lot of gray dusts. LVN 10 stated Resident 65's electric fan should have been kept clean as the resident can inhale the air coming out from the fan with the dust particles and can be a source of infection, and it was also not providing a homelike environment for Resident 65. During an interview on 1/13/2026 at 1:05 p.m. with the Director of Maintenance (DOM), the DOM stated the maintenance department was responsible in maintaining the cleanliness of furnishings such as electric fans and other resident care equipment in the facility. During a concurrent interview and record review on 1/14/2026 at 2:59 p.m., a photograph of Resident 65's electric fan was reviewed with the Minimum Data Set Coordinator (MDSC). The MDSC stated that the front and back panel of Resident 65' electric fan was dirty and had a lot of gray dusts. The MDSC stated that from her knowledge, the housekeeping department was responsible in ensuring that any resident care equipment or furnishings cleanliness should be maintained at all times, but all staff are supposed to report if they see any equipment of furnishings that is not clean. The MDSC stated Resident 65 has existing respiratory illnesses and the air coming out from dirty electric fan can cause respiratory issues for Resident 65, and it was not promoting or providing the resident a homelike environment. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, last reviewed 5/24/2025, the P&P indicated the facility provides and maintains a homelike, non-institutional environment that supports resident dignity, choice, privacy, and quality of life. The P&P further indicated: - Promote a living environment that is comfortable, respectful, and as homelike as possible while ensuring resident health, safety, and regulatory compliance. - A homelike environment shall be maintained without compromising resident safety and infection prevention and control. - All staff should support resident dignity, respect personal space, and promote a homelike atmosphere in daily interactions. - Maintenance and environmental services maintain the physical environment in a safe, clean, and welcoming manner. During a review of the facility's P&P titled, General Maintenance and Plant Operations Policy, last reviewed 4/24/2025, the P&P indicated the facility is committed to maintaining a safe, clean, and functional physical environment for residents, staff, and visitors. All facility systems, equipment, and structures shall be maintained in good working order in compliance with federal, state, and local regulations. The P&P further indicated: - General maintenance responsibilities include maintaining all building systems in safe working conditions and conducting routine inspections for facility grounds and interiors. - Establish standards and procedures for routine, preventive, and corrective maintenance to ensure resident safety, comfort, and uninterrupted facility operations. - All staff are responsible for reporting maintenance concerns promptly. - Maintenance staff shall prioritize requests based on safety and urgency. During a review of the facility's P&P titled, Air Filter and Electric Fan Cleaning Policy, last reviewed on 4/24/2025, the P&P indicated the facility ensures air filters and electric fans are cleaned routinely to reduce dust build up, improve air circulation, maintain equipment function, and support infection prevention standards. The P&P further indicated: - The facility will maintain air filters and electric fans in clean working condition. Filters and fans will be inspected, cleaned, or replaced on a routine schedule and anytime visible dust build up is observed. - All portable and fixed electric fans will be cleaned routinely to prevent dust accumulation and reduce the spread of particles. Fans used in resident rooms must be cleaned on a routine schedule, when visibly soiled, and between resident use if reassigned. - Nursing staff must report visibly dirty fans in resident rooms and report equipment concerns to maintenance or environmental services department. 2) During a review of Resident 55's admission Record (AR), the AR indicated the facility admitted the resident on 9/12/2018, and readmitted the resident on 11/13/2025, with diagnoses including cellulitis (a skin infection that causes swelling and redness) of the left and right lower limb and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system). During a review of Resident 55's History and Physical (H&P), dated 11/14/2025, the H&P indicated the resident had the ability to understand and make decisions. During a review of Resident 55's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). During a review of Resident 55's Order Summary Report (OSR), dated 12/3/2025, the OSR indicated an order for enhanced barrier precautions (gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism [MDRO, bacteria or germs that have developed resistance to multiple, commonly used antibiotics] as well as those at increased risk of MDRO acquisition)- staff to utilize gowns and gloves for high-contact resident care activities related to device peripherally inserted central catheter (PICC, a long, thin, flexible tube inserted through a vein in the upper arm and passed through the venous system until the tip rests in a large vein near the heart) line, left lower leg (LLL) venous wound (can occur when the veins in the legs do not push blood back up to the heart as well as they should), right lower leg (RLL) venous wound. During a review of Resident 55's Care Plan (CP) Report titled, The resident will be staying long-term in the facility, last revised on 11/14/2025, the CP indicated a goal of the resident will be comfortable in their environment. During an observation and interview on 1/12/2026, at 10:13 a.m., with Resident 55, inside Resident 55's room, observed Resident 55's electric fan with dust buildup on the fan blades and the front and back grill enclosure of the fan. Resident 55 stated she (Resident 55) has spoken to the Maintenance Department about it but has not cleaned the fan yet. During an observation and interview on 1/12/2026, at 3:30 p.m., with the Respiratory Therapist Supervisor (RTS), inside Resident 55's room, observed the electric fan with dust buildup on the fan blades and the front and back grill enclosure of the fan. The RTS stated the fan was dirty and needed to be cleaned to prevent the resident from getting respiratory infection. The RTS stated she will report them to the Maintenance Department to clean them right away. During an interview and record review on 1/14/2026, at 2:59 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed the photo taken of the electric fan of Resident 55 on 1/12/2026, at 10:13 a.m. The MDSC stated Resident 55's fan was dirty and should have been cleaned by the housekeeper. The MDSC stated everybody in the facility is mandated to report them to the housekeepers when they see the electric fans of the resident dirty covered with dust. The MDSC stated the failure of the facility to report and clean the dirty electric fan covered with dust on the fan blade and back and front grill can cause respiratory infections to the resident and does not promote a homelike environment. During an interview on 1/16/2026, at 10:06 a.m., with the Director of Nursing (DON), the DON stated the housekeeping is in charge of cleaning the electric fans in the facility. The DON stated Resident 55's electric fan should have been cleaned by the housekeeper to prevent the dust from being introduced to the resident causing the resident to get sick. During a review of the facility's recent policy and procedure (P&P) titled, Air Filter and Electric fan Cleaning Policy, last reviewed on 4/24/2025, the P&P indicated to ensure air filters and electric fans are cleaned routinely to reduce dust buildup, improve air circulation, maintain equipment function, and support infection prevention standards at the facility. PROCEDURE 2. Electric Fan Cleaning All portable and fixed electric fans will be cleaned routinely to prevent dust accumulation and reduce the spread of particles. 3a) During a review Resident 33's admission Record (AR), the AR indicated the facility admitted Resident 33 on 1/19/2023, with diagnoses including congestive heart failure (CHF – a heart disorder which causes the heart not to pump the blood efficiently sometimes resulting in leg swelling) and depression (a serious, common mood disorder causing persistent sadness, loss of interest, and affecting how you think, feel, and handle daily activities). During a review of Resident 33's H&P dated 3/5/2025, the H&P indicated Resident 33 did not have the capacity to understand or make decisions. During a review of Resident 33's MDS dated [DATE], the MDS indicated Resident 33 was dependent upon staff for all activities of daily living (ADLs- activities such as bathing, dressing, and toileting) requiring maximum assistance of staff to complete daily tasks. During a review of Resident 33's plan of care revised on 2/16/2025, the plan of care indicated Resident 33 preferred an in room-based activity program with activities preformed in room, three times per week an intervention indicated in room activities would be offered due to Resident 33's preferences. 3b) During a review of Resident 39's AR, the AR indicated Resident 39 was admitted to the facility on [DATE], with diagnoses including heart failure (heart is not pumping blood as well as it should) and epilepsy (a brain condition that causes repeated seizures). During a review of Resident 39's H&P dated 5/4/2025 the H&P indicated Resident 39 did not have the ability to understand or make decisions. During a review of Resident 39's MDS dated [DATE], the MDS indicated Resident 39 was dependent upon staff for all activities of daily living requiring maximum assistance of staff to complete daily tasks. During a review of the plan of care for Resident 39 revised on 9/16/2025, the plan of care indicated that that Resident 39 preferred a room base activity program with activities occurring in the room three times per week. A plan of care intervention was to offer additional activities in Resident 39's room based on preferences. 3c) During a review of Resident 72's AR, the AR indicated Resident 72 originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control ad poor wound healing) and chronic myeloproliferative disease (a group of long-term blood cancers where the bone marrow makes too many blood cells). During a review of Resident 72's H&P dated 12/31/2025, the H&P indicated Resident 72 did not have the capacity to understand and make needs known. During a review of Resident 72's MDS dated [DATE] the MDS indicated Resident 72 was dependent upon staff for all activities of daily living requiring maximum assistance of staff to complete daily tasks. During a review of Resident 72's plan of care revised 10/14/2025, the plan of care indicated that Resident 72 preferred a room base activity program with activities occurring in the room three times per week. A plan of care intervention was to offer additional activities in Resident 72's room based on preferences. During a concurrent observation and interview on 1/14/2025 at 12 p.m. with the Director of Maintenance (DOM), Resident 33, Resident 39, and Resident 72's room was observed with loose floorboards. The DOM pulled out a closet drawer containing a white substance. The DOM stated the closet drawer is dirty and stated the white substance was a result of water damage and can be a potential infection control issue for the residents in the room. During an interview on 1/15/2026 at 12:30 p.m., with the DON, the DON stated the water damage in the residents' room can create an infection control concern because moisture can promote mold and bacteria growth putting our residents at risk and stated the state of the room did not look homelike. During a concurrent observation and interview on 1/14/2026 at 2:30 p.m. with the DOM, the laundry room was observed. There were two wash basins on the laundry room floor placed under leaking pipes. One pipe leaked water into a wash basin. Another pipe leaked soap suds into the other wash basin. There was a water puddle in front of the washing machines. The DOM stated the water had been leaking for several weeks. A bath blanket was present on the laundry room floor. The DOM stated the blanket was placed on the floor to absorb the leaking water. The DOM stated the leaking pipes in the laundry room caused water damage to Resident 33, Resident 39, and Resident 72's room. The DOM stated the water damage in Resident 33, Resident 39, and Resident 72's room included loose and damp laminate floor tiles, warped wood on the drawers and closet panels, and wall damage. The DOM stated the leaking water was a safety and infection control risk. During a review of the facility's policy and procedure (P&P) undated, titled, Homelike Environment, the P&P indicated (facility name) provides and maintains a homelike, noninstitutional environment that supports resident dignity, choice, privacy, and quality of life. The facility shall maintain clean, safe, and comfortable resident rooms and a pleasant décor. A homelike environment shall be maintained without compromising infection prevention and control. The homelike environment is monitored through resident feedback, quality assurance activities, and regulatory inspections. During a review of the facility's policy and procedure (P&P) undated, titled General Maintenance and Plant Operations, the P&P indicated maintaining a safe, clean and functional physical environment for resident. All facility systems, equipment and structures shall be maintained in good working order. Preventive maintenance schedules shall be established equipment inspected may include plumbing .

Based on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of residents) for two of four residents (Resident 1 and Resident 2) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1. This deficient practice resulted in Resident 1 sustaining abrasions (when the surface layers of the skin have been broken) on bilateral (both) knees and left thumb laceration (a deep cut or tear in skin) on 3/16/2025 at 8:29 a.m. On 3/16/2025, Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) for further evaluation and wound treatment. Resident 1 ' s left thumb laceration, measuring three (3) centimeters (cm - unit of measurement) in length, 0.2 cm in width, with unknown depth, required eight stitches (fine, threadlike materials used to hold the edges of a wound together, promoting healing). On 3/19/2025 at 4:12 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator and the Director of Nursing (DON) for the facility ' s failure to provide staff supervision on 3/16/2025 at 8:26 a.m., when Resident 1 and Resident 2 were both in the facility ' s smoking patio. On 3/22/2025 at 7:41 p.m., the DON provided an acceptable IJ removal plan (a plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility ' s failure to provide supervision on 3/16/2025 at 8:26 a.m., to Resident 1 and Resident 2. On 3/22/2025 at 8:15 p.m., while onsite and after verifying the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review, the SSA removed the IJ situation in the presence of the Administrator and the DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On 3/16/2025 at 8:31 a.m., Resident 1 approached Nursing Station 500 for assistance. Registered Nurse (RN) 1 noted that Resident 1 had a cut on his left thumb with bleeding. RN 1 immediately gave first aid (initial assistance and care given to a resident who has been injured) and called Licensed Vocational Nurse (LVN) 1 to attend to Resident 1. RN 1 asked Resident 1 how he (Resident 1) got the cut on his (Resident 1) left thumb and Resident 1 stated, The guy (referring to Resident 2) is waving his (Resident 2) knife and I tried to seize (take hold of) it (knife). RN 1 immediately went to the smoking patio to check and found Resident 2 about to go inside the facility with no visual (sight) of the alleged knife. 2. On 3/16/2025 at 9 a.m., RN 1 initiated a change of condition (COC - when there is a sudden significant change in a resident ' s health status) on Resident 2. RN 1 did a body check on Resident 2 and noted an abrasion (a superficial injury where the outermost layer of skin is rubbed or torn off, often caused by contact with a rough surface) on Resident 2 ' s left hand and wrist. RN 1 gave first aid to Resident 2 who denied any pain. RN 1 called Resident 2 ' s primary medical doctor (MD) 1 on 3/16/2025 at approximately 9 a.m. who ordered to transfer Resident 2 to GACH 2 for further evaluation. Resident 2 was assigned a 1:1 sitter (refers to a facility staff dedicated to providing continuous, one-on-one observation and care to a single resident, often to ensure their safety and prevent potential harm) to monitor his (Resident 2) aggressive behavior (any behavior intended to harm or cause distress to another person, either physically or emotionally). Resident 2 was transferred to GACH 2 for further psychiatric evaluation (a comprehensive assessment of an individual ' s mental health status, conducted by a qualified mental health professional) and treatment on 3/16/2025 at 6:10 p.m. 3. On 3/16/2025 at approximately 9:15 a.m., RN 1 initiated body assessment on Resident 1 and noted abrasions on both of his (Resident 1) knees. RN 1 initiated the COC on Resident 1. RN 1 called the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) who arrived on 3/16/2025 at around 9:20 p.m. and transferred Resident 1 to GACH 1. RN 1 called the local police. 4. On 3/16/2025 at 9:05 p.m., Resident 1 came back from GACH 1 with eight stitches of sutures on Resident 1 ' s left thumb cut. Resident 1 was monitored for 72 hours for any fall complications and symptoms of emotional distress related to the altercation with Resident 2. Social Services staff continued to do a wellness visit to Resident 1 from 3/16/2025 to 3/19/2025 for emotional support and feeling of safety. The Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) visited Resident 1 on 3/17/2025 at 4 p.m. A Psychologist (a mental health professional who specializes in understanding and treating mental, emotional, and behavioral disorders) visited Resident 1 on 3/19/2025. 5. On 3/16/2025 at 2:30 p.m., the Director of Nursing (DON) via telephone had provided a 1:1 education (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) to RN 1 regarding facility policies for abuse prevention that included all type of abuse and educating on the facility ' s policy and procedure on resident supervision specifically on following the residents ' smoking schedule to ensure that supervision is provided to residents in the smoking patio and on the other areas of the facility like the front entrance backyard and other patio location to ensure each resident ' s safety. On 3/21/2025 and 3/22/2025, the DON provided 1:1 education to RN 2, Certified Nursing Assistant (CNA) 1, and CNA 2 regarding resident safety, supervision, and abuse prevention and management. Licensed Vocational Nurse (LVN) 1, who is currently on vacation, will be educated prior to coming back on the floor. 6. On 3/17/2025 at 2 a.m., the facility readmitted Resident 2 from GACH 2. The facility provided 1:1 sitter to Resident 2 to monitor his aggressive behavior. Social Services staff continued doing wellness visit (an appointment to create or update a personalized prevention plan focusing on preventative care and health risk assessments) to Resident 2 starting on 3/17/2025 at 1:17 p.m. who verbalized he (Resident 2) is doing well in the facility. On 3/18/2025 at 2:30 p.m., The Psychiatrist had seen Resident 2. On 3/18/2025 at 12:44 p.m., four local police officers came to the facility and apprehended Resident 2. 7. On 3/17/2025, the Administrator posted signs of No Weapons Allowed in the facility. The signs are posted in the front entrance door, facility entrance, and employee lounge. Additional posts will be done in other areas of the facility. 8. On 3/17/2025 until 3/22/2025, the Director for Staff Development (DSD), the Administrator, DON, and Assistant Administrator provided all facility staff with an in-service (a planned, workplace-based training program designed to enhance staff competency, improve job performance, and keep staff up to date with current best practices and new techniques) for all types of Abuse. 9. The facility made the following efforts to locate the knife used by Resident 2 to injure Resident 1: a. On 3/16/2025, RN 1 and LVN 1 attempted to search Resident 2, however, Resident 2 refused. b. On 3/16/2025, RN 1 and LVN 1 searched the Smoking Patio but could not locate the knife. c. On 3/16/2025, the Administrator asked the police officer to conduct body search on Resident 2, the police officer stated that he cannot conduct it at this time. d. On 3/16/2025, LVN 2 conducted a search in Resident 2 ' s room, in the trash cans, all drawers, closets, inside the shoes, under the mattresses, and the bathroom. Resident 2 ' s knife was not located. e. On 3/16/2025, the housekeeper and laundry employees searched all trash carts, and laundry area, knife was not located. f. On 3/19/2025, the Department heads conducted searches in all residents' rooms and belongings. Resident 2 ' s knife was not located. g. On 3/19/2025, the Maintenance Supervisor searched the roof top, knife was not located. h. On 3/22/2025, Administrator started reviewing the video footage to find the location of the knife. The Administrator is new, who started on 12/7/2024, was not given yet the capability to review the surveillance camera but is now able to review as of 3/22/2025. The Administrator is currently working with the Information Technology (IT) staff to assist if there will be any issues regarding the video surveillance footages. i. The Administrator/designee will coordinate all efforts to exhaustively and continuously search for the missing knife used by Resident 2 until it (the knife) is found. Once knife is found the administrator will take a picture of where the knife was found, will place it in a bag, will handle with caution, and will turn it in to the police department. A notification will be sent to the SSA. 10. On 3/19/2025 and 3/20/2025, the Department Heads conducted resident safety check on their assigned rooms using the resident inventory of personal belongings log to identify presence of any weapons or sharp objects after obtaining consents from self-responsible and alert residents and from residents ' responsible parties for residents who are not self-responsible. 11. On 3/19/2025 and 3/20/2025, the MDS Nurse, DON, and Activity Staff smoking attendant conducted 1:1 smoking observation of residents smoking in the smoking patio. After the smoking observation of residents, the MDS Nurse conducted a Smoking Risks Evaluation to determine if a smoker requires supervision or is an independent smoker during smoking time. The MDS Nurse have identified eight residents who require supervision during smoking and ten residents who can independently smoke in the smoking patio. All the 18 residents have the potential to be affected by the deficient practice therefore the facility shall provide residents supervision both for supervised and independent smokers to ensure residents ' safety. 12. On 3/21/2025, a new policy and procedure for Firearms and Other Weapons was initiated and will be presented to the Medical Director on 3/24/2025 during an emergency meeting. 13. Department head managers during their routine rounds will conduct a safety room check on their assigned rooms to inspect the presence of sharp objects. Any kinds of sharp objects will be seized and reported to the Administrator for further follow-up. Findings: 1. During a review of Resident 1 ' s Admission Record (undated), the Admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024, the MDS indicated Resident 1 ' s cognition was moderately impaired. The MDS indicated Resident 1 ' s mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating. During a review of Resident 1 ' s Non-Compliance for Smoking Policy warning, dated 1/11/2024, the Non-Compliance for Smoking Policy warning indicated Resident 1 was given a verbal warning after Resident 1 was found on the smoking patio during a non-smoking time turning an ashtray dispenser (a device or container designed to hold and dispense ashtrays) upside down to remove any cigarettes that had already been discarded and Resident 1 chewed on the cigarette butts. During a review of Resident 1 ' s care plan on chronic (recurring) disruptive behavior (actions that interfere with the functioning of an individual or a group and cause disturbances to those around them, often involving aggression, defiance, or violation of social norms), revised on 9/28/2024, the care plan indicated Resident 1 had a history of physical abuse with another resident (name not indicated). During a review of Resident 1 ' s care plan with the focus on the resident as a smoker and chews tobacco, revised on 10/3/2024, the care plan indicated Resident 1 was non-compliant (disobedient) with the smoking policy and was on the patio during non-smoking time, turning the ash tray dispenser upside down to remove cigarette butts to chew. The care plan indicated Resident 1 will not smoke without supervision. During a review of Resident 1 ' s COC, dated 3/16/2025 at 9 a.m., the COC indicated Resident 1 came to the nursing station on 3/16/2025 at approximately around 8:40 a.m. with bleeding on left thumb. The COC indicated RN 1 conducted a body assessment on Resident 1 with noted laceration on left thumb and abrasion to bilateral knees. The COC indicated the paramedics transferred Resident 1 to GACH 1 for further evaluation. 2. During a review of Resident 2 ' s Admission Record (undated), the Admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side. During a review of Resident 2 ' s Inventory of Personal Effects (an itemized list of belongings of a resident), dated 7/19/2024, the Inventory of Personal effects did not indicate that Resident 2 was in possession of a knife. The form was completed and documented by CNA 4 and counter signed (a signature attesting the authenticity of a document already signed by another) by Resident 2. During a review of Resident 2 ' s H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions. During a review of Resident 2 ' s care plan on resident as a supervised smoker (refers to an individual who, due to assessed needs or identified risks, requires direct supervision or assistance when smoking to ensure their safety and the safety of those around them), revised on 10/10/2024, the care plan indicated Resident 2 was non-compliant with the use of the smoking apron, schedule time, and was at risk for injury from unsafe smoking practices. The care plan indicated Resident 2 ' s risk to smoke without supervision will be minimized, and Resident 2 will be monitored for any unsafe smoking practices. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognition was intact. The MDS indicated Resident 2 ' s mobility devices included the use of a walker (a mobility aid designed to assist individuals with difficulty walking) and manual wheelchair. The MDS indicated Resident 2 needed partial/moderate assistance with toilet transfer. During a review of Resident 2's COC Evaluation, dated 3/17/2025, the COC indicated that on the morning of 3/16/2025 Resident 2 had an altercation with another resident (Resident 1). During a review of the facility ' s Smoking Schedule, (undated), the Smoking Schedule indicated that on Saturdays and Sundays, residents are scheduled to smoke between 9 a.m. to 9:30 a.m., 11 a.m. to 11:30 a.m., 1 p.m. to 1:30 a.m., 3 p.m. to 3:30 p.m., and 7 p.m. to 7:30 p.m. During a concurrent observation and interview on 3/18/2025 at 10:10 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 ' s left thumb was observed covered in a foam dressing. Resident 1 stated Resident 2 was disrespectful and used inappropriate words. Resident 1 stated, He (referring to Resident 2) has no respect for anybody, he (Resident 2) can ' t talk like that. During an interview on 3/18/2025 at 10:34 a.m. with RN 1, RN 1 stated on 3/16/2025 at approximately 8:40 a.m. Resident 1 came to the nursing station and informed RN 1 that Resident 2 cut his (Resident 1) hand while Resident 1 was trying to take a knife from Resident 2 in the smoking patio. RN 1 also stated that Resident 1 was bleeding from the laceration on his left thumb. RN 1 stated while in the smoking patio, he (RN 1) questioned Resident 2 regarding possession of a knife but Resident 2 denied. RN 1 stated he (RN 1) did not inspect Resident 2 for the possession of a knife since Resident 2 denied having a knife. RN 1 stated it was him (RN 1) who opened the door to the smoking patio for a resident (name not specified) and left it open allowing Resident 1 and Resident 2 to enter the smoking patio with no staff present to supervise the two residents (Resident 1 and Resident 2). RN 1 stated that he (RN 1) was in the nursing station when Resident 1 and Resident 2 had a physical altercation. During an interview on 3/18/2025 at 11:56 a.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/16/2025. CNA 1 stated she was with another resident (name not specified) when the physical altercation between Resident 1 and Resident 2 happened in the smoking patio. CNA 1 stated the next time she (CNA 1) saw Resident 1 was in the hallway near the nursing station with RN 1 applying pressure on Resident 1 ' s bleeding hand. CNA 1 stated she (CNA 1) heard Resident 1 saying he (Resident 1) was trying to get a knife from another resident (Resident 2). During a concurrent observation and interview on 3/18/2025 at 3:18 p.m. with Activity Staff (AS) 1 in the hallway, AS 1 was sitting in the hallway, near the smoking patio with doors closed. Two residents (names not indicated) were observed smoking in the patio through the glass panel on the doors. AS 1 stated the residents smoking in the patio are independent smokers but require supervision since occasionally, they pick up cigarette butts from the floor and try to chew them. AS 1 also stated she should have supervised residents while staying outdoors in the smoking patio. AS 1 stated the entire smoking patio is not visible from behind the hallway doors and she is not able to see all the residents in the patio. AS 1 stated all residents smoking in the patio should be supervised to prevent resident injury. During an interview on 3/19/2025 at 9:15 a.m., with RN 1, RN 1 stated on 3/16/2025 between 8 a.m. and 8:30 a.m., Resident 1 and Resident 2 were smoking in the smoking patio without supervision. RN 1 stated Residents 1 and 2 should have been supervised while smoking in the patio. During a concurrent interview and record review on 3/19/2025 at 11:22 a.m. with the MDS Specialist, Resident 2 ' s Smoking Evaluation, dated 10/10/2024, was reviewed. The Smoking Evaluation indicated Resident 2 was noted with episode of non-compliance with the use of the smoking apron and required periodic supervision. The MDS Specialist stated Resident 2 was a supervised smoker. The MDS Specialist also stated residents should not be smoking outside of the scheduled smoking times and all residents should be supervised by the facility staff while smoking. During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility ' s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and Resident 2) were on their wheelchairs, were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times: a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen. b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance. c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and they were exchanging words. d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1 ' s hand while Resident 1 was pointing his hand towards Resident 2. e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1 ' s face. f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2 ' s hands. g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking patio as observed in the video surveillance. During an interview on 3/19/2025 at 1:36 p.m. with the DON, the DON stated the facility failed to provide supervision to Resident 1 and Resident 2 on 3/16/2025 in the smoking patio, which led to a physical altercation between the two residents (Resident 1 and Resident 2) and Resident 1 sustaining an injury. The DON stated the facility has not found the knife used by Resident 2. The DON stated there is a possibility that the knife is still in the facility or in the possession of another resident. During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated Resident 1 had informed the Administrator that Resident 2 was using inappropriate words towards Resident 1. The administrator also stated the physical altercation between Resident 1 and Resident 2 could have been prevented if the two residents (Resident 1 and Resident 2) were supervised in the smoking patio. During an interview on 3/20/2025 at 2:45 p.m. with the Administrator, the Administrator stated the knife used by Resident 2 to injure Resident 1 was not found. The Administrator also stated body inspection was not done on Resident 2 since Resident 2 refused. The Administrator stated there was a possibility Resident 2 ' s knife is still in the facility. During a review of the current facility-provided policy and procedure titled, Smoking Policy-Residents, last reviewed on 4/2024, the policy and procedure indicated, This facility has established and maintains safe resident smoking practices Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. During a review of the current facility-provided policy and procedure titled, Safety and Supervision of Residents, last reviewed on 4/2024, the policy and procedure indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities Individualized, Resident-Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision Systems Approach to Safety: . 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment of if there is a change in the resident ' s condition.

Based on observation, 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) for one of four sampled residents (Resident 1) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 3/16/2025 at 8:29 a.m., Resident 1 sustained abrasions (when the surface layers of the skin have been broken) on bilateral (both) knees and left thumb laceration (a deep cut or tear in skin). Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) on 3/16/2025 for further evaluation and wound treatment. Resident 1 ' s left thumb laceration, measuring three (3) centimeters (cm - unit of measurement) in length, 0.2 cm in width, with unknown depth, required eight stitches (fine, threadlike materials used to hold the edges of a wound together). Based on the Reasonable Person Concept (what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer because of the noncompliance), due to Resident 1 ' impaired cognition (mental action or process of acquiring knowledge and understanding) and medical condition, an individual subjected to physical abuse may have physical pain, 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 yourself). On 3/19/2025 at 4:12 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ - a situation in which the facility ' s non-compliance with one or more requirements of participations had caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator and the Director of Nursing (DON) for the facility ' s failure to ensure that Resident 1 was kept free from physical abuse, as evidenced by Resident 2 injuring (to hurt or cause physical harm to another person) Resident 1 with a knife in the facility ' s smoking patio. On 3/22/2025 at 5:48 p.m., the Administrator provided an acceptable IJ removal plan (a plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility ' s failure to keep Resident 1 free from physical abuse. On 3/22/2025 at 8:15 p.m., while onsite and after verifying the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review and determined the IJ situation was no longer present. The IJ situation was removed while onsite, in the presence of the Administrator and the DON. The acceptable IJ Removal Plan included the following summarized actions: 1. On 3/16/2025 at 8:31 a.m., Resident 1 approached Nursing Station 500 for assistance. Registered Nurse 1 (RN 1) noted that Resident 1 had a cut on his left thumb with bleeding. RN 1 immediately gave first aid (initial assistance and care given to a resident who has been injured) and called Licensed Vocational Nurse (LVN) 1 to attend to Resident 1. RN 1 asked Resident 1 how he (Resident 1) got the cut on his (Resident 1) left thumb and Resident 1 stated, The guy (referring to Resident 2) is waving his (Resident 2) knife and I tried to seize (take hold of) it (knife). RN 1 immediately went to the smoking patio to check and found Resident 2 about to go inside the facility with no visual (sight) of the knife. 2. On 3/16/2025 at 9 a.m., RN 1 initiated a change of condition (COC - when there is a sudden significant change in a resident ' s health status) on Resident 2. RN 1 did a body check on Resident 2 and noted an abrasion (a superficial injury where the outermost layer of skin is rubbed or torn off, often caused by contact with a rough surface) on Resident 2 ' s left hand and wrist. RN 1 gave first aid to Resident 2 who denied any pain. RN 1 called Resident 2 ' s primary medical doctor (MD) 1 on 3/16/2025 at approximately 9 a.m. who ordered to transfer Resident 2 to GACH 2 for further evaluation. Resident 2 was assigned a 1:1 sitter (refers to a facility staff dedicated to providing continuous, one-on-one observation and care to a single resident, often to ensure their safety and prevent potential harm) to monitor his (Resident 2) aggressive behavior (any behavior intended to harm or cause distress to another person, either physically or emotionally). Resident 2 was transferred to GACH 2 for further psychiatric evaluation (a comprehensive assessment of an individual ' s mental health status, conducted by a qualified mental health professional) and treatment on 3/16/2025 at 6:10 p.m. 3. On 3/16/2025 at approximately 9:15 a.m., RN 1 initiated body assessment on Resident 1 and noted abrasions on both of his (Resident 1) knees. RN 1 initiated the COC on Resident 1. RN 1 called the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) who arrived on 3/16/2025 at around 9:20 p.m. and transferred Resident 1 to GACH 1. RN 1 called the local police. 4. On 3/16/2025 at 9:05 p.m., Resident 1 came back from GACH 1 with eight stitches of sutures on Resident 1 ' s left thumb cut. Resident 1 was monitored for 72 hours for any fall complications and symptoms of emotional distress related to the altercation with Resident 2. Social Services staff continued to do a wellness visit to Resident 1 from 3/16/2025 to 3/19/2025 for emotional support and feeling of safety. The Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) visited Resident 1 on 3/17/2025 at 4 p.m. A Psychologist (a mental health professional who specializes in understanding and treating mental, emotional, and behavioral disorders) visited Resident 1 on 3/19/2025. 5. On 3/16/2025 at 2:30 p.m., the Director of Nursing (DON) via telephone had provided a 1:1 education (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) to RN 1 regarding facility policies for abuse prevention that included all type of abuse. On 3/21/2025 and 3/22/2025, the DON provided 1:1 education to RN 2, Certified Nursing Assistant (CNA) 1, and CNA 2 regarding resident safety, supervision, and abuse prevention and management. Licensed Vocational Nurse (LVN) 1, who is currently on vacation, will be educated prior to coming back on the floor. 6. On 3/17/2025 at 2 a.m., the facility readmitted Resident 2 from GACH 2. The facility provided 1:1 sitter to Resident 2 to monitor his aggressive behavior. Social Services staff continued doing wellness visit (an appointment to create or update a personalized prevention plan focusing on preventative care and health risk assessments) to Resident 2 starting on 3/17/2025 at 1:17 p.m. who verbalized he (Resident 2) is doing well in the facility. On 3/18/2025 at 2:30 p.m., The Psychiatrist had seen Resident 2. On 3/18/2025 at 12:44 p.m., four local police officers came to the facility and apprehended Resident 2. 7. On 3/17/2025, the Administrator posted signs of No Weapons Allowed in the facility. The signs are posted in the front entrance door, facility entrance, and employee lounge. Additional posts will be done in other areas of the facility. 8. On 3/17/2025 until 3/22/2025, the Director for Staff Development (DSD), the Administrator, DON, and Assistant Administrator provided all facility staff with an in-service (a planned, workplace-based training program designed to enhance staff competency, improve job performance, and keep staff up to date with current best practices and new techniques) for all types of Abuse. 9. The facility made the following efforts to locate the knife used by Resident 2 to injure Resident 1: a. On 3/16/2025, RN 1 and LVN 1 attempted to search Resident 2, however, Resident 2 refused. b. On 3/16/2025, RN 1 and LVN 1 searched the Smoking Patio but could not locate the knife. c. On 3/16/2025, the Administrator asked the police officer to conduct body search on Resident 2, the police officer stated that he cannot conduct it at this time. d. On 3/16/2025, LVN 2 conducted a search in Resident 2 ' s room, in the trash cans, all drawers, closets, inside the shoes, under the mattresses, and the bathroom. Resident 2 ' s knife was not located. e. On 3/16/2025, the housekeeper and laundry employees searched all trash carts, and laundry area, knife was not located. f. On 3/19/2025, the Department heads conducted searches in all residents' rooms and belongings. Resident 2 ' s knife was not located. g. On 3/19/2025, the Maintenance Supervisor searched the roof top, knife was not located. h. On 3/22/2025, Administrator started reviewing the video footage to find the location of the knife. The Administrator is new, who started on 12/7/2024, was not given yet the capability to review the surveillance camera but is now able to review as of 3/22/2025. The Administrator is currently working with the Information Technology (IT) staff to assist if there will be any issues regarding the video surveillance footages. i. The Administrator/designee will coordinate all efforts to exhaustively and continuously search for the missing knife used by Resident 2 until it (the knife) is found. Once knife is found the administrator will take a picture of where the knife was found, will place it in a bag, will handle with caution, and will turn it in to the police department. A notification will be sent to the SSA. 10. On 3/19/2025 to 3/22/2025, the DSD, Administrator, DON, and Assistant Administrator conducted in-services to staff regarding resident-to-resident verbal altercation and separating the residents to avoid escalation (an increase in the intensity or seriousness of something), recognizing potential threats, and handling situations where a weapon may be involved. 11. On 3/21/2025, a new policy and procedure for Firearms and Other Weapons was initiated and will be presented to the Medical Director on 3/24/2025 during an emergency meeting. 12. On 3/22/2025, RN Mentor in-serviced the Administrator and DON on the policy and procedure for abuse, how to detect and what is the definition of Abuse. 13. Department head managers during their routine rounds will conduct a safety room check on their assigned rooms to inspect the presence of sharp objects. Any kinds of sharp objects will be seized and reported to the Administrator for further follow-up. 14. Upon admission and during quarterly Interdisciplinary Team (IDT - a collaborative group of individuals from different discipline who work together to achieve a common goal) meetings, the Social Services will educate residents and their representatives about the policy and procedure on abuse and the facility ' s protocol of not bringing any sharp objects or weapons to the facility. Anyfindings of such will be confiscated immediately and will be handed to the Administrator/DON. 15. Upon returning from out on pass (refers to a planned, temporary absence of a resident from the facility, authorized by a physician ' s order, for a specific purpose, with the expectation of the resident ' s return), if residents or representatives bring any items back to the facility, the charge nurse or RN supervisor will be asking for any items the resident would like to be added to the inventory list. (Cross Reference to F689) Findings: 1. During a review of Resident 1 ' s Admission Record (undated), the Admission Record indicated the facility originally admitted Resident 1 on 9/15/2020 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thoughts), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024, the MDS indicated Resident 1 ' s cognition was moderately impaired. The MDS indicated Resident 1 ' s mobility (movement) device includes the use of a manual wheelchair (a wheeled mobility chair propelled by human power, either by the user themselves or by a caregiver pushing the wheelchair). The MDS indicated Resident 1 needing partial/moderate assistance (helper does less than half the effort and helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower or bathing self. The MDS indicated Resident 1 needing setup or clean-up assistance (helper sets up or cleans up; resident completes activity with helper assisting only prior to or following the activity) with eating. During a review of Resident 1 ' s COC, dated 3/16/2025 at 9 a.m., the COC indicated Resident 1 came to the nursing station on 3/16/2025 at approximately around 8:40 a.m. with bleeding on left thumb. The COC indicated RN 1 conducted a body assessment on Resident 1 with noted laceration on left thumb and abrasion to bilateral knees. The COC indicated the paramedics transferred Resident 1 to GACH 1 for further evaluation. 2. During a review of Resident 2 ' s Admission Record (undated), the Admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), schizophrenia, and hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain) affecting right dominant side. During a review of Resident 2 ' s Inventory of Personal Effects (an itemized list of belongings of a resident), dated 7/19/2024, the Inventory of Personal effects did not indicate that Resident 2 was in possession of a knife. The form was completed and documented by CNA 4 and counter signed (a signature attesting the authenticity of a document already signed by another) by Resident 2. During a review of Resident 2 ' s H&P, dated 7/22/2024, the H&P indicated Resident 2 had the mental capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognition was intact. The MDS indicated Resident 2 ' s mobility devices included the use of a walker (a mobility aid designed to assist individuals with difficulty walking) and manual wheelchair. The MDS indicated Resident 2 needed partial/moderate assistance with toilet transfer. During a review of Resident 2's COC Evaluation, dated 3/17/2025, the COC indicated that on the morning of 3/16/2025 Resident 2 had an altercation with another resident (Resident 1). During a concurrent observation and interview on 3/18/2025 at 10:10 a.m., with Resident 1 in Resident 1 ' s room, Resident 1 ' s left thumb was observed covered in a foam dressing. Resident 1 stated Resident 2 was disrespectful and used inappropriate words. Resident 1 stated, He (referring to Resident 2) has no respect for anybody, he (Resident 2) can ' t talk like that. During an interview on 3/18/2025 at 10:34 a.m. with RN 1, RN 1 stated on 3/16/2025 at approximately 8:40 a.m. Resident 1 came to the nursing station and informed RN 1 that Resident 2 cut his (Resident 1) hand while Resident 1 was trying to take a knife from Resident 2 in the smoking patio. RN 1 also stated that Resident 1 was bleeding from the laceration on his left thumb. RN 1 stated while in the smoking patio, he (RN 1) questioned Resident 2 regarding possession of a knife but Resident 2 denied. RN 1 stated he (RN 1) did not inspect Resident 2 for the possession of a knife since Resident 2 denied having a knife. RN 1 stated it was him (RN 1) who opened the door to the smoking patio for a resident (name not specified) and left it open allowing Resident 1 and Resident 2 to enter the smoking patio without staff supervision. RN 1 stated that he (RN 1) was in the nursing station when Resident 1 and Resident 2 had a physical altercation. During an interview on 3/18/2025 at 11:56 a.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/16/2025. CNA 1 stated she was with another resident (name not specified) when the physical altercation between Resident 1 and Resident 2 happened in the smoking patio. CNA 1 stated the next time she (CNA 1) saw Resident 1 was in the hallway near the nursing station with RN 1 applying pressure on Resident 1 ' s bleeding hand. CNA 1 stated she (CNA 1) heard Resident 1 saying he (Resident 1) was trying to get a knife from another resident (Resident 2). During an interview on 3/19/2025 at 9:15 a.m., with RN 1, RN 1 stated on 3/16/2025 between 8 a.m. and 8:30 a.m., Resident 1 and Resident 2 were smoking in the smoking patio without staff supervision. RN 1 stated Residents 1 and 2 should have been supervised while smoking in the patio. RN 1 stated the physical abuse incident could have been prevented if a staff member was supervising the two residents (Resident 1 and Resident 2). During a concurrent observation, interview, and record review on 3/19/2025 at 12:10 p.m., the facility ' s video surveillance footage of the smoking patio with the recording date and time of 3/16/2025 at 8:22:57 a.m. (adjusted to reflect actual time) was observed and reviewed with the Administrator. The Administrator verified Resident 1 and Resident 2 as the residents in the video surveillance. Both residents (Resident 1 and Resident 2) were on their wheelchairs and were in the East Smoking Patio. The Administrator stated the video surveillance time stamp was not updated to reflect spring daylight savings time (refers to the practice of advancing clocks forward one hour from standard time, typically on the second Sunday in March, to make better use of natural daylight during the warmer months) and was one hour behind the actual time. The Administrator also stated the entrance to the East Smoking Patio was not visible in the video surveillance due to the location of the camera. The Administrator stated there was only one camera in the East Smoking Patio. The Administrator stated the following with time stamps adjusted to reflect the actual times: a. On 3/16/2025 at 8:22:59 a.m., Resident 1 entered the East Smoking Patio from the hallway between Nursing Station 500 and the kitchen. b. On 3/16/2025 at 8:24:08 a.m., Resident 2 entered the East Smoking Patio from the same entrance. c. On 3/16/2025 at 8:26:58 a.m., Resident 1 stood up from his wheelchair and walked towards Resident 2 and started exchanging words. d. On 3/16/2025 at 8:27:08 a.m., Resident 2 attempted to slap Resident 1 ' s hand while Resident 1 was pointing his hand towards Resident 2. e. On 3/16/2025 at 8:29:22 a.m., Resident 2 pointed a knife towards Resident 1 ' s face. f. On 3/16/2025 at 8:29:56 a.m., Resident 1 fell on the ground after trying to take the knife from Resident 2 ' s hands. g. On 3/16/2025 at 8:30:20 a.m., Resident 1 went back and sat in his wheelchair and entered the facility at 8:30:42 a.m. The Administrator stated there was no facility staff present in the smoking patio as observed in the video surveillance. During an interview on 3/19/2025 at 1:36 p.m., with the DON, the DON stated the facility failed to provide supervision to Resident 1 and Resident 2 on 3/16/2025 in the smoking patio, which led to a physical altercation between the two residents (Resident 1 and Resident 2) and Resident 1 sustaining an injury. The DON stated the facility has not found the knife used by Resident 2. The DON stated there is a possibility that the knife is still in the facility or in the possession of another resident. During an interview on 3/19/2025 at 3:16 p.m. with the Administrator, the Administrator stated Resident 1 had informed the Administrator that Resident 2 was using inappropriate words towards Resident 1. The Administrator also stated the physical altercation between Resident 1 and Resident 2 could have been prevented if the two residents (Resident 1 and Resident 2) were supervised in the smoking patio and were immediately separated by staff once the verbal altercation started between Resident 1 and Resident 2. The Administrator stated there was physical abuse and that Resident 2 willfully acted on injuring Resident 1. During an interview on 3/20/2025 at 2:45 p.m. with the Administrator, the Administrator stated the knife used by Resident 2 to injure Resident 1 was not found. The Administrator also stated body inspection was not done on Resident 2 since Resident 2 refused. The Administrator stated there was a possibility Resident 2 ' s knife is still in the facility. During a review of the current facility-provided policy and procedure titled, Abuse, Neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress), Exploitation (means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion) and Misappropriation (the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident ' s belongings or money without the resident ' s consent) Prevention Program, revised on 4/2021 and reviewed on 4/2024, the policy and procedure indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: . b. other residents 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents During a review of the current facility-provided policy and procedure titled, Smoking Policy-Residents, reviewed on 4/2024, the policy and procedure indicated, This facility has established and maintains safe resident smoking practices Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. During a review of the current facility-provided policy and procedure titled, Abuse Policy, last reviewed on 4/2024, the policy and procedure indicated, Communities does not condone (accept and allow) resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including . other residents Residents have the right to be free from abuse 1. Providing a safe environment for the resident is one of the most basic and essential duties of our facility 4. Identification of abuse shall be the responsibility of every employee Resident abuse is defined as the willful infliction of injury, unreasonable . resulting in physical harm or pain, mental anguish Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking . and willful neglect of the resident ' s basic needs If abuse happens: 1. Separate the assailant from the victim. 2. Isolate the assailant to protect others.

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 resident towards another) for one of 11 sampled residents (Resident 9). On 10/17/2024 at 7:30 p.m., Certified Nursing Assistant 4 (CNA 4) witnessed Resident 10's left arm was around Resident 9's neck from behind, while Resident 10 punched Resident 9 with his (Resident 10) right closed fist multiple times on the face while Resident 9 was sitting on the wheelchair watching television (TV) in their (Resident 9 and Resident 10's) room. This deficient practice resulted in Resident 9 being subjected to physical abuse by Resident 10 while under the care of the facility. Resident 9 sustained swelling on the lips with bleeding and pain. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Residents 9's severely impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to physical abuse may have physical pain, 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: During a review of Resident 9's Admission Record, the Admission Record indicated the facility admitted Resident 9 on 9/16/2024 with diagnoses including aphasia (a disorder that makes it difficult to speak) following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), abnormalities of gait (the manner of walking or moving on foot) and mobility (the ability to move freely and easily), and muscle weakness. During a review of Resident 9's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 9's cognition was severely impaired. The MDS indicated Resident 9 had little interest or pleasure in doing things, feeling down, depressed (in a state of general unhappiness), or hopeless for 12 to 14 days or nearly every day. The MDS indicated Resident 9 felt bad about self, a failure or let self or family down for 12 to 14 days or nearly every day. The MDS indicated Resident 9 sometimes felt lonely or isolated from those around the resident. During a review of Resident 9's Change in Condition (COC - a significant change in resident's health status) Evaluation, dated 10/17/2024, the COC Evaluation indicated that on 10/17/2024 at 7:30 p.m., the resident (Resident 9) received physical abuse from another resident (Resident 10). The COC Evaluation indicated Resident 9 was found sitting in a wheelchair watching TV when Resident 10 hit Resident 9 on the face. Resident 9 sustained swelling on the lips and had a five out of 10 pain level on the pain scale (a common scale that uses numbers from zero to 10, with zero representing no pain and 10 representing the worst possible pain). The COC Evaluation indicated Resident 9 required ice pack to be placed on the swollen lip. The COC Evaluation indicated Resident 9's Attending Physician was notified at 8:41 p.m. on 10/17/2024. During a review of Resident 9's Progress Notes, dated 10/17/2024, the Progress Notes (documented by Licensed Vocational Nurse 2 [LVN 2]) indicated that on 10/17/2024 at 7:30 p.m., he (LVN 2) was called inside Resident 9 and Resident 10's room (Resident 9 and Resident 10 were roommates). Resident 9's Progress Note indicated CNA 4 witnessed Resident 10 held Resident 9's neck from behind. The Progress Notes indicated Resident 10 punched Resident 9 multiple times with a closed fist (the Progress Note did not indicate which fist). The Progress Notes indicated Resident 9 was noted with swollen lips. During a review of Resident 10's Admission Record, the Admission Record indicated the facility admitted Resident 10 on 3/31/2021 with diagnoses including encephalopathy (damage or disease that affects the brain), rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber into the blood), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10's cognition was severely impaired. During a review of Resident 10's Care Plan (untitled), last revised on 1/4/2023, indicated the resident (Resident 10) was noted with aggressive behavior and getting upset for no reason. The interventions included were to re-direct resident behavior and for the resident not to hurt others or damage property. During a review of Resident 10's History and Physical (HP), dated 4/29/2024, the HP indicated the resident had the capacity to understand and make decisions. During a review of Resident 10's Care Plan (untitled), last revised on 9/30/2024, indicated the resident (Resident 10) had mood swings with poor impulse control. The Care Plan interventions included were to monitor, record, and report to the physician risk for harming others, increased anger, labile mood (rapid, often exaggerated changes in mood occur), or agitation (a state of anxiety or nervous excitement), feeling threatened by others or thoughts of harming someone. During a review of Resident 10's Physician Orders, dated 9/28/2024, the Physician Order indicated to monitor behavior episodes of sudden outburst of anger and tally with hashmark for each episode on the Medication Administration Record (MAR - a report detailing the medications administered to a resident) every shift. During a review of Resident 10's MAR, dated 10/1/2024 to 10/31/2024, the MAR indicated that on 10/14/2024 on the 11 p.m. to 7 a.m. shift, Resident 10 had two episodes of anger outburst. During a review of Resident 10's COC Evaluation, dated 10/17/2024, the COC Evaluation indicated on 10/17/2024 at 7:30 p.m., Resident 10 was witnessed behind Resident 9 while hitting the resident (Resident 9) on the face multiple times. During an interview on 10/24/2024 at 9:58 a.m. with Resident 9, Resident 9 stated another resident punched him on the face. Resident 9 was not able to provide other information about the incident. During a telephone interview on 10/24/2024 at 10:12 a.m. with CNA 4, CNA 4 stated she (CNA 4) heard Resident 9 yelling inside the resident's room. CNA 4 stated she (CNA 4) then went inside Resident 9's room and found Resident 9 sitting on a wheelchair. CNA 4 stated Resident 10's left arm was around Resident 9's neck, while Resident 10 punched Resident 9's face with his (Resident 10) right closed fist multiple times. CNA 4 stated that Resident 10's punches were hits and misses on Resident 9's right cheek, right jaw, and right side of the mouth area. CNA 4 stated Resident 9 and Resident 10 were separated. CNA 4 stated Resident 9 had blood (amount not indicated) in the mouth and in the right lower lip that required an ice pack. CNA 4 stated Resident 10 punching Resident 9 is physical abuse. During a telephone interview on 10/24/2024 at 12:26 p.m. with LVN 2, LVN 2 stated he heard someone screaming at Station 1 LVN 2 stated that when he (LVN 2) entered inside Resident 9 and Resident 10's room, both residents were already separated. LVN 2 stated CNA 4 witnessed Resident 10 punching Resident 9 on the face. LVN 2 stated Resident 9's middle part of the lower lip was bleeding requiring an ice pack to be placed on the lips to prevent swelling and to stop the bleeding. LVN 2 stated Resident 10 had a history of aggressive behavior towards another resident. LVN 2 stated that Resident 10 punching Resident 9 is physical abuse. During an interview on 10/24/2024 at 12:38 p.m. with the Director of Nursing (DON), the DON stated residents should be free from abuse. The DON stated the physical act of intentionally punching a person is physical abuse. Resident 10 punching Resident 9 was considered as an abuse. The DON stated the facility failed to prevent the physical act of abuse from happening between Resident 9 and Resident 10. During a review of the facility's policy and procedure (PnP) titled, Abuse, Neglect (fail to care properly), Exploitation (the act of using someone or something unfairly for your own advantage) and Misappropriation (to steal something that you have been trusted to take care of and using it for yourself) Prevention Program, last reviewed on 4/2024, the PnP indicated the resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The PnP indicated that it included freedom from . verbal, mental, sexual, or physical abuse The PnP indicated the facility objective to protect residents from abuse by anyone including .b. other residents.

Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 135) was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when on 10/8/2024, Resident 135, who was allergic to onions, was served baked beans containing onions for lunch. This deficient practice resulted in Resident 135 being served baked beans containing onions which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]) and/or death for Resident 135. On 10/8/2024 at 4:03 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation in the presence of the Administrator (ADM) and the Director of Nursing (DON) for the facility's failure to ensure that facility staff did not provide food containing a known allergen to Resident 135. On 10/11/2024 at 8:35 a.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 10/8/2024, Resident 135 was assessed by a licensed nurse (Licensed Vocational Nurse 7 [LVN 7]) for signs and symptoms (s/s) of food allergies. No allergic reaction was observed. 2. On 10/8/2024, the DON notified Resident 135's primary physician indicating the resident was mistakenly served food (baked beans) containing onions during lunch on 10/8/2024. 3. On 10/8/2024, the Dietary Supervisor (DS) visited Resident 135 to discuss the resident's food allergies and food preferences. 4. On 10/8/2024, the DS conducted a review of all current resident's medical records residing in the facility with noted food allergies and there were no issues found. 5. On 10/8/2024, the DS conducted an in-service (staff training) with all dietary staff on the facility's Food Allergy Policy which included implementing colored meal tray card [a card that lists a resident's dietary needs, preferences, and restrictions] and reviewing menu or recipe to offer substitutes addressing food allergies. 6. On 10/8/2024, for higher visibility (how clear the food allergies can be noticed), green meal tray cards indicating food allergies were created for residents with food allergies. 7. On 10/8/2024, residents with food allergies were provided a green non-removable arm band with their names and food allergies. 8. On 10/8/2024, the Director of Staff Development (DSD) provided an in-service to the licensed nurses and Certified Nursing Assistants (CNAs) which included the green non-removable arm bands as visual identifier for residents who have food allergies. 9. On 10/9/2024, the Registered Dietitian (RD) reviewed current residents' medical records to ensure food allergies are up to date. 10. On 10/9/2024, the RD conducted a one to one (1:1- when one trainer works with one learner) in-service with the Cooks (Cooks 1 and [NAME] 2) and the DS regarding the facility policy on food allergies, food likes or dislikes, menu, recipes, and to accommodate food item substitution to address food allergies. 11. On 10/9/2024, before the breakfast service, the RD, the Cooks (Cooks 1 and [NAME] 2), and the DS conducted kitchen huddles (short, regular meeting where the staff discusses resident safety and plans for the day ahead) on menu, recipes, and meal substitution (if applicable) for residents with food allergies. 12. A list of residents and their food allergies will be posted in the kitchen meal preparation area to allow dietary staff to easily identify all residents' food allergies. The list of residents and their food allergies will be written in English and Spanish. Identified residents with food allergies will be served alternate meals. 13. The facility will implement a new menu system called Menus 2U which integrates Electronic Health Records (EHR - digital version of a resident's medical records stored in a computer) and ensures that all new dietary orders and food allergies are automatically entered into the facility's EHR. The software will include printing of the updated diet slip (includes diet orders, food/drink preferences, food allergies, special utensils, and meal instructions) for each meal by the DS or designee and the dietary staff will reference the meal preparation during meal tray line (an area where resident's food is assembled), avoiding inaccuracies, and identifying allergies. Included in the diet slip are the following: a. Diet order b. Diet consistency c. Diet texture d. Likes and dislikes e. Food allergy f. Beverage preferences g. Tray instruction h. Feed instructions i. Special utensils. 14. Starting on 10/9/2024, the DS or designee will conduct a daily review of all current residents' medical records to ensure that residents with food allergies are included on the allergy list visibly posted during the meal tray line process. 15. Starting on 10/9/2024, the DS or designee will conduct daily huddles with all dietary staff in English and Spanish to discuss current residents with food allergy to ensure meals that will be served will not contain food allergies. 16. Starting on 10/9/2024, the DS or designee will conduct daily meal tray audit for allergies using the Tray line Supervisory Inspection Log every breakfast, lunch, and dinner meals and every 10 a.m., 2 p.m., and 8 p.m. snacks. 17. Licensed Nurses shall check meal trays for any food allergies, food dislikes, and preferences before serving the residents. Any discrepancy in accuracy on the meal prepared in comparison with the diet slip will be returned to the kitchen by the licensed nurse for correction and replacement. 18. The DS will conduct a review of food preferences and allergies upon admission, readmission, quarterly, and as needed. The Health Information Department will conduct an audit monthly to validate this process. Audit findings will be forwarded to the DON and to the ADM for further follow through. 19. The RD will conduct monthly review of residents with food allergies and update the list of residents and their food allergies as needed. On 10/11/2024 at 3:21 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the DON. Findings: During a review of Resident 135's Admission Record, the Admission Record indicated the facility initially admitted Resident 135 on 10/1/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems), chronic viral hepatitis C (long term liver inflammation and infection), and essential hypertension (chronic elevation of blood pressure from an unknown cause). During a review of Resident 135's Minimum Data Sheet (MDS - a federally mandated resident assessment tool) dated 10/5/2024, the MDS indicated Resident 135's cognition (ability to think and make decisions) was severely impaired. The MDS indicated Resident 135 needed set-up and clean-up assistance (helper sets up and cleans up, resident completes the activity) when eating. During a review of Resident 135's Physician Orders dated 10/1/2024, the Physician Orders indicated to provide mechanical soft (a texture-modified diet that consists of foods that are soft and easy to chew and swallow) chopped texture (a food texture that is intended to be safe and easy to swallow) diet. During a review of Resident 135's Allergy List dated 10/1/2024, the Allergy List indicated Resident 135 was allergic to onions. During a review of Resident 135's Care Plan (undated), the Care Plan indicated Resident 135 has an allergy to onions. The Care Plan goal was for Resident 135 not to be served with food containing onions at any time. Resident 135's Care Plan included the following interventions: o Inform staff or caregivers of resident's allergy. o Label the Physician's Order Sheet, Medication Administration Record (MAR - a document of the medications administered to a resident), treatment sheet, and face sheet of Resident 135's allergy. During a review of Resident 135's MAR dated 10/8/2024, the MAR indicated Resident 135 was allergic to onions. During a review of the facility's daily spreadsheet titled Therapeutic Spreadsheet Cycle 4, dated 10/8/2024, the daily spreadsheet indicated residents on mechanical soft diet would include the following foods in the tray: o Ground barbecue pork (BBQ) three (3) ounces (oz, a unit of measurement) o Baked beans half (1/2) cup (c, a household measurement) o Finely chopped creamy coleslaw 1/2 c o Biscuit o Peach cobbler o Beverage eight (8) oz During an observation of the meal tray line process on 10/8/2024 at 11:53 a.m., the trays with utensils, condiments, and meal tray tickets (includes resident's diet, allergy, likes/dislikes, food preferences) were set in the meal carts (used to transport or deliver the meal trays). Dietary Aide 1 (DA 1) announced the resident's diet textures, likes, and dislikes then the allergies. [NAME] 1 and [NAME] 2 dished out (distributed) the foods from the steamtable (food-holding equipment designed to keep hot foods at a safe holding temperature) to the plates. DA 1 checked the accuracy and completeness of each tray. The DS checked the accuracy of the trays before the meal carts came out of the kitchen. During a review of Resident 135's meal tray ticket on 10/8/2024 at 12:25 p.m., Resident 135's meal tray ticket indicated Resident 135 was on mechanical soft diet, was allergic to onions, disliked salad and coleslaw, and preferred soup and juice. During a concurrent observation and interview on 10/8/2024 at 12:25 p.m. at the kitchen with the DS, observed Resident 135's meal tray contained chopped pork with BBQ sauce, a bowl of beans with chopped onions, biscuit, cake, and juice. The DS stated Resident 135 did not get the soup as the dietary staff forgot to put the soup on the tray. The DS requested a vegetable soup from the dietary staff and placed the vegetable soup on Resident 135's tray. The DS stated Resident 135 was okay with cooked onions that was included in the vegetable soup. The SSA informed the DS that onions were listed as an allergy of Resident 135. The DS replaced the vegetable soup with clear broth for Resident 135. During an observation on 10/8/2024 at 12:29 p.m. in the kitchen hallway, LVN 2 and LVN 3 checked the meal trays for Station 2's meal cart where Resident's 135 lunch tray was placed. LVN 3 read the diet list (a list of residents with diet, allergies, likes, and dislikes) and LVN 2 checked the meal tray and meal tray ticket for Resident 135's tray accuracy. LVN 2 and LVN 3 stated the meal trays for Station 2 residents were okay to distribute to Station 2. Resident 135's meal tray was served and was set on Resident 135's bedside table. During an observation on 10/8/2024 at 12:39 p.m., in Resident 135's room, observed Resident 135's meal tray at bedside. Resident 135's meal tray had chopped pork with BBQ sauce, beans in a bowl with pieces of chopped onions, biscuit, clear broth, cake, and juice. During an interview and a record review of the facility's recipe titled Baked Beans #2 on 10/8/2024 at 12:56 p.m. with [NAME] 1 and the Assistant Dietary Supervisor (ADS), [NAME] 1 stated with ADS interpreting in [NAME] 1's language that she (Cook 1) used only the recipe titled Baked Beans #2 for the baked beans. The Baked Beans #2 recipe indicated the following ingredients: pork and beans, light brown sugar, chopped onions, ketchup, and yellow mustard. [NAME] 1 stated she did not use the pork and beans and used the pinto beans from scratch instead. [NAME] 1 stated she then added ketchup, onions, brown sugar, and mustard. [NAME] 1 stated she did not prepare a separate recipe for any resident. During an interview on 10/8/2024 at 12:59 p.m. with the DS, the DS stated that if Resident 135 consumed the food item with onions, he (Resident 135) would have food reactions such as rash (an area of the skin that has changes in texture or color and may look inflamed or irritated) and other allergic reactions. During an interview on 10/8/2024 at 1:08 p.m. with Resident 135, Resident 135 stated he did not eat the beans on his meal tray because he was afraid that the beans had onions. Resident 135 stated the staff (unable to recall who) told him that the baked beans may have contained onions, and the meal tray was taken away from him by the staff (unable to recall who). Resident 135 stated his throat will swell up and close if he consumes onions. During an interview on 10/9/2024 at 9:52 a.m. with DA 1, DA 1 stated his role in meal tray line was to announce the allergy and check the meal trays for accuracy with what the meal tray ticket indicated. DA 1 stated he did not know that the baked beans had onions as it was not specified on the spreadsheet or the menu. DA 1 stated it was important for the meal tray to be allergen-free for residents with food allergies because they (residents) could be in danger and could potentially cause death. During an interview on 10/9/2024 at 11 a.m. with LVN 2 and LVN 3, LVN 2 stated they (LVN 2 and LVN 3) checked all the trays for accuracy, food dislikes, allergies, and diet types on 10/8/2024 for lunch meal. LVN 2 stated she checked the tray, meal tray tickets, and food on the meal tray and LVN 3 read and checked the diet list. LVN 2 stated they checked all the trays from Station 1 to Station 4. LVN 3 stated she (LVN 3) did not see any onions in any of the food served for Resident 135 and there was no way that they could know if onion was an ingredient in the baked beans. During an interview on 10/10/2024 at 10:56 a.m. with the ADM, the ADM stated that he (ADM) needed to verify with [NAME] 1's interpreter (ADS) about the ingredient that she (Cook 1) used in cooking the baked beans as he (ADM) was told that [NAME] 1 stated she used onion powder. During a review of the ADM's email on 10/10/2024 at 1:48 p.m., the ADM email indicated that he confirmed with the ADS who interpreted during [NAME] 1's interview on 10/8/2024, that [NAME] 1 stated she (Cook 1) used onion powder in the baked bean dish. During an interview on 10/10/2024 at 2:09 a.m. with the RD, the RD stated the dietary staff should not serve any food items, derivatives, flavoring, powder, and all products containing a particular allergen. The RD stated residents with onion allergies should not get onions, onion derivatives, onion powder, onion flavor, and all onion products on their meal trays. The RD stated residents could have the same anaphylactic reactions (anaphylactic shock) if they (residents) consumed food and food products containing the food allergen. During a concurrent interview and record review on 10/10/2024 at 2:34 p.m. with [NAME] 1 and the RD with the Interpreter's (translating [NAME] 1's language via phone) assistance, the facility's undated recipe titled Baked Beans #2 was reviewed. Baked Beans #2 had an ingredient of pork and beans, light brown sugar, chopped onions, and mustard. [NAME] 1 stated she did not use the pork and beans and used pinto beans for the baked bean dish. [NAME] 1 stated she used the ketchup, light brown sugar, and yellow mustard but did not use chopped onions. [NAME] 1 stated she used onion powder instead of chopped onions because she did not like the flavor of the onion but likes the onion powder when making the baked beans. [NAME] 1 stated she used onion powder and added one spoon to the baked beans using estimation on how the food would taste as it (recipe) did not indicate the amounts. [NAME] 1 stated she said onion to ADS who was interpreting in [NAME] 1's language during the interview on 10/8/2024 and never mentioned onion powder because she (Cook 1) forgot to say powder. [NAME] 1 stated raw onions were available in the kitchen on 10/8/2024. The RD stated the staff (unable to recall who) notified her of the substitution of onions to onion powder after the IJ was called. The RD stated she did not agree with the substitution of using onion powder for onions based on how [NAME] 1 felt about the flavor as it was not a standard of practice. The RD stated the onion powder could have more ingredients that would contain more food allergens. The RD stated the recipe must be followed to ensure residents got the nutrients that they needed and so they could be aware of the ingredients for food allergies. During an interview on 10/11/2024 at 2:45 p.m. with the DS, the DS stated onion powder was a derivative of onion and residents could have same reaction if they were allergic to onions; hence, it (onion powder) should not be given on the meal tray. During a review of the facility's product ingredient titled Ingredient Specification Onion dated 9/15/2024, the facility's product specification indicated, Description: Dehydrated onion (Allium cepa [common onion/bulb onion]) product prepared from fresh, sound, wholesome, first quality white onion. During a review of the facility's policies and procedures (P&P) titled Food Allergies and Intolerances dated 4/2024, the P&P indicated, Residents with food allergies and/or intolerances are identified upon admission and offered food substitution of similar appeal and nutritional value. Steps are taken to prevent residents' exposure to the allergen. General Guidelines: 1. Food Allergies are immune system responses to allergens (food). Immunoglobulin E ([NAME]) antibodies (type of protein in the body that are part of the immune system and play a role in allergic reactions) to foods attach to mast (white blood cells that are part of the body's immune system and act as the body's alarm system) cells in body tissue (e.g., skin, nose, throat, lungs, and gastrointestinal tract) and basophils (a type of white blood cell that help the body's immune system fight allergens) in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine (chemical released by the body's immune system that causes many effects, including allergy symptoms), an inflammatory compound. Assessment and Interventions: o Residents are assessed for history of food allergies and intolerances upon admission and as part of the comprehensive assessment. o All residents reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan. o Meals for residents with severe food allergies are specifically prepared so that cross-contamination (the unintentional transfer of harmful bacteria or other microorganisms from one food, utensil, or surface to another) with allergens does not occur. o Residents with food intolerances and allergies are offered appropriate substitutions for food that they cannot eat. During a review of the facility's P&P titled Allergies dated 4/2024, the P&P indicated, Procedure: (1) Upon admission to the community resident allergies will be identified. These will be noted on the nutritional assessment that is completed on admission. (4) The resident's menu will be modified to eliminate foods to which the resident is allergic. During a review of the facility's P&P titled Accurate Diet Service dated 4/2024, the P&P indicated Policy: Each resident will receive the proper diet as prescribed by their physician or qualified designee. Procedure: (1) Before each meal service, a Food and Nutrition Services Department employee will check the meal tray cards with master list to assure the correct diet order, consistency order, and liquid consistency order on the card. (2) Prior to serving the tray, the nurse aide must check the diet cart to assure that the correct meal tray is being served to the resident. If there is doubt, the charge nurse should be notified, and the chart checked for the current physician's order.

Based on interview and record review, the facility failed to ensure the resident was not subjected to a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for a second time by a resident who was physically abusive for one of three sampled residents (Resident 3). The facility failed to: 1. Ensure Resident 4 did not hit Resident 3 ' s left leg with his (Resident 4) wheelchair on 7/19/2023. 2. Ensure the facility ' s policy and procedures (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, was followed to ensure Resident 3 was free form physical abuse. This deficient practice resulted in Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility resulting in Resident 3 ' s left leg pain requiring pain medication. Findings: 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 depression (is a common and serious medical illness that negatively affects how you feel, the way you think, and how you act), hypertension ([HTN] high blood pressure), and other abnormalities of gait (manner of walking or moving on foot) and mobility (the ability to move or be moved freely and easily). During a review of Resident 3's History and Physical, dated 1/06/2024, the History and Physical indicated the resident had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set ([MDS] - a standardized assessment and care-screening tool), dated 7/3/2024, the MDS indicated the resident ' s cognitive skills (ability to understand and make decisions) for daily decision making were intact (not affected). The MDS indicated Resident 3 required supervision or touching assistance for oral hygiene and rolling left and right. The MDS indicated Resident 3 required moderate assistance with upper body dressing, personal hygiene, and substantial/maximal assistance with toileting, shower/bathe, lower body dressing, putting on/taking off footwear, sit lying, lying to sitting on the side of bed, and sit to stand. During a review of Resident 4 ' s COC, dated 7/4/2024, the COC indicated the Licensed Vocational Nurse (LVN 5) reported that Resident 4 had a physical aggression towards Resident 3. During a review of Resident 3 ' s COC, dated 7/4/2024, the COC indicated the resident was heard at the Station 2 hallway reporting that he was hit by Resident 4 on the right forehead resulting in two to three pain level on a pain scale from zero to 10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain possible). During a review of Resident 3 ' s Progress Notes, dated 7/4/2024 timed at 6:04 p.m., the Progress Notes indicated at 3:30 p.m., Resident 3 while seated in a wheelchair, wheeled himself outside Resident 4 ' s room where LVN 5 was with Resident 4. LVN 5 witnessed Resident 3 and Resident 4 talking to each other when Resident 3 tapped Resident 4 ' s right knee and Resident 4 complained of pain and punched Resident 3 ' s right side of the head. During a review of Resident 3's Change in Condition Evaluation (COC), dated 7/19/2024, the COC indicated Resident 3 reported that Resident 4 kicked Resident 3 ' s left leg and left side of his abdomen on 7/19/2024 in the afternoon (time not indicated). The COC indicated Resident 3 had no signs of injury but complained of moderate pain rated 5 out of 10 in his left leg and asked for pain medication. During a review of Resident 3 ' s Physician ' s Order Summary Report, dated 12/28/2023, the Physician ' s Order Summary Report indicated an order dated 12/28/2023, for Tylenol tablet 500 milligrams ([mg]- a unit of measure) two tablets for moderate to severe pain rated 5 out of 10 on a pain rating scale. During a review of Resident 3's Medication Administration Record (MAR), dated 7/19/2024, and timed 5:45 p.m., the MAR indicated the resident received Tylenol 500 mg two tablets for moderate to severe pain rated 5 out of 10 on a pain rating scale. During a review of Resident 4 ' s Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including depression, hypertension, and personal history of other mental and behavior disorders. During a review of Resident 4's History and Physical, dated 1/06/2024, the History and Physical 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 ' s cognitive skills for daily decision making were intact. The MDS indicated Resident 4 required supervision or touching assistance for oral hygiene. The MDS indicated Resident 4 required moderate assistance with upper body dressing, personal hygiene and substantial/maximal assistance with transferring, showering, toileting, and lower body dressing. During an interview on 8/1/2024 at 11:37 a.m., the Social Services Director (SSD) stated that she talked to Resident 3 on 7/22/2024. The SSD stated Resident 4 was transferred to general acute care hospital 1 (GACH 1) on 7/20/2024 due to aggressive behavior and returned to the facility same day. The SSD also stated that on 7/22/2024, Resident 3 reported to her (SSD) that he (Resident 3) observed Resident 4 going up and down the nurses ' station using his (Resident 4) wheelchair when he (Resident 3) was sitting in front of his (Resident 3) room. Resident 3 stated Resident 4 headed back towards Resident 3 and tried to kick him (Resident 3) with his (Resident 4) raised left leg. Resident 4 ' s wheelchair ended up hitting Resident 3 ' s left leg. The SSD stated staff saw what happened and immediately separated the residents from each other. The SSD also stated Resident 4 was transferred out to GACH 2 on 7/23/2024 due to concerns about Resident 4 ' s cognition and physical aggression. During an interview on 8/1/2024 at 1:13 p.m., Resident 3 recalled the altercation between him and Resident 4 on 7/19/2024. Resident 3 stated while he was sitting in his wheelchair in the hallway in front of his room, Resident 4 went past him (Resident 3) five times in his (Resident 4) wheelchair and then he (Resident 4) tried to kick him (Resident 3) with his (Resident 4) raised left leg and missed; however, Resident 4 ' s wheelchair hit his (Resident 3) left leg. Resident 3 stated that Resident 4 tried to push his (Resident 3) face, but Licensed Vocational Nurse 1 (LVN 1) immediately came and took Resident 4 to his (Resident 4) room. Resident 3 stated that his left leg hurt after the incident and LVN 1 gave him (Resident 3) Tylenol for the pain and offered him (Resident 3) an ice pack. Resident 3 stated the incident was the second time that Resident 4 had hurt him (Resident 3). Resident 3 stated that he had no injuries to his left leg. Resident 3 stated that he had no interaction with Resident 4 after the incident, and Resident 4 was being monitored by staff continuously. Resident 3 stated that he feels safe in the facility but not when Resident 4 attacked him. During an interview on 8/1/2024 at 3:23 p.m., LVN 1 stated that on 7/19/2024 at around 5 p.m., Resident 4 was trying to strike out at Resident 3 and she separated the residents. LVN 1 stated she saw Resident 3 was hit in the left leg with Resident 4 ' s wheelchair. LVN 1 stated she gave Resident 3 Tylenol for his left leg pain. LVN 1 stated Resident 3 had no injuries, redness, or skin breakdown. LVN 1 stated that Resident 4 was never hit or kicked by Resident 3 or by anyone. LVN 1 stated that Resident 4 was placed on one-to-one supervision and taken to his room. LVN 1 stated that abuse should never happen in the facility; sometimes it can be hard to prevent, but no resident should be abused in the facility. During an interview on 8/5/2024 at 12:01 p.m., Resident 3 stated that he needed pain medication for the first three days for his left leg after the incident with Resident 4. During an interview on 8/5/2024 at 1:19 p.m., the Administrator (ADM) stated the facility ' s job is to protect and prevent abuse from happening to residents and the abuse should not have happened between Resident 3 and Resident 4. The ADM stated that no one should be abused in the facility. During a review of undated facility ' s P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), who was cognitively (mental action or process of acquiring knowledge and understanding) intact and had a history of right-sided weakness following a cerebral infarction (stroke-a loss of blood flow to part of the brain, which damages brain tissue), was free from sexual abuse (sexual behavior or a sexual act forced upon a woman, man, or child without their consent). On 5/26/2024 at 8:45 p.m., Certified Nursing Assistant 2 (CNA 2) and CNA 3, after hearing Resident 1 yelling for help, went to Resident 1 ' s room. CNA 2 and CNA 3 witnessed Resident 2, Resident 1 ' s roommate, on top of Resident 1 and was kissing Resident 1 ' s neck area. Resident 1 was lying in his bed with both feet on the floor and Resident 2 was pulling Resident 1 ' s jeans down to his knees. Resident 1 told CNA 2 and CNA 3 to separate Resident 2 off him because Resident 2 was kissing and touching him (Resident 1). When CNA 2 and CNA 3 separated Resident 2 from Resident 1, Resident 2 ' s hands were still holding Resident 1 ' s jeans. As a result, Resident 1 was subjected to a nonconsensual (without permission) sexual abuse by Resident 2 while under the care of the facility. CNA 2 stated Resident 1 was yelling, his face and body were shaking, trying not to cry, and looked nervous (having or showing feelings of being worried and afraid about what might happen). CNA 3 stated Resident 1 was found trying to get up and fight Resident 2, but Resident 1 cannot move his right arm. Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 appeared in shock (person's emotional and physical condition when something very frightening or upsetting has happened to them), shaking, hyperventilating (rapid or deep breathing, usually caused by anxiety [a feeling of fear, dread, and uneasiness] or panic [painful agitation in the presence or anticipation of danger] and was at a loss for words when she went to Resident 1 ' s room following CNAs 2 and 3. On 6/4/2024 at 11:22 a.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of Director of Nursing (DON) and Payroll Staff 1 (PS 1) due to the facility ' s failure to prevent the sexual abuse to Resident 1. On 6/7/2024 at 12:34 p.m., the Administrator (ADM), provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 6/7/2024 at 2:24 p.m., while onsite and after verifying the facility ' s full implementation of IJ Removal Plan through observation, interview, and record review, the SSA removed the IJ situation in the presence of the DON, Assistant Director of Nursing (ADON), Director of Staff Development (DSD) and PS 1. The acceptable IJ Removal Plan included the following summarized actions: 1. On 5/26/24 at around 9 pm, LVN 1 responded and helped CNA 2 and CNA 3 separate Resident 2 from Resident 1. LVN 1 stayed with Resident 1 inside the room to provide emotional support to ensure safety. Resident 2 was removed from the room and placed in the hallway near the nurse's station away from other residents and was provided with one CNA assigned to Resident 2 and three other residents. 2. On 5/26/2024, Registered Nurse 1 (RN 1) assessed Resident 1 with no physical injury, denied any pain and no skin discoloration. 3. On 5/26/2024 at around 9 p.m., RN 1 notified the Medical Doctor (MD). LVN 1 called 911 (an emergency number if in need of any police, fire, or medical response) at around 9:43 p.m. The paramedics (health professionals certified to perform advanced life support procedures) and police officers arrived at the facility at 9:58 p.m. and spoke to Resident 1 and offered to go to the hospital for further support and evaluation, however, Resident 1 refused three times. 4. On 5/26/24 at around 10 pm, two police officers came to the facility to investigate the situation. The police officers suggested calling county Psychiatric (branch of medicine that deals with mental, emotional or behavior disorder) Emergency Team (PET- are mobile teams operated by psychiatric hospitals approved by the Department of Mental Health (DMH) to provide 5150 [ law code that lets adults be involuntary held in a mental hospital for 72 hours] and 5585 [allows involuntary detainment of a minor experiencing a mental health crisis for a 72-hour]. Team members are licensed mental health clinicians to evaluate the resident). 5. On 5/27/2024 at 12:02 a.m., RN 1 called PET team and spoke to the DMH operator who stated they will discuss and will call the facility back. At around 7:30 a.m., the DMH called and informed RN 2 that they will evaluate Resident 2 at the facility. 6. On 5/26/2024 at 11:56 p.m., RN 1 initiated an order to monitor Resident 1 every shift for psychological (concerned with a person's mind and thoughts) and emotional status. On 6/7/2024, Quality Assurance Nurse (QAN) clarified monitoring order that Resident 1 will be monitored for emotional and psychosocial indicators such as sudden or unexplained changes in behavior and or activities example fear or avoidance of a person or place, fear of being alone, fear of the dark, nightmares, disturbed sleep, verbalization of sadness, decrease appetite, restlessness, episodes of crying, change in daily routine. The care plan about monitoring for psychological and emotional behavior was initiated for Resident 1 on 5/27/24 by the RN 1 and updated by QAN on 6/7/24. 7. On 5/26/2024, RN 1 initiated the investigation and interviewed the two CNA witnesses and LVN 1. 8. On 5/26/2024 at 10 p.m., Resident 2 was closely monitored by nursing staff until he was transferred to the General Acute Care Hospital 1 (GACH 1) psychiatric unit on 5/27/24 at 11 am. Resident 2 stayed in his wheelchair, mostly in the hallway near the nurse's station the entire night shift and in the morning shift, RN 2 watched him in front of the nurse ' s station at the start of the shift. Patio Staff Attendant 1 (PSA 1) supervised Resident 2 at the smoking patio from 8:30 a.m. until he was brought to the family room to be evaluated by the DMH staff. Resident 2 was attended to by the activity staff in the activity room awaiting pick-up by paramedics for GACH 1 transfer. 9. On 5/27/2024 at 8:30 a.m., the DMH evaluated and found Resident 2 qualified for a psychiatric hold (a legally mandated stay at a psychiatric facility aimed at providing a safe space and professional care to those going through a mental health crisis). The DMH set up transportation and Resident 2 was picked up by paramedics and taken to GACH 1 Psychiatric Unit emergency room at 11 a.m. Resident 2 was seen by the Psychiatrist Doctor (medical practitioner specializing in the diagnosis and treatment of mental illness) with modification of medications and was deemed stable to return to facility on 5/28/24. 10. On 5/28/2024, Resident 2 returned to the facility and his psychoactive medications (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) were modified to the following: a. Haloperidol (used to treat certain mental or mood disorders) tablet five milligrams (mg - unit of measurement), give one tablet by mouth two times a day for schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) manifested by outburst (sudden release of strong emotion) of anger. b. Trazodone hydrochloride (used to improve your mood, appetite, and energy level) tablet 50 mg, give half tablet by mouth at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) manifested by inability to sleep. 11. On 5/28/2024 at 3:25 p.m., upon return from GACH 1, Resident 2 was monitored by licensed nursing staff of his behavioral status and whereabouts of every shift. On 6/4/2024 from 3 p.m., Resident 2 was placed on closer visual checks and monitoring of whereabouts every two hours by both LVN and CNA assigned. 12. On 6/6/2024, Resident 2 had an order for behavioral monitoring to include monitoring for any signs and changes in behavior, mood, cognition, hallucinations (to seem to see, hear, feel, or smell something that does not exist, usually because of a health condition or because you have taken a medication), delusions (a person with a delusion believes something that is not true no matter how much evidence you give to the contrary), social isolation (lack of social contacts and having few people to interact with regularly), suicidal thoughts (involve a person thinking about ending their own life), withdrawal (not finishing an activity), and decline in activities of daily living. The ADON updated Resident 2 ' s care plan on 6/6/24. 13. The Social Service Director (SSD) conducted psychosocial (relating to the mutual relationship of social factors and individual thought and behavior) visits to Resident 1 on 5/28/24, 5/29/24, 5/30/24, and as needed. 14. On 5/30/2024, the Psychologist Doctor (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) saw Resident 1 who denied any issues with any other residents and appeared to not be aware of what the Psychologist was referring to as the subject of unwanted contact by another resident. Resident 1 stated that he had no issues or concerns related to other residents. 15. On 6/3/2024, the Psychiatrist Doctor (a medical doctor who specializes in psychiatry. They treat people with mental illness) saw Resident 1 who stated he had persistent losses that contributed to his feelings of sadness and denied any recent physical or sexual abuse by another resident. Resident 1 was started on Lexapro (used to treat certain mental or mood disorders) five mg by mouth every morning. 16. On 5/28/2024, the DON and Director of Staff Development (DSD) provided an in-service about sexual abuse to staff; CNA ' s, LVN ' s, RN ' s, Rehabilitation Department, housekeeping staff, activity staff, maintenance staff, kitchen staff, and laundry staff. 17. The Department Managers, as part of their daily quality initiative rounds, conducted rounds for safety and observations of any reports of sexual abuse with interviews to identify and address any concerns on 5/28/24, 5/29/24, 5/30/24, 5/31/24, 6/3/24, and 6/4/24. No safety issues were identified, and residents did not mention anything related to abuse or sexual allegations. 18. On 6/4/2024, the Department Managers conducted interviews to alert residents in their assigned resident rounds to identify any abuse or sexual allegations. The SSD conducted full facility rounds to screen all residents in-housed on 6/04/2024 and no concerns of any forms of abuse were identified. 19. On 5/28/2024, the DON and DSD provided in-services and interaction with staff on Abuse Prevention Program specific to sexual abuse to facility staff and identified no other resident involved during in-service discussion. 20. The DSD continued providing in-services to all staff: CNAs, LVNs, RNs rehabilitation department, housekeeping staff, activity staff, maintenance staff, kitchen staff and laundry staff that was started on 5/28/2024 and had 65 percent (% - the symbol used to indicate a percentage, a number or ratio as a fraction of 100) of active staff attendees and will continue to educate active staff members to achieve a minimum of 80% of active employees by 6/6/2024 and 100% by 6/7/2024. Any employee that was on per diem (a flexible work arrangement where employers employ individuals on an as-needed basis, often in temporary or part-time roles), part time or had missed the in-services will be trained in advance of their scheduled date or upon arrival prior to working on the floor. 21. On 6/4/2024, the Department Managers conducted daily quality initiative rounds for safety and observation of any report of sexual abuse and as a part of the rounds will interview current residents with capacity to be interviewed daily. 22. LVNs and RNs will prompt staff at shift huddles with CNAs to identify any reported allegation of abuse every shift. 23. During weekends, the Manager of the Day (MOD) will ensure that nursing staff will continue to monitor the whereabouts of any resident placed on behavior monitoring. The MOD will do frequent rounds to check if there are any residents with concerns of unwanted contact by other residents. The MOD will ensure completion of the MOD tool and report any negative findings to the ADM or DON timely. 24. Any negative findings during room round monitoring and shift huddles will be reported immediately to the ADM or DON and will conduct investigation appropriately and report the matter to appropriate agencies (local police, long term care Ombudsman [assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences], and SSA) in conjunction with the abuse reporting policies and procedures. 25. The ADM will report any negative findings and/or concerns related to any allegation of abuse involving residents. Any follow-up needed will be reported to the monthly Quality Assurance and Performance Improvement (QAPI - a process used to ensure services are meeting quality standards and assuring care reaches a certain level) Committee for additional recommendations. 26. The QAPI Committee will evaluate weekly the implementation of the plan of correction including room rounds, daily observation of the residents, monitor for effectiveness and revise care plan as necessary for continuous improvement until the resolution is achieved. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 1/12/2018 with diagnoses that included end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest with symptoms including shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]), hemiplegia (the loss of the ability to move on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant (preference to use one side of the body over the other) side, and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1 ' s Preadmission Screening and Resident Review (PASRR - screening to identify if resident had mental illness or an intellectual or developmental disability), dated 2/8/2023, indicated Resident 1 had no mental illness. A review of Resident 1 ' s History and Physical (H&P), dated 1/2/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Trauma Informed Care form, dated 4/16/2024, indicated sexual assault and other unwanted or uncomfortable sexual experience did not apply to Resident 1. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/18/2024, indicated Resident 1 needed maximum assistance from staff for lower body dressing (ability to dress and undress below the waist), bed mobility from sitting to standing, and walking. The MDS indicated Resident 1 was occasionally incontinent (unable to control) of bowel and bladder functions. A review of Resident 1 ' s Psychologist Note, dated 5/13/2024, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). A review of the Physician ' s Order of Resident 1, dated 5/26/2024 timed at 9 p.m., indicated an order to monitor Resident 1 for signs and symptoms of emotional and psychological distress after incident with Resident 2. A review of Resident 1 ' s Change in Condition Evaluation (COC), dated 5/27/2024, indicated that on 5/26/2024, Resident 2 was found on top of Resident 1. The COC indicated Resident 1 denied pain and had no bruising. The COC indicated the Attending Physician (AP) was notified on 5/26/2024 at 9 p.m. and ordered to assess Resident 1 emotionally and psychologically. The COC indicated the paramedics arrived at 9:45 p.m., but Resident 1 refused to be transferred to the emergency room . A review of Resident 1 ' s Progress Note dated 5/26/2024 timed at 10:47 p.m., indicated RN 1 was notified about the alleged sexual aggression between Resident 1 and Resident 2. The Progress Note indicated Director of Nursing (DON), Administrator (ADM), and local law enforcement (Police officers) were notified. The COC indicated Resident 2 was placed on one-to-one staff monitoring. A review of Resident 1 ' s Progress Note, dated 5/27/2024 timed at 00:14 a.m., indicated LVN 1 responded to a sound of verbal altercation (loud argument) on 5/26/2024 at 9 p.m., from Resident 1 and Resident 2 ' s room. The Progress Note indicated LVN 1 saw CNA 2 removing Resident 2 on top of Resident 1 while Resident 1 was in his bed. The Progress Note indicated CNA 2 and CNA 3 reported that Resident 2 was groping and kissing Resident 1. The Progress Note also indicated that Resident 1 reported that Resident 2 was on top of Resident 1 touching him and kissing him non-consensually. The Progress notes indicated LVN 1 had Resident 2 removed from the room and placed on one-to-one staff monitoring. The Progress Note indicated LVN 1 observed Resident 1 shaking. The Progress Note indicated MD, ADM, DON, and ADON was notified. The Progress Note indicated 911 was called, police officers and paramedics arrived but Resident 1 refused to be transferred out and refused to report anything to the police officers. A review of Resident 1 ' s Physicians Order, dated 5/27/2024 timed at 7:30 a.m., indicated an order for Psychology (the scientific study of the mind and behavior) consult. A review of Resident 1 ' s Progress Note, dated 5/27/2024 timed at 2:04 p.m., indicated LVN 4 documented that Resident 1 had been in bed sleeping all morning from having no sleep from the night before. A review of Resident 1 ' s Physician ' s Order, dated 5/27/2024 timed at 5:04 p.m., indicated an order for Psychiatry (branch of medicine concerned with the study, diagnosis, and treatment of mental illness) evaluation and treatment as needed related to Resident 2 kissing and found on top of Resident 1. A review of Resident 1 ' s Care Plan on at risk for emotional and psychological distress related to Resident 2 kissing and found on top of Resident 1, dated 5/27/2024, indicated an intervention to recognized nonverbal cues (the process of sending information through ways that do not require the use of language) for behavioral and or psychological change. A review of Resident 1 ' s Restorative Nursing Assistant (RNA) Program indicated, on 5/27/2024, Resident 1 refused passive range of motion (someone physically moves or stretches a part of your body) to right lower extremity (the part of the body that includes the hip, thigh, knee, leg, ankle, and foot). A review of Resident 2 ' s H&P, dated 1/2/2024, indicated Resident 2 can make needs known but cannot make medical decisions. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed supervision from staff for walking and transfers. A review of Resident 2 ' s COC Evaluation, dated 5/26/2024, indicated Resident 2 was found on top of Resident 1. The COC indicated on 5/26/2024 at 9 p.m., LVN 1 responded to sound of verbal altercation coming from Resident 1 and Resident 2 ' s room. The COC indicated LVN 1 saw CNAs 2 and 3 removing Resident 2 on top of Resident 1. CNA 2 reported to LVN 1 that Resident 2 was on top groping and kissing Resident 1. The COC indicated Resident 1 stated Resident 2 was touching and kissing him non consensually. The COC indicated MD was notified at 9 p.m. and Family Member 2 (FM 2) was notified at 10 p.m. A review of Resident 2 ' s Progress Note, dated 5/26/2024, indicated at 9 p.m., LVN 1 responded to sound of verbal altercation and saw CNAs 2 and 3 removing Resident 1 on top of Resident 2. LVN 1 had Resident 2 removed from the room and placed on one-to-one monitoring. The Progress Note indicated MD was notified and ordered 5150 and to call the police. The Progress Note indicated the police arrived at 10 p.m. and police suggested to call the county PET team. The Progress Note indicated Resident 1 was on continued one-to-one monitoring by CNA and endorsed to the next shift to coordinate and maintain one-to-one observation by CNA. A review of the Physician ' s Order of Resident 2, dated 5/27/2024, indicated the following orders: a. Department of Mental Health Evaluation after an incident with Resident 1. b. Transfer to GACH 1 Psychiatry Unit emergency room . During an interview on 5/28/2024 at 3:31 p.m., Resident 1 stated on 5/26/2024 at 9 p.m., he was taking a nap when he woke up and saw Resident 2 wanting to kiss and tried to rub him. Resident 1 stated Resident 2 jumped on Resident 1 ' s bed and tried to take Resident 1 ' s pants out. Resident 1 stated he did not give permission for Resident 2 to touch and kiss him. Resident 1 stated Resident 2 wanted to take his (Resident 1 ' s) pants off. During an interview on 5/28/2024 at 3:42 p.m., RN 1 stated on 5/26/2024 between 9 p.m., to 10 p.m., she was in Station C when she was paged to Resident 1 and Resident 2 ' s room. RN 1 stated she saw CNA 2, CNA 3, and LVN 1 inside Resident 1 ' s room. RN 1 stated she saw Resident 1 in his bed and Resident 2 outside the room with LVN 5. RN 1 stated LVN 1 reported that CNA 2 and CNA 3 heard Resident 1 screaming and found Resident 2 on top of Resident 1. RN 1 stated Resident 1 reported that he was getting ready to sleep when Resident 2 approached him, went to his bed, and tried to go on top of him. RN 1 stated she reported the incident to the ADM, called police, and called 911. RN 1 stated she assessed Resident 1 and had no pain, no injury, and no bruising. RN 1 stated police officers came but Resident 1 do not want to discuss the incident and refused to answer the questions from the police officers. RN 1 stated Resident 2 stayed up all night, did not want to go to his room and was placed on one-to-one monitoring. RN 1 stated LVN 5 stayed with Resident 2 from 10 p.m., until 11 p.m., then CNA 10 watched Resident 2. During an interview on 5/28/2024 at 4:13 p.m., LVN 1 stated on 5/26/2024 at 8:45 p.m., to 9 p.m., she was in Station A hallway passing medications when she heard sound of verbal altercation and found CNA 2 and CNA 3 beside Resident 1 who was lying in his bed who appeared to be in shock. LVN 1 stated Resident 2 was just separated from Resident 1 and placed back on a wheelchair beside his bed. LVN 1 stated as she was walking towards Residents 1 and 2 ' s room, CNA 2 reported that Resident 2 was on top of Resident 1, kissing and rubbing Resident 1 in bed. LVN 1 stated Resident 1 reported that it was nonconsensual, he was yelling for help because Resident 2 was on top of him, touching him and Resident 1 do not want to be touched. LVN 1 described Resident 1 to be in shock as Resident 1 was shaking, hyperventilating, and loss for words. LVN 1 stated the incident was nonconsensual because Resident 1 was yelling and did not give consent. LVN 1 stated Resident 2 sexually abused Resident 1. During an interview on 5/28/2024 at 4:30 p.m., CNA 2 stated on 5/26/2024 at 8:45 p.m., she and CNA 3 were making their rounds in Station A when she heard somebody yelling for help in Spanish. CNA 2 stated she saw Resident 1 laying in the bed with his feet on the floor by the left side of the bed, Resident 1 ' s jeans was down to his knees, incontinent brief open on the right side, Resident 1 ' s face and body was shaking and about to cry. CNA 2 stated she saw Resident 2 on top of Resident 1 and kissing Resident 1 ' s neck area. CNA 2 stated Resident 1 reported that Resident 2 was kissing and touching him. CNA 2 stated as she was trying to separate Resident 2, Resident 2 touched Resident 1 again in the right hip. CNA 2 stated Resident 1 reported that he feared Resident 2. CNA 2 stated she had known Resident 1 for three years and that he was a strong person but that time he looked like he wanted to cry. During an interview on 5/28/2024 at 5:01 p.m., RN 1 stated based on Resident 1 ' s report, the incident was nonconsensual. During an interview on 5/28/2024 at 5:15 p.m., Resident 2 stated he touched Resident 1 ' s tummy (abdomen) but denied pulling Resident 1 ' s pants down. Resident 2 stated he did not know why he got closer to him and stated he did not ask permission to get close and touch him. Resident 2 stated he did not think of asking permission to touch Resident 1. During an interview on 5/29/2024 at 8:08 a.m., CNA 3 stated on 5/26/2024 at around 8:45 p.m., CNA 2 and CNA 3 were doing their last rounds when she heard Resident 1 yelling for help in Spanish and heard a whistling sound. CNA 3 stated she saw Resident 1 in bed trying to get up and trying to fight Resident 2 who was on top of Resident 1, but he cannot move his right arm. CNA 3 stated she saw Resident 2 trying to pull down Resident 1 ' s pants. CNA 3 stated Resident 1 was shaking, looked nervous, scared and Resident 1 saying he did not want Resident 2 in his room. CNA 3 stated when Resident 2 saw CNA 2 and CNA 3 in the room, CNA 3 saw Resident 2 dropped himself and sat on the floor while still holding onto Resident 1 ' s pants. CNA 3 stated, CNA 2 and CNA 3 pulled Resident 2 away from Resident 1. CNA 3 stated Resident 2 walked back to his wheelchair on his side of the bed and wheeled himself out. CNA 3 stated Resident 2 abused Resident 1 because Resident 1 did not allow Resident 2 to touch him. During an interview on 5/29/2024 at 11:24 a.m., Restorative Nursing Assistant 1 (RNA 1) stated she noticed that Resident 1 gets more upset since Monday, 5/27/2024, and refused to walk and shower on 5/27/2024. RNA 1 stated Resident 1 was quieter since 5/27/2024. RNA 1 stated she felt like what happened on Sunday, 5/26/2024, could have affected Resident 1 ' s behavior, regarding refusal of shower and exercises, and wanting to be alone. RNA 1 stated Resident 1 loves coffee and on the morning of 5/29/2024, RNA 1 did not see Resident 1 attending the activity for coffee social. During an interview on 5/29/2024 at 11:36 a.m., the Activity Director (AD) stated Resident 1 likes attending all activities especially outdoor exercises and coffee social. The AD stated on 5/27/2024, Resident 1 did not attend the coffee social. During an interview on 5/29/2024 at 12:15 p.m., the AD stated Resident 1 did not attend any activity on 5/27/2024. During an interview on 5/29/2024 at 12:16 p.m., the ADON stated based on the report she received from RN 1, Resident 2 sexually abused Resident 1. The ADON stated as of 5/29/2024, Resident 1 was not yet seen by Psychologist and Psychiatrist. The ADON stated it is important for Resident 1 to be seen by the Psychologist and Psychiatrist because of the possible trauma that may cause depression. The ADON stated Resident 1 may get scared and feel not safe with his roommates. During an interview on 5/29/2024 at 12:27 p.m., the DON defined abuse as willful intent (means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm) to cause harm to another person. The DON stated it is only willful if the resident was alert and oriented, cognitively intact and no diagnoses of dementia and schizophrenia. The DON stated Resident 1 was sexually abused by Resident 2 because it was nonconsensual, because Resident 1 was harassed by Resident 2. During an interview on 5/30/2024 at 10:20 a.m., CNA 2 stated on 5/26/2024 at 8:45 p.m., she saw Resident 1 in his bed with legs on the floor, Resident 1 ' s jeans were down to just above the knees, Resident 2 was on the left side of Resident 1 ' s bed with Resident 2 was almost kneeling, and his body was on top of Resident 1. CNA 2 stated Resident 2 ' s head was on Resident 1 ' s chest and Resident 2 ' s face was close to Resident 1 ' s neck. CNA 2 stated she worked double shift that day from 5/26/2024 at 3 p.m., until 5/27/2024 at 7 a.m., CNA 2 stated Resident 1 did not sleep the night of 5/26/2024. CNA 2 stated that usually in the morning when she brings the breakfast tray, Resident 1 would be asleep but that morning on 5/27/2024 Resident 1 was awake, refused to shower and appeared to be mentally affected because he did not want to speak to anybody and stayed outside most of the day separated from other residents. During an interview on 5/30/2024 at 10:54 a.m., CNA 3 stated she saw Resident 2 on top of Resident 1, Resident 2 ' s face was on Resident 1 ' s neck, Resident 1 ' s pants was down to his knees. CNA 3 stated when Resident 2 saw CNA 2 and CNA 3 entering in the room, Resident 2 slid himself down to the floor from Resident 1 ' s top while still pulling down the pants of Resident 1. CNA 3 stated she saw Resident 1 ' s face pale and was shaking. During an interview on 5/30/2024 at 11:27 a.m., LVN 6 stated Resident 1 was not yet seen by Psychologist and Psychiatrist. LVN 1 stated Resident 1 was scheduled to be seen by Psychologist on 5/31/2024. LVN 1 stated she attended an in-service for abuse after the incident and it was about abuse in general and not about sexual abuse. During a concurrent interview and record review on 5/30/2024 at 11:55 a.m., with the ADM, facility ' s policy, and procedure (PnP) titled, Identifying Sexual Abuse and Capacity to Consent, dated 9/2022, was reviewed. The facility ' s PnP indicated Sexual abuse is a nonconsensual sexual contact of any type with a resident, as defined at 42 Code of Federal Regulations (CRF) 483.5. Sexual Abuse includes but is not limited to a. unwanted intimate touching of any kind .Generally sexual contact is non-consensual if the resident either; a. appears to want the contact to occur but lacks the cognitive ability to consent or b. does not want the contact to occur. The ADM stated on 5/26/2024 there was a loud commotion in Resident 1 and Resident 2 ' s room and CNA 2 and CNA 3 found Resident 2 on top of Resident 1 attempting to kiss and grope Resident 1. The ADM stated Resident 2 was placed on one-to-one staff monitoring. The ADM stated Resident 1 reported nothing had happen. The ADM stated there was no foul play (unfair dealing) and it was not an abuse. The ADM stated definition of abuse is willful act. The ADM stated Resident 2 not having the capacity and not in his right mind had no willful intent to harm. The ADM stated their policy for sexual abuse defines sexual abuse as nonconsensual sexual contact with a resident. The ADM stated Resident 2 did not sexually abuse Resident 1 because Resident 2 was not in his right mind due to diagnosis of dementia and schizophrenia. The ADM stated if somebody does not have the capacity then they do not have the capacity to make act willful. The ADM stated based on the report he received, Resident 1 did not agree to have consensual contact. A review of Resident 1 ' s Psychological Consultation, dated 5/30/2024, indicated the consultation was requested by the facility about a report of Resident 1 being kissed by Resident 2 without consent from Resident 1. The Psychological Consultation indicated Resident 1 was seen by the Psychologist through a telehealth (the use of communications technologies to provide health care at a distance) session using a non-public remote communication product (use of phone or computer). The Psychological Consultation indicated the Psychologist was in his office while Resident 1 was in the facility. The Psychological Consultation indicated Resident 1 had no psychotropic medication (relating to or denoting drugs that affect a person ' s mental state) and appeared to not be aware of what the Psychologist was referring to when the subject of unwanted contact by other resident was brought up. Resident 1 denied any issues or concerns with other residents. The Psychological Consultation indicated Resident 1 verbalized a[TRUNCATED]

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), who needed an indwelling urinary catheter (a flexible plastic tube [a catheter] inserted into the bladder [a hollow organ that stores urine] to provide continuous urinary drainage) because of a diagnosis of urinary retention (inability to voluntarily void urine), was provided treatment and care based on the comprehensive assessment and plan of care. The facility failed to: 1. Monitor the amount of urine eliminated (urinary output) after Resident 1 ' s urinary catheter was pulled out and was not replaced on 11/3/2023, as ordered by Resident 1 ' s attending physician (Physician 1). 2. Inform Physician 1 that the facility did not have policies and procedures (P&Ps) on monitoring the urinary output on incontinent (unable to control voiding) residents. 3. Utilize a bladder scanner (ultrasound device that uses sound waves to determine how much urine is in the bladder) the facility had but there was no P&P to guide the licensed nurses on its use and the licensed nurses were not trained on its use. As a result, on 11/14/2023, during a urologist (medical doctor specialized in the study and treatment of the function and diseases of the urinary system) consult, Urologist 1 drained a total of eight (8) liters (8,000 milliliters [ml - unit of measurement]) of urine in the bladder (men ' s bladder maximum capacity is approximately 700 ml) from Resident 1 bladder. From his office, Urologist 1 sent Resident 1 to General Acute Care Hospital 1 (GACH 1) emergency room (ER), where Resident 1 was diagnosed with obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) most likely due to prostatomegaly (enlargement of the prostate gland [located just below the bladder and surrounds the top portion of the tube that drains urine from the bladder, the urethra]). Other diagnoses were acute kidney injury (condition in which the kidneys suddenly cannot filter waste from the blood) and status post bladder decompression (use of a catheter to continuously release urine from the bladder). Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident as a new admission on 11/2/2023. Resident 1 ' s diagnoses included pneumonia (inflamed or swollen lung tissue caused by infection with a germ) for continued antibiotic therapy, autism (serious developmental disorder that impairs the ability to communicate and interact), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). A review of Resident 1 ' s Baseline Care Plan, dated 11/2/2023, indicated on the bowel and bladder section that the resident had an indwelling (inside the body) catheter. There was no documented intervention for Resident 1 ' s indwelling catheter. A review of Resident 1 ' s Care Plan for the use of the indwelling urinary catheter, initiated on 11/2/2023, indicated the goal was for Resident 1 to be free from catheter related trauma. The intervention included monitoring and documenting the intake (amount of fluid consumed) and the output as per facility ' s policy. A review of Resident 1 ' s Catheter Evaluation, dated 11/2/2023, indicated the resident was admitted with an indwelling catheter. The justification for the catheter indicated Resident 1 ' s inability to manage urinary retention or incontinence with intermittent catheterization (these catheters are inserted several times a day for just long enough to drain your bladder, and then removed). A review of the Physician ' s Order for Resident 1, dated 11/2/2023, indicated Lasix (a water pill that makes the person urinate more) 40 milligrams (mg - unit of measurement) one tablet by mouth two times a day. A review of Resident 1 ' s Change in Condition (COC) Evaluation, dated 11/3/2023, indicated Resident 1 ' s indwelling urinary catheter was (accidentally) pulled out and Resident 1 ' s urinary retention would make his condition worse and increasing the fluid intake would make the condition better. The COC indicated Physician 1 was notified and Physician 1 ordered to discontinue Resident 1 ' s indwelling urinary catheter and monitor him for urinary retention. A review of Resident 1 ' s Progress Notes, dated 11/3/2023, indicated the resident ' s urinary catheter was pulled out, Physician 1was notified and ordered monitoring Resident 1 for urinary retention for 72 hours. A review of Resident 1 ' s Care Plan initiated on 11/3/2023, indicated Resident 1 ' s indwelling urinary catheter was pulled out. The care plan interventions included monitoring Resident 1 for bleeding, pain, and for urinary retention. The manner for nursing staff to monitor Resident 1 ' s for urinary retention was not indicated in the care plan. A review of Resident 1 ' s Progress Notes, dated 11/4/2023, indicated nursing was monitoring Resident 1 for urinary retention. There was no documented evidence of the amount of urine Resident 1 had eliminated (urine output). A review of Resident 1 ' s Progress Notes, dated 11/5/2023 and 11/6/2023, indicated nursing was monitoring Resident 1 for urinary retention. The progress notes indicated that Resident 1 ' s wet disposable brief was changed two times with no foul-smelling yellow output on the disposable brief. There was no documented evidence of the amount of urine Resident 1 had eliminated (urine output) and no documented evidence the incontinent brief was weighed before (clean) and after to estimate the volume of urine. According to the National Institutes of Health (www.ncbi.nih.gov), individual diapers are typically weighed prior to patient application and then this value is subtracted from the wet weight; the mass of one liter is equivalent to on kilogram of weight. A review of Resident 1 ' s undated Bowel and Bladder 72 Hour Toileting Diary indicated there was no documented output during the 72-hour monitoring from the time of the order on 11/3/2023 to 11/6/2023. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/13/2023, indicated the resident ' s cognition (involving conscious intellectual activity such as thinking, reasoning, or remembering) was severely impaired. The MDS indicated that Resident 1 was dependent on staff for bed mobility, transfers, personal hygiene, and toilet use. Resident 1 was assessed as incontinent of urine. A review of the Recapitulation of Stay and Discharge Summary, dated 11/13/2024, indicated Resident 1 was discharged to prior living arrangement (lower level of care) per Responsible Party (RP) request. The summary section for Overall Summary of Discharge indicated Resident 1 improved and no longer needed the services of the facility. A review of Resident 1 ' s Patient Summary from a Urology Clinic indicated the resident was seen on 11/14/2023 at 11 a.m. with the diagnosis of BPH with lower urinary tract symptoms, retention of urine, and cystitis (inflammation of the bladder). Urologist 1 documented the follow up visit was because Resident 1 had abdominal distention and was not feeling well. Urologist 1 indicated that an indwelling urinary catheter was placed in Resident 1 which drained eight liters of urine output. The Patient Summary also indicated that Resident 1 was sent to the emergency room for evaluation. A review of Resident 1 ' s GACH 1 Emergency Documentation - MD, dated 11/14/2023 at 3:22 p.m., indicated the resident presented at the emergency room with a complaint of urinary retention. Urologist 1 placed an indwelling urinary catheter with eight liters output. Resident 1 was admitted as an inpatient in GACH 1. A review of Resident 1 GACH 1 Inpatient Discharge Summary, dated 11/16/2023, indicated the resident was discharged from GACH 1 to home on 11/16/2023 with diagnoses including obstructive uropathy most likely due to prostatomegaly complicated by acute kidney injury and status post bladder decompression. On 11/17/2023 at 8:29 a.m. during an interview, RP stated she requested Resident 1 discharge from the facility because she felt they were not taking good care of Resident 1. RP stated that on 5/2023 (prior to Resident 1 ' s admission to the facility), Resident 1 was hospitalized because of urinary retention and Urologist 1 informed RP that Resident 1 needed the indwelling urinary catheter for the rest of his life. RP stated that once Resident 1 was discharged , she contacted Urologist 1 ' s office for him to evaluate Resident 1, who was not well and had abdominal pain. On 11/20/2023 at 11:27 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1) and a review of Resident 1 ' s clinical record, LVN 1 stated that Resident 1 ' s 72-hour monitoring for urinary retention should have been documented but LVN 1 was unable to find it. LVN 1 stated she did not document the sign and symptoms of urinary retention and did not describe Resident 1 ' s disposable brief saturation with urine. LVN 1 stated that Resident 1 was admitted for antibiotic treatment and resident had an indwelling urinary catheter, but she did not know the reason for the catheter. LVN 1 stated certified nursing assistants (CNAs) would report to her how many times the resident ' s disposable brief was changed. LVN 1 was not able to answer how the amount of output was determined to identify that Resident 1 was or not retaining urine. LVN 1 stated that they do not weigh or describe the saturation of the disposable briefs. On 11/20/2023 at 2:52 p.m., an interview with the Director of Nursing (DON) and a concurrent review of Resident 1 ' s clinical was conducted. A review of the Intake and Output Record after Resident 1 ' s indwelling urinary catheter indicated that at 7 a.m. to 3 p.m., Resident 1 voided (urinated) three times. The record indicated that at 3 p.m. to 11 p.m., Resident 1 voided two times. There were no other documented intake and output amount. The DON stated Resident 1 should be monitored for urinary retention for 72 hours after the urinary catheter was removed and document the resident ' s intake and output in the medical record. The DON stated licensed nurse should have monitored Resident 1 ' s output by describing the urine saturation in the disposable brief or ideally staff should have used a bladder scanner (used to measure the amount of urine in the bladder). The DON stated she was unsure where the bladder scanner was, and it was probably at another Nursing Station. The DON was unable to provide P&Ps on intake and output, measuring output on an incontinent resident, or the use of a bladder scanner. The DON was unable to provide documented evidence the licensed nurses were trained on the use of the bladder scanner. On 11/20/2023 at 4:16 p.m., during a telephone interview, the ADON stated that if the resident had an indwelling urinary catheter pulled out accidentally or removed (discontinued), the nurses would initiate the COC and monitor for urinary retention for 72 hours every shift. If the resident did not have an output in the first 4-6 hours after catheter removal, the charge nurse would call the doctor. The ADON stated CNAs should report to the charge nurse how many incontinent briefs were changed and the saturation of the disposable briefs. The ADON stated the facility had a bladder scanner but was unsure if it was working or calibrated. On 12/12/2023 at 11:15 a.m., during a telephone interview, Urologist 1 stated Caretaker brought Resident 1 to his office and that was the best thing that happened to Resident 1 because he (Urologist 1) inserted an indwelling urinary catheter and drained 8 liters at one time. Urologist 1 stated Resident 1 should never have been without the indwelling urinary catheter due to urinary retention, and he should have been contacted immediately for him to insert a new one. Urologist 1 stated Resident 1 ' s urine was flowing back to the kidneys and was causing damage. A review of the facility ' s policy and procedure titled, Charting and Documentation, dated 5/2023, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional, or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. A review of the facility ' s policy and procedure titled, Acute Condition Changes - Clinical Protocol, dated 5/2023, indicated that the staff will monitor and document the resident ' s progress and responses to treatment. It also indicated that direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse.

Based on interview and record review the facility failed to provide a safe environment and supervision for one of four resident (Resident 1). On 6/23/2023 at 10:40 a.m. Resident 1, while unsupervised, was walking out of room became dizzy and fell . Resident 1 was observed with laceration (cut) to forehead and sent to General Acute Care Hospital 1 (GACH 1). On 6/24/2023 at 7:17 a.m. Resident 1 returned to facility. At 8:18 a.m. Resident 1 was found in her room lying on her left side with reopened wound on left forehead and bleeding, Resident 1 was transferred to GACH 2. As a result, Resident 1 fell and sustained a laceration on the left side of the forehead requiring transfer to GACH 2 where she was diagnosed with cervical vertebra fracture (C2 fracture- a break in the second vertebra [the small circular bones that form the spine of a human being or animal] of your neck). Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 12/26/2020 and readmitted the resident on 6/24/2023 with diagnosis that included encephalopathy (damage or disease that affects the brain), difficult in walking, muscle wasting and atrophy (decrease in size of an organ or tissue; wasting), and vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain). A review of Resident 1 ' s Fall Risk assessment dated [DATE] indicated Resident 1 had a score of 5 (total score of 10 or greater, the resident should be considered at high risk for potential falls). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/12/2023 indicated the resident was able to understand and be understood. Resident 1 required supervision with bed mobility, transfer, walking in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. A review of Resident 1's Change of Condition Evaluation (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains documentation), dated 5/29/2023, indicated resident had a fall and sustained a lump to right forehead, skin intact. A review of Resident 1 ' s Care plan developed on 5/30/2023 for fall found on floor on 5/29/2023 sustained right forehead skin discoloration. The intervention included answer call light in timely manner, may keep the bed in lowest position, except when resident is out of bed or during care or fall precaution, every shift. A review of Resident 1 ' s Fall Risk assessment dated [DATE] indicated Resident 1 had a score of 14 (total score of 10 or greater, the resident should be considered at high risk for potential falls). A review of the Physician ' s Orders for Resident 1 dated 6/7/2023 indicated apply sensor pad alarm in bed to remind the resident to call for assistance and alert staffs when moving or getting up from bed every shift. A review of Resident 1's COC Evaluation dated 6/23/2023 at 10:40 a.m. indicated resident was found walking out of her room towards the front of building. Two Certified Nursing Assistants (CNAs) were walking towards Resident 1 but did not make it to her in time, Resident 1 got dizzy and that is what caused her to fall. Registered Nurse Supervisor assessed resident and observed a cut to Resident 1 ' s forehead. A review of the Physician ' s Orders for Resident 1 dated 6/23/2023 indicated transfer to GACH 1 for further evaluation due to fall and hitting head. A review of Resident 1 ' s Nursing Home to Hospital Transfer Form dated 6/23/2023 indicated resident transferred to GACH 1 due to fall. A review of Resident 1 ' s Care plan developed on 6/23/2023 for fall found on the floor, resident felt dizzy and fell . The intervention included assist resident to wheelchair transfer to bed, body assessment noted with laceration on forehead initial treatment rendered, and doctor notified with new order to transfer resident to acute hospital. A review of Resident 1 ' s Care plan developed on 6/23/2023 resident is high risk for minor injury/major or serious injury such sustain fracture and head injury r/t multiple falls in the last 90 days, poor balance or control, poor communication/comprehension, attempt to get up from bed/wheelchair unassisted, unaware of safety needs, impaired balance, altered thought process, impaired cognition, get up from bed unassisted, not using the call light for assistance for mobility, transfer and toilet needs, forgetfulness and confusion. The interventions included anticipate and meet the residents needs, apply sensor pad alarm in bed to remind resident to call for assistance and alert staffs when moving or getting up from bed every shift. A review of Resident 1 ' s nursing Progress Note dated 6/24/2023 at 7:17 a.m. indicated hospice and Family Member (FM 1) made aware of Resident 1 ' s return to facility. A review of Resident 1 ' s COC Evaluation dated 6/24/2023 at 8:18 a.m. indicated resident found lying on her left side on the floor. Resident 1 noted with reopened wound on left forehead and bleeding. A review of Resident 1 ' s nursing Progress Note dated 6/24/2023 at 8:40 a.m. indicated at around 8:20 a.m. Resident 1 had a fall, was laying on left side and was covered with blood on head from a new laceration. A review of the Physician ' s Orders for Resident 1 dated 6/24/2023 indicated transfer to GACH 2 for further evaluation due to fall and hitting head. A review of Resident 1 ' s Nursing Home to Hospital Transfer Form dated 6/24/2023 indicated resident transferred to GACH 2 due to fall. A review of Resident 1 ' s Fall Risk assessment dated [DATE] indicated Resident 1 had a score of 14 (total score of 10 or greater, the resident should be considered at high risk for potential falls). A review of Resident 1 ' s GACH 2 Hospital Discharge Summary indicated Resident 1 was admitted on [DATE] and discharged from GACH 2 on 7/1/2023. The Discharge Summary indicated Resident 1 had significant left frontal scalp soft tissue swelling, hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel) with laceration and evidence of C2 fracture. During an interview on 11/14/2023 at 3:15 p.m. with Certified Nursing Assistant 3 (CNA 3) stated on 6/23/2023 she heard bed alarm going off and saw Resident 1 walking in hallway coming out of her room. CNA 3 stated Resident 1 was about three steps away from her when she fell . CNA 3 stated Resident 1 fell sideways and hit the floor causing a laceration to her forehead. CNA 3 stated the following day (6/24/2023) was told by another staff that Resident 1 had fallen and when CNA 3 went to see Resident 1 the charge nurse was already there. CNA 3 stated Resident 1 had reopened the laceration, there was blood. The CNA 3 stated Resident 1 ' s room was not near the nurses ' station; it would have been beneficial for Resident room to be close to nurses ' station. During an interview on 11/14/2023 at 4:15 p.m. with the Assistant Director of Nursing (ADON) stated Resident 1 was on the falling star program which means the resident is a fall risk, those residents get a star on their front door, wheelchair and back of bed so that staff are aware the resident is at risk for falls. The ADON stated resident will be placed near nurses ' station, use bed alarms if applicable and have constant visualization of the resident. The ADON stated Resident 1 ' s room was not near the nurses ' station, but it was in a visible area. The ADON stated Resident 1 had a fall on 6/23 was sent to hospital and then returned on 6/24. The ADON stated could have provided one on one for the resident due to the frequency of falls. The ADON stated not moving Resident 1 ' s room close to nursing station and not providing one on one to the resident placed the resident at risk to continue to have falls and was a risk for injury. During an interview on 11/14/2023 at 4:55 p.m. with the Administrator (Adm) stated typical interventions when a resident has a fall is to move the resident room and review their medications. The Adm stated Resident 1 may have benefited from a one on one to prevent falls. The Adm stated Resident 1 ' s room was no changed and the facility did not provide one on one for the resident. A review of the facility ' s current policy and procedure titled, Falls and Fall Risk, Managing, revised date of 3/2018, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical and mental abuse (deliberate aggressive or violent behavior with the intention to cause harm by one resident to another) inflicted by Resident 2. On 9/16/2023 at 9 a.m. while Resident 1 was sitting on his bed, one of his three roommates (the room was a four-bed room occupied by Residents 1, 2, 4, and 5), Resident 2, approached Resident 1 propelling himself in the wheelchair, took the metal footrest from his wheelchair with the right hand, stood by Resident 1 and tried hitting Resident 1 with the metal footrest. Resident 1 reacted by holding Resident 2's right arm (which was holding the footrest) and avoiding being injured by the metal footrest but then, Resident 2 hit Resident 1 several times with his left hand. During the incident, Resident 1 was screaming for help. At the time of the incident, Certified Nursing Assistant 4 (CNA 4) and CNA 5, were inside the room by Resident 4, and did not intervene immediately. Licensed Vocational Nurse 1 (LVN 1), who was close to Resident 1's room, heard the screaming, went inside the room, and removed the footrest from Resident 2. As a result, Resident 1 was fearful for his life, felt intimidated, and had trouble sleeping the night of the incident worried that Resident 2 would return to harm him. In addition, Resident 1 sustained two skin tears (wounds that happens when the skin layers separate) to the left forearm (by the wrist) and the left hand between the thumb and the index finger. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 11/9/2021 with diagnoses including gastrostomy tube (GT, a surgical procedure to insert a soft tube through the abdomen and into the stomach for food and medication), dysphagia (difficulty in swallowing), and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 1's History and Physical exam, dated 8/28/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/15/2023, indicated Resident 1's was able to remember and make decisions and needed supervision for all activities of daily living (ADLs, such as bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene). A review of Resident 2's Admission Record indicated the facility admitted the resident on 4/18/2023 with diagnoses including Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), and diabetes mellitus (uncontrolled elevated blood sugar). A review of Resident 2's MDS, dated [DATE], indicated resident had decline in memory and thinking abilities and required extensive assistance from staff for dressing and personal hygiene. Resident 2 used a wheelchair for mobility. A review of Resident 2's Situation-Background-Assessment-Recommendation (SBAR) Communication Form (a technique that provides a framework for communication between members of the health care team about a resident's condition), dated 9/16/2023 and timed at 9:15 a.m., indicated Resident 2 did not recall the reason for hitting the roommate (Resident 1) but accused him of trying to poison him (Resident 2). A review of facility's final Investigation Report, dated 9/21/2023, sent to the State Survey Agency (SSA), indicated Resident 2 hit Resident 1 on the left forearm with a metal footrest. CNA 4 saw Resident 2 going to Resident 1's direction and thought Resident 2, who had no history of aggressive behavior, was just confused about his bed. CNA 4 turned to Resident 4 and when heard Resident 1 started yelling that Resident 2 hit him, CNA 4 rushed to separate them, and two other staff to de-escalate (reduce the intensity of a conflict or potentially violent situation) the situation. Resident 2 was moved to a different room, On 9/23/2023 at 6 a.m., during an observation and concurrent interview of Resident 1, Resident 1 was walking with using a walker with a folding chair. Resident 1 stated that on the day of the incident (9/16/2023) after breakfast he was sitting on his bed when he saw Resident 2 pushing his wheelchair (while sitting on the wheelchair) towards him (Resident 1). Resident 1 stated he told Resident 2 to stop (coming to him) but instead Resident 2 grabbed the metal wheelchair footrest with the right hand, stood up, and tried to hit him with it. Resident 1 stated he grabbed Resident 2's right arm to block him from hitting him but then Resident 2 hit him with his left hand causing him two bleeding cuts on his left arm and hand. Resident 1 stated he turned around to call for help and saw two staff just watching him get beaten up. Resident 1 stated both staff did not help him. Resident 1 stated he was scared and felt intimidated by Resident 2 and despite Resident 2 being moved the same day, he could not sleep that night thinking Resident 2 would come back to harm him. Resident 1 showed the Evaluator his healing skin tears which measured about 1 centimeter (cm - unit of measure) each, one was on his left hand, between the thumb and the index finger and the other on the left forearm by the wrist. During an interview on 9/23/2023 at 8:52 a.m., LVN 1 stated on 9/16/2023 at 8:50 a.m., she was making rounds when she heard somebody screaming in Residents 1's room. She entered the room and saw Resident 1 sitting on his bed with Resident 2 on top of him trying to hit him with a wheelchair footrest. LVN 1 stated she removed the footrest from Resident 1's hand and separated the residents. LVN 1 stated CNAs 4 and 5 were inside the room. LVN 1 stated CNA 4 was assigned to Resident 4 as a one-to-one sitter (staff assigned to be always with a resident due to safety reasons). LVN 1 stated she paged (through an overhead paging system that broadcasts a message to a building area via overhead speakers) the Registered Nurse (also the Infection Preventionist, IP) to help her do a body check on Resident 1. LVN 1 stated Resident 1 had one skin tear on the left hand and one on the left forearm with minimal bleeding. On 9/23/2023 at 9:21 a.m., during an interview, CNA 5 stated that on 9/16/2023 after breakfast he was inside the room of Residents 1, 2, 4, and 5 talking to CNA 4 and Resident 4 when he heard a sound of a curtain moving. CNA 5 stated when he turned around, he saw Resident 2 open the privacy curtain of Resident 1 while holding a wheelchair footrest. CNA 5 stated he saw Resident 2 throwing himself on top of Resident 1 trying to hit him with the footrest. CNA 5 stated he grabbed Resident 2's arm to prevent him from hitting Resident 1. CNA 5 stated he was not assigned to any resident in that room. On 9/23/2023 at 9:37 a.m., during an interview, CNA 4 stated that on 9/16/2023 after the residents' breakfast meal, she was talking to CNA 5 at Resident 4's bed, who was sleeping at that time. CNA 4 stated she heard Resident 1 scream and when she turned around, she saw Resident 2 standing on Resident 1's right side of the bed while holding a wheelchair footrest on his right hand and Resident 1 was pushing Resident 2 away. CNA 4 stated she saw blood in Resident 1's left arm after the two residents were separated by LVN 1. During an interview on 9/26/2023 at 10:12 a.m., the IP stated on 9/16/2023, she was overhead paged to Resident 1's room at 9 a.m., and when she arrived LVN 1 and CNA 4 were in the room with Resident 1 sitting on his bed and Resident 2 sitting in a wheelchair away from Resident 1. The IP stated she was not aware that CNA 5 was inside the room when the incident happened. The IP stated all residents have the right to be free from abuse. On 9/26/2023 at 12:20 p.m., during an interview with the Director of Nursing (DON) and concurrent review of facility's abuse policy, titled, Abuse and Neglect-Clinical Protocol, dated 3/2018 and reviewed on 5/2023, the DON defined abuse as willful intent to inflict harm. The DON stated she did not think Resident 2 had a willful intent to hurt Resident 1 due to confusion; therefore, it was not abuse but just a resident-to-resident altercation. During an interview on 9/26/2023 at 1:13 p.m., the Administrator (ADM) defined abuse as the willful infliction of injury. The ADM stated they reported the incident as abuse as Resident 2 had intent of hitting Resident 1 and acted on doing it. A review of facility's policy and procedure titled, Abuse and Neglect-Clinical Protocol, dated 3/2018 and reviewed on 5/2023, indicated Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, mental anguish .Willful as defined .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program , reviewed on 5/2023, indicated, Residents have the right to be free from abuse, neglect misappropriation of resident property and exploitation. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to, b. Other residents .

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as high risk for wandering (going about from place to place), with a wander-guard (a device designed to activate alarms when a resident gets closer to entries and exit points) in place as ordered by the physician was kept free from accidents and hazards by: 1. Failing to monitor and provide supervision to Resident 1 who was at risk for wandering and high risk for falls. 2. Failing to ensure Resident 1 ' s wander guard bracelet (a device designed to activate alarms when a resident gets closer to entry and exit points) activated the wander guard alarm or system when Resident 1, in his wheelchair, exited the exit door near Station 1 while wheeling himself going outside the building to the smoking patio. 3. Failing to ensure staff were monitoring and checking Resident 1 ' s wander guard bracelet was working properly per manufacturer ' s guidelines. 4. Failing to ensure the door alarms at Station 1 exit door activated when Resident 1 exited using that door going to the smoking patio. 5. Failing to ensure the surveillance cameras were monitored when Resident 1 exited by the exit door at Station 1 while wheeling himself going outside the building to the smoking patio in the pouring rain. As a result, Resident 1 exited to the smoking patio on 8/20/2023 at 6:38 p.m. unnoticed and sustained an unwitnessed fall and was exposed to the rain for 13 minutes until the staff assisted Resident 1 back inside the facility at 6:51 p.m. This happened during a hurricane named [NAME] that was expected to cause extreme rain and flooding. This placed Resident 1 at high risk for hypothermia (a medical emergency that occurs when your body loses heat faster that it can produce heat, causing a dangerously low body temperature, which may lead to cardiac [referring to the heart] and respiratory [referring to the lungs] failure and eventually to death) from staying wet and cold for a prolonged period. Also, 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 outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills and medical condition, an individual subjected to neglect, 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 yourself). On 9/4/2023 at 6:39 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.25(d) Accidents. The Administrator and Registered Nurse 2 (RN 2) were notified of the IJ from the failure to ensure staff provided the necessary care and services to prevent Resident 1 to wander outside the facility to the smoking patio without supervision and sustained an unwitnessed fall. On 9/7/2023 at 11:23 a.m., the IJ was removed in the presence of the Administrator and Director of Nursing (DON), while onsite, after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan which included the following summarized actions: 1. Resident 1 ' s whereabouts were monitored by licensed nurses every shift. Resident 1 was continuously being placed in a highly visible area such as in front of the nurse station, activity room and dining room for close observation. The assigned certified nursing assistant (CNA) to continue frequent visual monitoring of the resident every two hours during shift. 2. Maintenance Supervisor checked all the facility ' s entry/exit doors including emergency exits on 9/1/2023. All stop alarms on emergency entry/exit doors were functioning well. 3. All facility ' s entry and exit doors to include emergency exits will be monitored by the maintenance staff/designee daily for proper function. In case an entry/exit door alarm is not working, a facility staff will be assigned to monitor until the malfunctioning (not working) entry/exit door is fixed. 4. Continue to ensure wander guards are in place and functioning on high-risk residents. 5. DON conducted a review of all residents on wander guards on 9/4/2023 to ensure placement and functional wander guards. 6. Director of Staff Development (DSD) started providing in-service to all staff on 9/5/2023 regarding the facility ' s policy and procedures on the following: a. Wander Guard Monitoring for Placement and Functioning based on Manufacturer ' s Guidelines b. Resident Monitoring for Safety and Supervision c. Resident Abuse, and Neglect d. Accident, Hazards, and Safety 7. The licensed nurse to check wander guard placement and functionality (whether it is working) every shift and document result. The date of placement will also be documented including the date of the replacement. 8. The Licensed Nurse to conduct nursing huddles to CNAs and charge nurses at the beginning of each shift to discuss residents at risk for wandering (to go about from place to place usually without a plan or definite purpose) including residents with wander guard devices. 9. Residents at risk for wandering will be checked by CNAs, restorative Nursing assistants (RNAs), and licensed nurses during routine bedside care, scheduled medication administration, room rounds, and mealtime. 10. Activity staff to observe residents at risk for wandering if they are attending group activities. 11. The charge nurse on duty will ensure direct supervision/monitoring high risk for wandering residents is being conducted by assigned staff/CNA and endorsed to the next shift. 12. The entry/exit doors including emergency entry/exit doors and patio entry/exit door monitoring logs will be collected by the DSD/designee and will be reported during daily stand-up meetings. The RN supervisor/charge nurse/designee on duty during weekends will continue the process and report any discrepancy to the DON/Administrator/designee. 13. The Administrator/designee will review the exit door alarm check log daily for 30 days, the wander guard information log, and follow up immediately if with any negative findings. Any follow-up needed will be reported to the monthly Quality Assurance and Performance Improvement Committee for additional recommendation if there are residents who are high risk for wandering in the facility. The QAPI Committee will provide written recommendations to the Administrator. The Administrator will review such recommendations and act accordingly. Cross Reference with F600. Findings: A review of Resident 1 ' s Admission Record indicated the facility originally admitted the resident on 1/30/2023 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it that deprives brain cells of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant (in control) side , encephalopathy (alteration of mental status due to medications or toxic chemicals), muscle weakness, other abnormalities of gait (walking) and mobility, repeated falls, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified severity, with other behavioral disturbance, and personal history of other mental and behavioral disorders. A review of Resident 1 ' s care plan, dated 5/9/2023, indicated resident was at risk for fall, injury, and wandering with history of wanting to go home. Interventions included to apply wander guard on the ankle and in wheelchair due to resident episodes of removing wander guard on wrist and to apply wander guard to monitor any attempts of getting out of the facility. Other interventions included to monitor and document for wander guard placement and function, monitor resident any attempts to wander/go outside unattended and unknown to staff, and tally with hashmark (tally marks). A review of the physician ' s order of Resident 1, dated 5/24/2023 at 5:47 p.m., indicated an order to apply wander guard to Resident 1 to monitor any attempts of getting out of the facility. The physician ' s order indicated to monitor Resident 1 for wander guard ' s placement and function by documenting Y for Yes or N for No. A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 8/4/2023, indicated Resident 1 ' s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive assistance with two-person physical assistance with bed mobility and transfer and required extensive assistance with one person assistance with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair), locomotion off unit (how resident moves to and returns from off-unit locations like areas set aside for dining, activities, or treatment. If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair), dressing, toilet use, and personal hygiene. A review of Resident 1 ' s Wandering Assessment form, dated 8/18/2023 at 4:33 p.m., indicated Resident 1 was a high risk for wandering. A review of Resident 1 ' s Fall Risk Assessment form, dated 8/18/2023 at 4:38 p.m., indicated Resident 1 was considered a high risk for potential falls. A review of Resident 1 ' s nursing progress note, dated 8/20/2023 at 8:22 p.m., indicated that on 8/20/2023 at 7:07 p.m. Resident 1 had an unwitnessed fall outside in the smoking patio and that Resident 1 was attempting to roll wheelchair but got stuck and tipped over. The nursing progress note indicated Resident 1 stated he was cold. On 8/26/2023 at 12:08 p.m., during an interview, Certified Nursing Assistant 6 (CNA 6) stated Resident 1 was a one-to-one (needing an assigned sitter). CNA 6 stated she was informed by another resident (name not given) that Resident 1 was on the floor in the smoking patio. CNA 6 stated that she went to check the smoking patio from Station 1 ' s exit doors and found Resident 1 lying on the ground still in his wheelchair. CNA 6 stated that it was raining, and Resident 1 fell with his wheelchair and was lying in a puddle of water. CNA 6 further stated that when she (CNA 6) exited the doors of Station 1 to the smoking patio, there were no door alarms that were heard. On 8/26/2023 at 12:26 p.m., during an interview, RN 1 stated that Resident 1 is a high risk for fall and a high risk for wandering. RN 1 stated that typically Resident 1 had an assigned one-to-one sitter but sometimes did not have anyone assigned as a one-to-one sitter because of staffing. RN 1 stated that on 8/20/2023, Resident 1 did not have anyone assigned to him as a one-to-one sitter for the 3 p.m. to 11 p.m. shift. On 8/26/2023 at 12:28 p.m., during an interview, the DON stated that Resident 1 had an unwitnessed fall on 8/20/2023. The DON stated that Resident 1 was a high risk for fall and a high risk for wandering. As part of a nursing intervention, the facility provides a one-to-one sitter but not all the time. When asked why not all the time, the DON answered because the one-to-one sitter was not a physician ' s order for Resident 1. On 8/27/2023 at 3:20 p.m., during an interview, CNA 7 stated that Resident 1 needed a one-to-one sitter to monitor him for wandering. CNA 7 stated that Resident 1 requires a one-to-one sitter to ensure his safety. CNA 7 further stated that Resident 1 needed more supervision because Resident 1 was an extreme fall risk. CNA 7 stated that he did not document Resident 1 ' s whereabouts during his 3 p.m. to 11 p.m. shift. On 8/27/2023 at 3:33 p.m., during an interview, CNA 8 stated that Resident 1 wandered around the facility. CNA 8 stated that facility staff were aware that Resident 1 was a fall risk and high risk for wandering. CNA 8 further stated that Resident 1 did not have a one-to-one sitter. CNA 8 stated she did not document Resident 1 ' s whereabouts during her 3 p.m. to 11 p.m. shift. On 8/27/2023 at 3:50 p.m., during an interview, LVN 9 stated that he was the assigned charge nurse for Resident 1 on 8/20/2023. When asked how the functionality of the wander guard bracelet was checked, LVN 9 stated that he did not check for the functionality of the wander guard bracelet on Resident 1. On 8/27/2023 at 4:00 p.m., during an interview, Housekeeping/Maintenance Staff (HMS) stated that exit doors in Station 1 had two alarms: the wander guard alarm and the red door alarms. The red door alarms should always be in the on position and no staff should be exiting through these doors. When the red alarm door is opened, the alarm will activate. The only way it will turn off is with a key held by housekeeping staff, maintenance staff, or licensed nurses. HMS stated that he did not know who was responsible to ensure that the red door alarms were armed (turned on). On 8/27/2023 at 4:15 p.m., during an interview, Licensed Vocational Nurse 10 (LVN 10) stated that on 8/20/2023 that she (LVN 10) saw Resident 1 wheeling himself around the facility. On 8/20/2023 another resident (name not given) informed LVN 10 that there was a resident that fell in the smoking patio. LVN 10 stated that together with CNA 6 they went to the smoking patio through the exit at Station 1 and found Resident 1 on the ground, in the pouring rain, with his wheelchair tipped over to his left side. LVN 10 stated that they found Resident 1 in a puddle of water, however, his head was not in the water. When asked if LVN 10 heard any alarms at that time, LVN 10 stated she did not hear any alarms because if she did, she would remember because the alarms ' noise is ear piercing. On 8/27/2023 at 4:50 p.m., during an interview, LVN 11 stated that Resident 1 currently has a wander guard bracelet. When asked how the functionality of the wander guard bracelet is checked, LVN 11 stated that she wheels Resident 1 near the door and if the alarm sounds Resident 1 ' s wander guard bracelet is functional. When asked how the functionality of the wander guard bracelet is checked if Resident 1 was in bed the whole day, LVN 11 stated she did not think of that and would not know how to check for functionality. LVN 11 further stated that she is not aware of the facility ' s policy on how to check for functionality of the wander guard bracelet. On 8/27/2023 at 6:11 p.m., during a concurrent observation and interview with the Assistant Director of Nursing (ADON), observed Certified Nursing Assistant 8 (CNA 8) wheeling Resident 1 (who was wearing the wander guard bracelet on his left ankle) in his wheelchair through Station 1 ' s exit that was facing the smoking patio. Observed Resident 1 outside in the smoking patio. Observed the wander guard system alarm did not sound an alarm. The ADON stated that the alarm did not sound and that the wander guard had malfunctioned. The ADON stated that the wander guard alarm should have started alarming prior to the resident exiting the door. On 9/3/2023 at 1:37 p.m., during a concurrent interview and review of the video footage taken from outside the building capturing the moment Resident 1, in his wheelchair, wheeling himself and exited the exit door near Station 1 going to the smoking patio, RN 2 stated the following events: 1. 5:38 p.m. (time adjusted considering daylight saving time to reflect the actual time of the event) - It was raining, and Resident 1 was wheeling himself towards the black gate (in the smoking patio). 2. 5:40 p.m. - Resident 1 was at the gate. 3. 5:41 p.m. - Resident 1 was wheeling self. It is difficult to tell what he is doing. 4. 5:42 p.m. - Resident 1 fell to the ground on his left side still sitting in his wheelchair (wheelchair also fell with Resident 1). Resident 1 was moving and looked like he is trying to get up but was unable to. It was still raining. 5. 5:49 p.m. - Facility staff came out. 6. 5:50 p.m. - Four staff went out to help Resident 1. It is difficult to distinguish who the staff are. On 9/3/2023 at 2:15 p.m., during an interview, the Administrator stated that based on the video footage that the facility reviewed, it showed that Resident 1 was wheeling himself through station 1 ' s exit door and Resident 1 was able to push through the door and was able to lead himself to the smoking patio unsupervised, where he did have an unwitnessed fall. The Administrator stated he did not have access and autonomy (the ability of the person to make his or her own decisions) to pull past video footages because that needs to be requested from the Information Technology (IT) department at the corporate level. The Administrator stated the reason of having camera footages is for security purposes and recording incidents and accidents. The Administrator stated he has no one monitoring the cameras. On 9/3/2023 at 2:25 p.m., during an interview, Maintenance Staff 1 (MS 1) stated that the wander guard alarm system is checked by MS 1 weekly. MS 1 stated the wander guard alarm system is checked for functionality by a testing devise that his department using. MS 1 stated that he points the testing device at the exit door where the wander guard system alarms are located, and it should alarm. When it alarms, MS 1 reset the wander guard system alarm with a code. MS 1 stated that currently the wander guard system alarm at Station 1 by the smoking patio is still not functioning and is waiting for a replacement part to be delivered. On 9/4/2023 at 1:25 p.m., during an interview, the Administrator stated that the red door alarm is the backup alarm for the exit doors. The Administrator stated that in the absence of the wander guard system the red door alarm is the fail-safe (guaranteed to work) alarm. The Administrator further stated that moving forward he will ensure that all exit doors that have the door alarms will be double- and triple-checked to ensure residents ' safety. On 9/4/2023 at 1:52 p.m., during an interview, RN 1 stated that Resident 1 ' s fall incident was avoidable. RN 1 stated that the facility did its best to supervise Resident 1 however the facility did not have enough staff to watch Resident 1 with a one-to-one sitter, which he needed. On 9/4/2023 at 4:02 p.m., during an interview, the Administrator stated Resident 1 ' s unwitnessed fall incident in the smoking patio was an avoidable incident. The Administrator stated that the incident would have been avoidable if the wander guard system was working. The Administrator stated that he believed that if the wander guard alarm went off and sounded it would have alerted someone to where Resident 1 was at the time. On 9/4/2023 at 4:35 p.m., during an interview, the DON stated that Resident 1 ' s unwitnessed fall incident in the smoking patio could have been avoided if there was proper supervision of Resident 1. The DON stated that someone should have known that Resident 1 was missing from the nurse ' s station. The DON stated that staff are supposed to supervise Resident 1 but, on that day, 8/20/2023, the facility had a lot of staff call outs because of the storm. A review of the facility provided policy titled, Safety and Supervision of Residents, revised 7/2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. A review of the facility provided policy titled, Wander Guard System, undated, indicated it is the policy of this facility to provide residents who are at risk for wandering, eloping (running away) and/or exit-seeking a safe environment and allow them to maintain their highest practicable label of well-being. Under Procedure: 1. Social Services and/or Nursing will assess for wandering, exit-seeking, and/or elopement behaviors on admission, quarterly, annually, and as needed; 2. Licensed nurses to check placement and function of the Wander guard every shift. Licensed nurses to use device tester and/or take resident to an exit door. A blinking green light means the device is working. If it is not working, the device will be replaced immediately; 6. Licensed Nurse or designee to write the date and application of the Wander guard on the Medication Administration Record (MAR); 7. Maintenance or designee to test the functionality of the Wander guard system (door) monthly; 8. Licensed Nurse to Initial MAR every shift for placement and functionality; 9. Resident with Wander guards will be documented and added in the elopement log each time. A review of the facility provided policy titled, Tab Alarms, Bed Alarms, Wanderguard System, undated, indicated, 6. After each application of the . wanderguard bracelet in place, a licensed nursing staff/appropriate designee will conduct a safety check to verify alarm device used is in proper working condition including proper function and placement to facility used alarm system per manufacturer instruction a) Documentation of the . wanderguard bracelet alarm proper function and placement checks will be made to the resident ' s clinical record on each unit and each shift daily and/or as directed per MD (medical doctor) order. b) Licensed Nursing Staff/Designee will be assigned to conduct safety check every shift on resident . wanderguard alarm device if repair or replacement needed c) Nursing Aide/staff to be made aware of resident on alarm system device use each shift for close supervision and will notify licensed nurse if identify . wanderguard bracelet alarm without proper function/placement immediately. A review of the facility provided policy titled, Closed-Circuit TVs, revised 4/2017, indicated, Our facility uses closed-circuit TVs in common areas of the facility (hallways, dining rooms, employee work areas, outside areas, etc.) to monitor the safety and well-being of our staff and residents. During a review of the facility provided manual on WanderGuard(R) ID SystemUser and Installation Manual, indicated Bracelet Testing: 1. Hold the Universal Tester within 1 foot from the bracelet, pointing the tester towards the bracelet. If the tester is not pointed towards the bracelet while testing a false bracelet test failure may occur; 2. Press and release the BRACLET button one time. The light above the button will flash and the test will search for a bracelet. You will notice the display will show scrolling animation until it detects the bracelet and then displays the test results. If the tester does not immediately detect the bracelet, it will continue to search for 10 seconds, then time out; 3. When the bracelet test is good, the tester display will show the bracelet ' s programmed 3-digit ID# and the bracelet test light will also blink green 4 times. The t3-digit ID # range is 000 to 899; 4. If a bracelet is in end of service mode, the tester display will show the bracelet ' s 3-digit ID # and the bracelet test light will stay steady red. This indicates the bracelet must be replaced immediately; 5. If a bracelet tests as bad, or is out of range of the tester, the display will show a dashed line across the center and the bracelet test light will stay steady red. Treat the result as indication of a non-functioning bracelet until proven otherwise. A second test should be conducted to confirm the state of the bracelet. Please refer to the Universal Tester User Manual for complete detailed instructions if you have any questions on the bracelet test procedure. Under DOOR Testing: The Universal Tester is designed to be used with the WanderGuard(R) ID System. The Universal Tester will also test WanderGuard(R) E, D, and 202 door modules but without the audio and visual feedback from the System Status Display or an audible chirp while testing for bracelet coverage. The Universal Tester will transmit a simulated bracelet signal. A normally functioning WanderGuard(R) ID System monitored door will recognize and react to this signal as if it were transmitted from a signaling device bracelet. The tester itself will not display the results of the test. Rather, the test results will be evident at the monitored door. The Primary Antenna and the System Status Display (SSD) will provide visual and audio feedback confirming normal operation. Under Detection Verification: 1. Make sure the door is closed or the Passive Infrared Sensor (PIR) is not detecting motion; 2. Hold the tester approximately six inches to the side of the door opening on the side opposite the monitor antenna at approximately door handle height. The tester should be held in a vertical (up-and-down) position for this test. If the WanderGuard(R) is monitoring a hallway or double doors, place the tester mid-way between the two antennas; 3. Press and hold the DOOR button on the Universal Tester. The amber light above the button will turn on and its display will show moving bars when the tester is transmitting. The Universal Tester will shut itself off after about 30 seconds of continuous button pressing. Releasing and again pressing the button will restart the test; 4. If the tester signal is detected, the primary antenna will begin chirping and the antenna light will flash orange. The System Status Display (SSD)will display DOOR TEST; 5. If the antenna does not chirp and the SSD displays BRACELET DETECTED instead, there is not sufficient signal to identify the tester ID (the system is still able to detect that a bracelet signal is present and will alarm if the door is opened or motion is sensed by a PIR). Moving the tester closer toward the antenna until the antenna begins to chirp will give an indication of where the ID detection begins; 6. The antenna not chirping and the SSD not indicating a bracelet has been detected may be an indication of: 1) The system is non-operational, 2) The system has reduced range or 3) The tester is not functioning or has shut itself off.; 7. In the case of no system response, move the tester to within 12 inches of an antenna and press and hold the DOOR button on the tester. If a response is now obtained, the system's range has been reduced and you should proceed to the troubleshooting section to try to resolve the problem; 8. If no response is obtained at 12 inches from the antenna, try the tester at a different WanderGuard(R) ID monitor to see if the tester is functioning. If the tester is working at a different monitor, then the door monitor is not working properly. Refer to the Troubleshooting section for more instructions. Alternatively, an active bracelet can be used at the non-responsive location to see if it is functional. The Medical Records personnel was not able to provide the facility ' s policy and procedure regarding red door alarms.

Based on observation, interview, and record review, the facility failed to protect a resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1) by: 1. Failing to monitor Resident 1 ' s whereabouts and failing to provide supervision to Resident 1 who was at risk for wandering (going about from place to place) and high risk for falls. 2. Failing to ensure Resident 1 ' s wander guard bracelet (a device designed to activate alarms when a resident gets closer to entry and exit points) activated the wander guard alarm or system when Resident 1, in his wheelchair, exited the exit door near Station 1 while wheeling himself going outside the building to the smoking patio. 3. Failing to ensure staff were monitoring and checking Resident 1 ' s wander guard bracelet was working properly per manufacturer ' s guidelines. 4. Failing to ensure the door alarms at Station 1 exit door activated when Resident 1 exited using that door going to the smoking patio. 5. Failing to ensure the surveillance cameras were monitored when Resident 1 exited by the exit door at Station 1 while wheeling himself going outside the building to the smoking patio in the pouring rain. As a result, Resident 1 exited to the smoking patio on 8/20/2023 at 6:38 p.m. unnoticed and sustained an unwitnessed fall and was exposed to the rain for 13 minutes until the staff assisted Resident 1 back inside the facility at 6:51 p.m. This happened during a hurricane named [NAME] that was expected to cause extreme rain and flooding. This placed Resident 1 at high risk for hypothermia (a medical emergency that occurs when your body loses heat faster that it can produce heat, causing a dangerously low body temperature, which may lead to cardiac [referring to the heart] and respiratory [referring to the lungs] failure and eventually to death) from staying wet and cold for a prolonged period. Also, 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 outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills and medical condition, an individual subjected to neglect, 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 yourself). On 9/4/2023 at 6:39 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation. The Administrator and Registered Nurse 2 (RN 2) were notified of the IJ from the failure to ensure Resident 1 was free from neglect. On 9/7/2023 at 11:23 a.m., the IJ was removed in the presence of the Administrator and Director of Nursing (DON), while onsite, after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan which included the following summarized actions: 1. Resident 1 ' s whereabouts were monitored by licensed nurses every shift. Resident 1 was continuously being placed in a highly visible area such as in front of the nurse station, activity room and dining room for close observation. The assigned certified nursing assistant (CNA) to continue frequent visual monitoring of the resident every two hours during shift. 2. Maintenance Supervisor checked all the facility ' s entry/exit doors including emergency exits on 9/1/2023. All stop alarms on emergency entry/exit doors were functioning well. 3. All facility ' s entry and exit doors to include emergency exits will be monitored by the maintenance staff/designee daily for proper function. In case an entry/exit door alarm is not working, a facility staff will be assigned to monitor until the malfunctioning (not working) entry/exit door is fixed. 4. Continue to ensure wander guards are in place and functioning on high-risk residents. 5. DON conducted a review of all residents on wander guards on 9/4/2023 to ensure placement and functional wander guards. 6. Director of Staff Development (DSD) started providing in-service to all staff on 9/5/2023 regarding the facility ' s policy and procedures on the following: a. Wander Guard Monitoring for Placement and Functioning based on Manufacturer ' s Guidelines b. Resident Monitoring for Safety and Supervision c. Resident Abuse, and Neglect d. Accident, Hazards, and Safety 7. The licensed nurse to check wander guard placement and functionality (whether it is working) every shift and document result. The date of placement will also be documented including the date of the replacement. 8. The Licensed Nurse to conduct nursing huddles to CNAs and charge nurses at the beginning of each shift to discuss residents at risk for wandering (to go about from place to place usually without a plan or definite purpose) including residents with wander guard devices. 9. Residents at risk for wandering will be checked by CNAs, restorative nursing assistants (RNAs), and licensed nurses during routine bedside care, scheduled medication administration, room rounds, and mealtime. 10. Activity staff to observe residents at risk for wandering if they are attending group activities. 11. The charge nurse on duty will ensure direct supervision/monitoring high risk for wandering residents is being conducted by assigned staff/CNA and endorsed to the next shift. 12. The entry/exit doors including emergency entry/exit doors and patio entry/exit door monitoring logs will be collected by the DSD/designee and will be reported during daily stand-up meetings. The RN supervisor/charge nurse/designee on duty during weekends will continue the process and report any discrepancy to the DON/Administrator/designee. 13. The Administrator/designee will review the exit door alarm check log daily for 30 days, the wander guard information log, and follow up immediately if with any negative findings. Any follow-up needed will be reported to the monthly Quality Assurance and Performance Improvement Committee for additional recommendation if there are residents who are high risk for wandering in the facility. The QAPI Committee will provide written recommendations to the Administrator. The Administrator will review such recommendations and act accordingly. Cross Reference with F689. Findings: A review of Resident 1 ' s Admission Record indicated the facility originally admitted the resident on 1/30/2023 and readmitted on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it that deprives brain cells of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant (in control) side , encephalopathy (alteration of mental status due to medications or toxic chemicals), muscle weakness, other abnormalities of gait (walking) and mobility, repeated falls, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified severity, with other behavioral disturbance , and personal history of other mental and behavioral disorders. A review of Resident 1 ' s care plan, dated 5/9/2023, indicated resident was at risk for fall, injury, and wandering with history of wanting to go home. Interventions included to apply wander guard in the ankle and in wheelchair due to resident episodes of removing wander guard on wrist and to apply wander guard to monitor any attempts of getting out of the facility. Other interventions included to monitor and document for wander guard placement and function, monitor resident any attempts to wander/go outside unattended and unknown to staff, and tally with hashmark. A review of the physician ' s order of Resident 1, dated 5/24/2023 at 5:47 p.m., indicated an order to apply wander guard to Resident 1 to monitor any attempts of getting out of the facility. The physician ' s order indicated to monitor Resident 1 for wander guard ' s placement and function by documenting Y for Yes or N for No. A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 8/4/2023, indicated Resident 1 ' s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive assistance with two-person physical assistance with bed mobility and transfer and required extensive assistance with one person assistance with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair), locomotion off unit (how resident moves to and returns from off-unit locations like areas set aside for dining, activities, or treatment. If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair), dressing, toilet use, and personal hygiene. A review of Resident 1 ' s Wandering Assessment form, dated 8/18/2023 at 4:33 p.m., indicated Resident 1 was a high risk for wandering. A review of Resident 1 ' s Fall Risk Assessment form, dated 8/18/2023 at 4:38 p.m., indicated Resident 1 was considered a high risk for potential falls. A review of Resident 1 ' s nursing progress note, dated 8/20/2023 at 8:22 p.m., indicated that on 8/20/2023 at 7:07 p.m. Resident 1 had an unwitnessed fall outside in the smoking patio and that Resident 1 was attempting to roll wheelchair but got stuck and tipped over. The nursing progress note indicated Resident 1 stated he was cold. On 8/26/2023 at 12:08 p.m., during an interview, Certified Nursing Assistant 6 (CNA 6) stated Resident 1 was a one-to-one (needing an assigned sitter). CNA 6 stated she was informed by another resident (name not given) that Resident 1 was on the floor in the smoking patio. CNA 6 stated that she went to check the smoking patio from Station 1 ' s exit doors and found Resident 1 lying on the ground still in his wheelchair. CNA 6 stated that it was raining, and Resident 1 fell with his wheelchair and was lying in a puddle of water. CNA 6 further stated that when she (CNA 6) exited the doors of Station 1 to the smoking patio, there were no door alarms that were heard. On 8/26/2023 at 12:26 p.m., during an interview, RN 1 stated that Resident 1 is a high risk for fall and a high risk for wandering. RN 1 stated that typically Resident 1 had an assigned one-to-one sitter but sometimes did not have anyone assigned as a one-to-one sitter because of no available staff to be a sitter. RN 1 stated that on 8/20/2023, Resident 1 did not have anyone assigned to him as a one-to-one sitter for the 3 p.m. to 11 p.m. shift. On 8/26/2023 at 12:28 p.m., during an interview, the DON stated that Resident 1 had an unwitnessed fall on 8/20/2023. The DON stated that Resident 1 was a high risk for fall and a high risk for wandering. As part of a nursing intervention, the facility provides a one-to-one sitter but not all the time. When asked why not all the time, the DON answered because the one-to-one sitter was not a physician ' s order for Resident 1. On 8/27/2023 at 3:20 p.m., during an interview, CNA 7 stated that Resident 1 needed a one-to-one sitter to monitor him for wandering. CNA 7 stated that Resident 1 requires a one-to-one sitter to ensure his safety. CNA 7 further stated that Resident 1 needed more supervision because Resident 1 was an extreme fall risk. CNA 7 stated that he did not document Resident 1 ' s whereabouts during his 3 p.m. to 11 p.m. shift on 8/20/2023. On 8/27/2023 at 3:33 p.m., during an interview, CNA 8 stated that Resident 1 wandered around the facility. CNA 8 stated that facility staff were aware that Resident 1 was a fall risk and high risk for wandering. CNA 8 further stated that Resident 1 did not have a one-to-one sitter. CNA 8 stated she did not document Resident 1 ' s whereabouts during her 3 p.m. to 11 p.m. shift on 8/20/2023. On 8/27/2023 at 3:50 p.m., during an interview, Licensed Vocational Nurse 9 (LVN 9) stated that he was the assigned charge nurse for Resident 1 on 8/20/2023. When asked how the functionality of the wander guard bracelet was checked, LVN 9 stated that he did not check for the functionality of the wander guard bracelet on Resident 1. On 8/27/2023 at 4:00 p.m., during an interview, Housekeeping/Maintenance Staff (HMS) stated that exit doors in Station 1 had two alarms: the wander guard alarm and the red door alarms. The red door alarms should always be in the on position and no staff should be exiting through these doors. When the red alarm door is opened, the alarm will activate. The only way it will turn off is with a key held by housekeeping staff, maintenance staff, or licensed nurses. HMS stated that he did not know who was responsible to ensure that the red door alarms were armed (turned on). On 8/27/2023 at 4:15 p.m., during an interview, Licensed Vocational Nurse 10 (LVN 10) stated that on 8/20/2023 that she (LVN 10) saw Resident 1 wheeling himself in his wheelchair around the facility. On 8/20/2023 another resident (name not given) informed LVN 10 that there was a resident that fell in the smoking patio. LVN 10 stated that together with CNA 6 they went to the smoking patio through the exit at Station 1 and found Resident 1 on the ground, in the pouring rain, with his wheelchair tipped over to his left side. LVN 10 stated that they found Resident 1 in a puddle of water, however, his head was not in the water. When asked if LVN 10 heard any alarms at that time, LVN 10 stated she did not hear any alarms because if she did, she would remember because the alarms ' noise is ear piercing. On 8/27/2023 at 4:50 p.m., during an interview, LVN 11 stated that Resident 1 currently has a wander guard bracelet. When asked how the functionality of the wander guard bracelet is checked, LVN 11 stated that she wheels Resident 1 near the door and if the alarm sounds Resident 1 ' s wander guard bracelet is functional. When asked how the functionality of the wander guard bracelet is checked if Resident 1 was in bed the whole day, LVN 11 stated she did not think of that and would not know how to check for functionality. LVN 11 further stated that she is not aware of the facility ' s policy on how to check for functionality of the wander guard bracelet. On 8/27/2023 at 6:11 p.m., during a concurrent observation and interview with the Assistant Director of Nursing (ADON), observed Certified Nursing Assistant 8 (CNA 8) wheeling Resident 1 (who was wearing the wander guard bracelet on his left ankle) in his wheelchair through Station 1 ' s exit that was facing the smoking patio. Observed Resident 1 outside in the smoking patio. Observed the wander guard system alarm did not sound an alarm. The ADON stated that the alarm did not sound and that the wander guard had malfunctioned. The ADON stated that the wander guard alarm should have started alarming prior to the resident exiting the door. On 9/3/2023 at 1:37 p.m., during a concurrent interview and review of the facility provided video footage taken from outside the building capturing the moment Resident 1, in his wheelchair, wheeling himself and exited the exit door near Station 1 going to the smoking patio on 8/20/2023, RN 2 stated the following events: 1. 5:38 p.m. (time adjusted considering daylight saving time to reflect the actual time of the event) - It was raining, and Resident 1 was wheeling himself towards the black gate (in the smoking patio). 2. 5:40 p.m. - Resident 1 was at the gate. 3. 5:41 p.m. - Resident 1 was wheeling self. It is difficult to tell what he is doing. 4. 5:42 p.m. - Resident 1 fell to the ground on his left side still sitting in his wheelchair (wheelchair also fell with Resident 1). Resident 1 was moving and looked like he is trying to get up but was unable to. It was still raining. 5. 5:49 p.m. - Facility staff came out. 6. 5:50 p.m. - Four staff went out to help Resident 1. It is difficult to distinguish who the staff are. On 9/3/2023 at 2:15 p.m., during an interview, the Administrator stated that based on the video footage that the facility reviewed, it showed that Resident 1 was wheeling himself through station 1 ' s exit door and Resident 1 was able to push through the door and was able to lead himself to the smoking patio unsupervised, where he did have an unwitnessed fall. The Administrator stated he did not have access and autonomy (the ability of the person to make his or her own decisions) to pull past video footages because that needs to be requested from the Information Technology (IT) department at the corporate level. The Administrator stated the reason of having camera footages is for security purposes and recording incidents and accidents. The Administrator stated he has no one monitoring the cameras. On 9/3/2023 at 2:25 p.m., during an interview, Maintenance Staff 1 (MS 1) stated that the wander guard alarm system is checked by MS 1 weekly. MS 1 stated the wander guard alarm system is checked for functionality by a testing devise that his department is using. MS 1 stated that he points the testing devise at the exit door where the wander guard system alarms are located, and it should alarm. When it alarms, MS 1 reset the wander guard system alarm with a code. MS 1 stated that currently the wander guard system alarm at Station 1 by the smoking patio is still not functioning and is waiting for a replacement part to be delivered. On 9/4/2023 at 1:25 p.m., during an interview, the Administrator stated that the red door alarm is the backup alarm for the exit doors. The Administrator stated that in the absence of the wander guard system the red door alarm is the fail-safe (guaranteed to work) alarm. The Administrator further stated that moving forward he will ensure that all exit doors that have the door alarms will be double- and triple-checked to ensure residents ' safety. On 9/4/2023 at 1:52 p.m., during an interview, RN 1 stated that Resident 1 ' s fall incident was avoidable. RN 1 stated that the facility did its best to supervise Resident 1 however the facility did not have enough staff to watch Resident 1 with a one-to-one sitter, which he needed. On 9/4/2023 at 4:02 p.m., during an interview, the Administrator stated Resident 1 ' s unwitnessed fall incident in the smoking patio was an avoidable incident. The Administrator stated that the incident would have been avoidable if the wander guard system was working. The ADM stated that he believed that if the wander guard alarm went off and sounded it would have alerted someone to where Resident 1 was at the time. On 9/4/2023 at 4:35 p.m., during an interview, the DON stated that Resident 1 ' s unwitnessed fall incident in the smoking patio could have been avoided if there was proper supervision of Resident 1. The DON stated that someone should have known that Resident 1 was missing from the nurse ' s station. The DON stated that staff are supposed to supervise Resident 1 but, on that day, 8/20/2023, the facility had a lot of staff call outs because of the storm. A review of the facility provided policy titled, Abuse Prevention Program, revised 12/2016, indicated a policy statement indicating, Our residents have the right to be free from . neglect Develop and implement policies and procedures to aid our facility in preventing . neglect A review of the facility provided policy titled, Abuse and Neglect - Clinical Protocol, revised 3/2018, indicated under Treatment and Management that, The facility management and staff will institute measures to address the needs of residents and minimize the possibility of . neglect. A review of the facility provided policy titled, Tab Alarms, Bed Alarms, Wanderguard System, undated, indicated, 6. After each application of the . wanderguard bracelet in place, a licensed nursing staff/appropriate designee will conduct a safety check to verify alarm device used is in proper working condition including proper function and placement to facility used alarm system per manufacturer instruction a) Documentation of the . wanderguard bracelet alarm proper function and placement checks will be made to the resident ' s clinical record on each unit and each shift daily and/or as directed per MD (medical doctor) order. b) Licensed Nursing Staff/Designee will be assigned to conduct safety check every shift on resident . wanderguard alarm device if repair or replacement needed c) Nursing Aide/staff to be made aware of resident on alarm system device use each shift for close supervision and will notify licensed nurse if identify . wanderguard bracelet alarm without proper function/placement immediately. A review of the facility provided policy titled, Closed-Circuit TVs, revised 4/2017, indicated, Our facility uses closed-circuit TVs in common areas of the facility (hallways, dining rooms, employee work areas, outside areas, etc.) to monitor the safety and well-being of our staff and residents. A review of the facility provided policy titled, Safety and Supervision of Residents, revised 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities When accident hazards are identifies, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of hazards and develop strategies to mitigate or remove the hazards to the extent possible. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accidents hazards and try to prevent accident. Under individualized, resident-centered approach to safety, it indicated that individualized resident-centered approach to safety addresses safety and accident hazards for individual residents The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devises. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Document interventions. Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed; and d. Evaluating the effectiveness of new or revised interventions. A review of the facility provided manual on WanderGuard(R) ID SystemUser and Installation Manual, indicated Bracelet Testing: 1. Hold the Universal Tester within 1 foot from the bracelet, pointing the tester towards the bracelet. If the tester is not pointed towards the bracelet while testing a false bracelet test failure may occur; 2. Press and release the BRACLET button one time. The light above the button will flash and the test will search for a bracelet. You will notice the display will show scrolling animation until it detects the bracelet and then displays the test results. If the tester does not immediately detect the bracelet, it will continue to search for 10 seconds, then time out; 3. When the bracelet test is good, the tester display will show the bracelet ' s programmed 3-digit ID# and the bracelet test light will also blink green 4 times. The t3-digit ID # range is 000 to 899; 4. If a bracelet is in end of service mode, the tester display will show the bracelet ' s 3-digit ID # and the bracelet test light will stay steady red. This indicates the bracelet must be replaced immediately; 5. If a bracelet tests as bad, or is out of range of the tester, the display will show a dashed line across the center and the bracelet test light will stay steady red. Treat the result as indication of a non-functioning bracelet until proven otherwise. A second test should be conducted to confirm the state of the bracelet. Please refer to the Universal Tester User Manual for complete detailed instructions if you have any questions on the bracelet test procedure. Under DOOR Testing: The Universal Tester is designed to be used with the WanderGuard(R) ID System. The Universal Tester will also test WanderGuard(R) E, D, and 202 door modules but without the audio and visual feedback from the System Status Display or an audible chirp while testing for bracelet coverage. The Universal Tester will transmit a simulated bracelet signal. A normally functioning WanderGuard(R) ID System monitored door will recognize and react to this signal as if it were transmitted from a signaling device bracelet. The tester itself will not display the results of the test. Rather, the test results will be evident at the monitored door. The Primary Antenna and the System Status Display (SSD) will provide visual and audio feedback confirming normal operation. Under Detection Verification: 1. Make sure the door is closed or the Passive Infrared Sensor (PIR) is not detecting motion; 2. Hold the tester approximately six inches to the side of the door opening on the side opposite the monitor antenna at approximately door handle height. The tester should be held in a vertical (up-and-down) position for this test. If the WanderGuard(R) is monitoring a hallway or double doors, place the tester mid-way between the two antennas; 3. Press and hold the DOOR button on the Universal Tester. The amber light above the button will turn on and its display will show moving bars when the tester is transmitting. The Universal Tester will shut itself off after about 30 seconds of continuous button pressing. Releasing and again pressing the button will restart the test; 4. If the tester signal is detected, the primary antenna will begin chirping and the antenna light will flash orange. The System Status Display (SSD)will display DOOR TEST; 5. If the antenna does not chirp and the SSD displays BRACELET DETECTED instead, there is not sufficient signal to identify the tester ID (the system is still able to detect that a bracelet signal is present and will alarm if the door is opened or motion is sensed by a PIR). Moving the tester closer toward the antenna until the antenna begins to chirp will give an indication of where the ID detection begins; 6. The antenna not chirping and the SSD not indicating a bracelet has been detected may be an indication of: 1) The system is non-operational, 2) The system has reduced range or 3) The tester is not functioning or has shut itself off.; 7. In the case of no system response, move the tester to within 12 inches of an antenna and press and hold the DOOR button on the tester. If a response is now obtained, the system's range has been reduced and you should proceed to the troubleshooting section to try to resolve the problem; 8. If no response is obtained at 12 inches from the antenna, try the tester at a different WanderGuard(R) ID monitor to see if the tester is functioning. If the tester is working at a different monitor, then the door monitor is not working properly. Refer to the Troubleshooting section for more instructions. Alternatively, an active bracelet can be used at the non-responsive location to see if it is functional. The Medical Records personnel was not able to provide the facility ' s policy and procedure regarding red door alarms.

Based on interview and record review, the facility failed to safely transfer one of six sampled residents (Resident 92) from bed to wheelchair using the sit-to-stand lift (a mechanical device that helps lift a resident to rise from a seated position) with one-person staff assistance instead of the recommended two-person staff assistance (needing the help of two trained caregivers for patients who are too weak, too unsteady or otherwise unable to move themselves safely) according to the equipment's manual and Resident 92's plan of care. On 9/9/2022 at 10:50 a.m., Certified Nursing Assistant 1 (CNA 1), with no help from another staff, assisted Resident 92 to transfer from bed to wheelchair using the sit-to-stand lift. While on the sit-to-stand machine during transfer from bed to wheelchair, Resident 92 fainted, fell , and hit his head on the floor. This deficient practice resulted to facility transferring Resident 92 to General Acute Care Hospital 1 (GACH 1) on 9/9/2022 at 11:35 a.m. for further treatment and evaluation. Resident 92 suffered a right head subdural hematoma (a type of bleed inside the head that occurs within the skull but outside the actual brain tissue, usually caused by a head injury strong enough to burst blood vessels) and underwent a right hemicraniectomy (a surgical procedure where a large flap of the skull is removed so brain swelling can be relieved inside the skull) for the removal of the subdural hematoma. Findings: A review of Resident 92's Face Sheet (Admission Record) indicated the facility admitted the resident on 8/5/2020 and readmitted on [DATE] with diagnoses that included thrombosis (a blood clot that reduces blood flow) of deep veins of right lower extremity (the right leg), embolism (obstruction of an artery by a blood clot), and traumatic subdural hemorrhage (also known as a subdural hematoma caused by trauma). A review of Resident 92's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2022, indicated Resident 92 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 92 required two-person extensive with bed mobility, transfer, locomotion on unit (how resident moves between locations in his/her room in a wheelchair), and locomotion off unit (how a resident moves to and returns from off-unit locations such as areas set aside for dining, activities or treatments). A review of Resident 92's Change of Condition Form (COC, a sudden clinical change from a patient's baseline in physical, cognitive, or behavioral functions), dated 9/9/2022, indicated that on 9/9/2022, during the morning shift, Resident 92 passed out while on the sit-to-stand machine during transfer from bed to wheelchair. The COC indicated the facility transferred Resident 92 to GACH 1. A review of Resident 92's Fall Risk Assessment, dated 8/10/2022, indicated Resident 92's risk for fall was moderate. A review of Resident 92's care plan for Risk for Falls, initiated on 8/6/2022, indicated Resident 92 was at risk for fall. The care plan indicated an intervention, initiated on 10/18/2022, for staff to use a mechanical lift (Hoyer or total body lift, a mechanical device to transfer a resident who is unable to move himself or help in moving in any way) for transfer with two-person assistance. A review of Resident 92's care plan for Activities of Daily Living (ADL, fundamental skills a person needs for self-care, such as combing hair and brushing teeth), dated 8/19/2022, indicated an intervention, initiated on 8/19/2022, that Resident 92 requires staff assistance to move between surfaces and staff may use the sit-to-stand machine with two-person assistance. A review of Resident 92's GACH 1 Computed Tomography (CT, a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) notes of the head, dated 9/9/2022, indicated Resident 92 suffered a right head subdural hematoma. A review of Resident 92's GACH 1 Operative Notes, dated 9/9/2022, indicated Resident 92 had a large right subdural hematoma. The Operative Notes indicated Resident 92 was immediately brought to the OR within one hour of arrival at GACH 1 and underwent a right hemicraniectomy for evacuation (removal) of the subdural hematoma. The Operative Notes indicated that after the operation, Resident 92 was kept intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into the trachea [airway/windpipe] so that air can get through) and brought in stable (not deteriorating in health after an operation) but critical condition (very sick or injured and likely to die) to GACH 1's Intensive Care Unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation). A review of Resident 92's Interdisciplinary Team (IDT, a group of professionals from various disciplines [such as nursing, nutrition, physical therapy] who work together to address a resident's physical and psychological needs) Review Note, dated 9/21/2022, indicated Resident 92 had a fall incident on 9/9/2022 at approximately 10:50 a.m. CNA 1 reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 92 passed out during transfer from bed to wheelchair using the sit-to-stand machine. The IDT note indicated LVN 1 saw Resident 92 lying on the floor, passed out, and LVN 1 called Resident 92's name, but Resident 92 did not respond for five to ten seconds. The IDT note indicated Resident 92's blood pressure (the pressure of circulating blood against the walls of blood vessels) was 90/67 millimeters of Mercury (mmHg, a unit of measure, the normal blood pressure being approximately 120/80 mmHg; the upper number being the systolic blood pressure which is the pressure in the arteries when the heart beats and the lower number, the diastolic, which is the pressure in the arteries when the heart rests between beats). The IDT note indicated the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) were called, Resident 92 was given oxygen at 2 liters per minute (L/min, a unit of measure) on a nasal canula (a tube to provide additional oxygen to a resident), and Resident 92 left the facility to go to GACH 1 on 9/9/2022 at 11:35 a.m. A review of Resident 92's IDT Review Note, dated 10/18/2022, indicated the investigation report related to the fall concluded that CNA 1 used the sit-to-stand machine with no assistance. The Note indicated an in-service was done for CNA 1 in which the proper use of the sit to stand lift is a two-person assistance during transfer. A review of Resident 92's Witness Statement for Investigation, dated 10/14/2022, indicated Resident 92 stated CNA 1 transferred him from bed to wheelchair using the sit-to-stand machine. The Witness Statement indicated Resident 92 stated the machine was slow and he lost consciousness as CNA 1 was putting him to the wheelchair and stated he tried hard to hold onto the machine. The Witness Statement indicated Resident 92 stated CNA 1 left the room to go call for help but came back right away. The Witness Statement indicated Resident 92 stated he was still holding onto the machine and CNA 1 was trying to help him to the floor and he felt he hit his head on the floor. A review of CNA 1's Witness Statement for Investigation, dated 10/14/2022, indicated CNA 1 stated he prepared Resident 92 for transfer after cleaning and changing Resident 92's clothes. The Witness Statement indicated CNA 1 stated he used the sit-to-stand machine to transfer Resident 92 and asked many times Resident 92 was ok and ready for transfer to which Resident 92 responded yes all the time. The Witness Statement indicated CNA 1 stated that while transferring Resident 92, Resident 92 suddenly fainted, and CNA 1 assisted Resident 92 fall on the floor. During an interview on 10/25/2022 at 12:47 p.m., Resident 92 stated CNA 1 was his CNA on 9/9/2022, the day of his fall. Resident 92 stated CNA 1 had no assistance (in using the sit-to-stand lift) from another staff and that he (Resident 92) fell . Resident 92 stated he hit his head on the floor and, as a result, had to go to the hospital. During an interview on 10/26/2022 at 4:33 p.m., the Director of Nursing (DON) stated CNA 1 used the sit-to-stand lift to move Resident 92 from bed to wheelchair. The DON stated CNA 1 was the only staff using the sit-to-stand lift with Resident 92 and, there should have been two people assisting when using the sit-to-stand machine. The DON stated there could have been a different outcome with two people in which Resident 92 would not have been injured. The DON stated he did not know when the assessment for the sit-to-stand lift machine was done and did not know when staff started using the sit-to-stand lift machine in moving Resident 92 from bed to wheelchair. The DON stated that on Resident 92's MDS, dated [DATE], Resident 92 required two-person assistance during transfers from bed to wheelchair. The DON stated he did not know why CNA 1 did not have another staff with him when moving Resident 92 on 9/9/2022 from a sitting position in bed to standing up and transfer to Resident 92's wheelchair. During an interview on 10/27/2022 at 2:49 p.m., and concurrent record review of CNA 1's LIFT/Hoyer (LIFT referring to sit-to-stand machine) Machine Training Acknowledgment, dated 6/23/2022, the Director of Staff Development (DSD) stated CNA 1 received training on how to use the sit-to-stand machine. The DSD stated the training for the sit-to-stand machine indicated to be accomplished by two staff present during a resident transfer. A concurrent record review of CNA 1's Employee One to One In-service Training form, dated 9/16/2022, indicated CNA 1 received an in-service on how to use the sit-to-stand machine on 9/16/2022. The DSD stated CNA 1 received an in-service on the sit-to-stand machine on 9/16/2022. A concurrent record review of CNA 1's Competency Assessment, using a Mechanical Lifting Machine, dated 9/16/2022, indicated that at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift (which included the sit-to-stand lift). During an interview on 10/28/2022 at 8:22 a.m., and concurrent record review of the undated sit-to-stand manual, the DON, who provided the manual stated two assistants are recommended for transfer to a wheelchair. The DON stated the manual indicated one assistant stands behind the chair and the other operates the patient lift. The manual indicated the assistant behind the chair pulls back on the grab handle or sides of the sling to seat the patient well into the back of the chair. The DON stated there needs to be two staff present when operating the sit-to-stand manual. The DON stated the importance of two staff using the sit-to-stand lift for resident transfer is for safety so that a resident is not injured during transfer. The DON stated there was no facility policy for the use of the sit-to-stand machine. The DON stated Resident 92 did not have an assessment for the use of the sit-to-stand machine. During an interview on 10/28/2022 at 9:10 a.m., CNA 1 stated he was trained to have another staff present when he transfers a resident with the sit-to-stand machine. CNA 1 stated he operated the sit-to-stand machine with no other staff assisting on 9/9/2022, when Resident 92 fell during transfer from bed to wheelchair. CNA 1 stated that when Resident 92 fainted, CNA 1 helped Resident 92 fall to the floor. CNA 1 stated Resident 92 really wanted to get up into the wheelchair that day and that was why he did not ask another staff to help him when he transferred Resident 92. During an interview on 10/28/22 at 10:50 a.m., the DON stated there is no facility policy for the sit-to-stand lift. The DON stated the two-person assistance indicated in the sit-to-stand training conducted by the DSD is what the facility uses as a guide in place of a facility policy.

Based on observation, interview and record review, the facility failed the following for two of four sampled residents (Resident 5 and Resident 93): a. For Resident 5 who had severe weight losses (weight loss greater than 5 percent [%, out of 100] for one month interval, 7.5% for three months interval, and 10% for six months interval) on 7/8/2022, 8/8/2022, 9/7/2022, and 10/13/2022, the facility: 1. Failed to ensure the Registered Dietitian's (RD's) recommendation on 6/23/2022 to add 120 milliliter (ml, unit of measurement) TwoCal (a nutritionally complete, high-calorie formula designed to meet the needs of people with increased protein and calorie requirements) twice a day during medication pass was given to Resident 5. 2. Failed to ensure the RD's recommendation on 7/21/2022 to add four ounces (oz., unit of measurement) of high protein nourishment with meals three time a day was added to Resident 5's diet. 3. Failed to ensure the RD's recommendation on 8/12/2022 for Resident 5 to receive Restorative Nursing Assistant (RNA, staff who have special training, skills and knowledge in therapeutic or rehabilitative techniques that they put into practice under the direct supervision of a licensed professional) feeding assistance during breakfast and lunch was implemented. 4. Failed to ensure the RD's recommendation on 9/28/2022 for Resident 5 to take Megace ES (an appetite stimulant) or equivalent per Medical Doctor's (MD's) discretion was carried out. This recommendation was carried out on 10/11/2022. These deficient practices resulted to Resident 5's hospitalization on [DATE] to 8/21/2022 to the General Acute Care Hospital 1 (GACH 1) with diagnosis including dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and chronic anemia (decreased oxygen-carrying capacity of the blood leading to tissue hypoxia [absence of enough oxygen in the tissues to sustain bodily functions]). As of 10/13/2022, Resident 5 had 14.1 % severe weight loss in three months and 21% severe weight loss in six months. b. For Resident 93, the facility failed to provide gastrostomy tube (GT - a tube inserted through the belly that brings nutrition directly to the stomach) according to physician's orders and to ensure weights were obtained and documented in Resident 93's medical record according to physician's orders and the facility's policy and procedure. These deficient practices had the potential to result in weight loss and inaccurate weight tracking for Resident 93. Findings: a. A review of Resident 5's Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), dementia (a group of thinking and social symptoms that interferes with daily functioning), and unspecified intellectual disabilities (a broad category of disorders characterized by an impairment to the intelligence an individual possesses). A review of Resident 5's General Acute Hospital 1's Skilled Nursing Facility (SNF) Transfer Orders, dated 8/21/2022, indicated GACH 1 admitted Resident 5 on 8/16/2022 and discharged back to the SNF facility on 8/21/2022, with diagnosis including dehydration, chronic anemia, and dysphagia (swallowing difficulties). A review of Resident 5's Quarterly Minimum Data Set (MDS, a standardized assessment and screening tool), dated 10/6/2022, indicated Resident 5 had the ability to sometimes makes self-understood and ability to sometimes understand others. The MDS indicated Resident 5 required extensive assistance for transfer, dressing, toilet use, personal hygiene, bathing and limited assistance with eating. On 10/24/2022 at 12:21 p.m., during an observation, Resident 5 was sitting in a wheelchair directly in front of the overbed table with a meal tray on top. Resident 5 was observed not eating at this time. There was no staff in the room helping with feeding or supervision to Resident 5. During a concurrent interview, Resident 5 was asked about the food, Resident 5 mumbled and was incoherent. On 10/24/2022 at 12:45 p.m., during an observation, Resident 5 was still sitting in the wheelchair in front of the overbed table with a meal tray on top. Resident 5 was observed still not eating at this time. Meal tray contained a plate with pureed food (food that has been crushed so that it forms a thick, smooth liquid) which were untouched, two bowls of soup containing yellow colored soup with one bowl half consumed, a cup of empty apple sauce and an eight oz. glass of thickened milk 1/4 consumed. There was no meal ticket on the tray. On 10/24/2022 at 12:58 p.m., during an observation, Certified Nurse Assistant 9 (CNA 9) was removing the meal tray of Resident 5. During a concurrent interview, CNA 9, upon exiting Resident 5's room, stated Resident 5 was finished eating. A photograph of Resident 5's meal tray was taken while interviewing CNA 9. On 10/26/2022 at 10:49 a.m., during a concurrent interview and record review of CNA 9's documentation of Resident 5's meal percentage intake on 10/24/2022, the Assistant Director of Nursing (ADON) stated CNA 9 documented Resident 5 had a 26% to 50% meal intake for lunch on 10/24/2022. During a concurrent record review of the photographs taken on 10/24/2022 of Resident 5's meal tray after CNA 9 took Resident 5's meal tray away, the ADON stated an estimate of Resident 5's intake was at 0 to 25%. The ADON stated CNA 9's documentation of 26% to 50% meal intake was inaccurate. The ADON stated an intake of 0 to 25% can result to a significant weight loss. On 10/26/2022 at 11 a.m., a record review of Resident 5's Weights and Vitals Exceptions (dated 3/3/2022 to 10/13 2022) and Registered Dietitian's (RD's) Progress Notes (dated 6/23/2022 to 9/28/2022), together with the ADON, indicated the following: 1. Resident 5's Weights and Vitals Exceptions: a. 3/3/2022 - 167 pounds (lbs., unit of measurement) b. 4/16/2022 - 162 lbs. c. 5/8/2022 - 160 lbs. d. 6/2/2022 - 159 lbs. e. 6/11/2022 - 156 lbs. f. 6/25/2022 - 152 lbs. g. 7/8/2022 - 149 lbs. (13 lbs. or 8% severe weight loss from 4/16/2022 or in three months) h. 8/4/2022 - 144 lbs. i. 8/8/2022 - 141 lbs. (8 lbs. or 5.4% severe weight loss from 7/8/2022 or in one month; 19 lbs. or 11.9% severe weight loss from 5/8/2022 or in three months) j. 8/15/2022 - 141 lbs. k. 9/7/2022 - 132 lbs. (9 lbs. or 6.4% severe weight loss from 8/8/2022 or in one month; 24 lbs. or 15.4% severe weight loss from 6/11/2022 or in three months; 35 lbs. or 21% severe weight loss from 3/3/2022 or in six months) l. 10/13/2022 - 128 lbs. (21 lbs. or 14.1% severe weight loss from 7/8/2022 or in three months; 34 lbs. or 21% severe weight loss from 4/16/2022 or in six months) 2. Progress Notes (RD-Registered Dietitian) Forms for Resident 5: a. A review of the RD Progress Notes, dated 6/23/2022, indicated Resident 5 had 20 lbs. weight loss in six months and weekly weights indicate six lbs. loss. The RD recommended to add 120 ml TwoCal twice a day during medication pass. b. A review of the RD Progress Notes, dated 7/21/2022, indicated Resident 5 had significant weight changes with 10 lbs. weight loss in one month and 23 lbs. weight loss in 6 months. The RD recommended to change diet to pureed/nectar thick liquid (liquids coats and drips off a spoon like a lightly set gelatin) and add 4 ounces of high protein nourishment with meals three time a day. c. A review of the RD Progress Notes, dated 8/12/2022, indicated the Interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) reviewed Resident 5 due to significant weight losses of 18 lbs. in 3 months or 11.11% and 28 lbs. in 6 months or 16.2%. The RD requested RNA feeding assistance during breakfast and lunch and requested updates on food preferences. d. A review of the RD Progress Notes, dated 9/28/2022, indicated the IDT team reviewed Resident 5 due to 12-lbs. weight loss. The RD recommended an appetite stimulant, Megace ES, or equivalent per MD discretion. On 10/26/22 at 4:13 p.m., during a concurrent record review and interview, the RD stated she recommended 120 ml TwoCal twice a day during medication pass on 6/23/2022, four oz. of high protein nourishment with meals three times a day on 7/21/2022, RNA feeding assistance during breakfast and lunch on 8/12/2022, and appetite stimulant Megace ES or equivalent per MD discretion on 9/28/2022. The RD, during a concurrent review of the photograph of the lunch meal tray taken on 10/24/2022, stated that it should have been documented as 1 to 25 % and not 26% to 50% which was inaccurate. The RD stated had the facility staff carried out the RD recommendations, it would have resulted to a different outcome with Resident 5's weight changes. On 10/27/22 at 9:06 a.m., during an interview, CNA 9 stated she was assigned to Resident 5 on 10/24/2022, and during lunch she passed the meal trays to Resident 5 and to other residents. CNA 9 stated she set up the tray on the overbed table of Resident 5 who was sitting in his wheelchair at that time and then she (CNA 9) left to feed another resident in another room. CNA 9 stated that Resident 5 was not on the RNA feeding program on 10/24/2022 that was why she did not assist in feeding Resident 5. On 10/27/22 at 11:46 a.m., during a concurrent interview and record review of Resident 5's Medication Administration Record (MAR) on 6/2022 to 10/2022, physician's orders, and care plans, the ADON stated there was no documented evidence that the RD recommendation on 6/23/22 to add TwoCal 120 ml twice a day was given to Resident 5 during medication pass. The ADON stated there was no documented evidence that the RD recommendation on 7/21/2022 to add four oz. of high protein nourishment with meals three times a day was given to Resident 5. The ADON stated there was no documented evidence the RD recommendation on 8/12/2022 to place Resident 5 on the RNA feeding assistance program for breakfast and lunch was done. The ADON stated there was no documented evidence Resident 5 had an RNA feeding program care plan. The ADON stated the RD recommendation on 9/28/2022 for Resident 5 to have an appetite stimulant was only carried out on 10/11/2022. The ADON stated that if Resident 5 was losing weight and was not provided interventions, he will continue to lose weight and with his comorbidities he will decline and can suffer malnutrition which could result to dehydration and complications that could lead to hospitalization . During a concurrent record review of Resident 5's laboratory results report, dated 10/26/2022, the ADON stated Resident 5's Prealbumin (a blood test to see whether you are getting enough protein in your diet) was at 15 milligram per deciliter (mg/dL, a unit of measurement) which was flagged as LOW with a normal reference range of 18 to 38 mg/dL. The ADON stated a low prealbumin means Resident 5 needs more protein in his diet or more protein supplement and the low number would indicate malnutrition and dehydration that can be caused by poor meal intake. The ADON stated that if a resident is consuming a meal below 50%, it can result to malnutrition. A review of the facility's current policy and procedure titled, Weight Assessment and Intervention, last reviewed on 4/2022, indicated that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss= (usual weight- actual weight)/ (usual weight) x 100]: a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe c. 6 months- 10% weight loss is significant; greater than 10% is severe. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. Cognitive or functional decline; b. Chewing or swallowing abnormalities; c. Pain; d. Medication-related adverse consequences; e. Environmental factors (such as noise or distractions related to ding); f. Increased need for calories and/or protein; g. Poor digestion or absorption; h. Fluid and nutrient loss; and or i. Inadequate availability of food or fluids. Care Planning: 1. Care Planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident`s legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified cause of weight loss; b. Goals and benchmarks for improvement; c. Time frame and parameters for monitoring and reassessment. Interventions: 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and Hydration needs of the resident; c. Functional factors that may inhibit independent eating; d. Environmental factors that may inhibit appetite or desire to participate in meals; e. Chewing and swallowing abnormalities and the need for diet modifications; f. Medications that may interfere with appetite, chewing, swallowing, or digestion; g. The use of supplementation and/or feeding tubes; and h. End of life decisions and advance directives. 2. The Dietitian will discuss undesired weight gain with the resident and/or family. 3. Interventions for undesired weight gain should consider resident preferences and rights. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. 4. If a resident declines to participate in a weight loss goal, the Dietitian will document the resident`s wishes, and those wishes will be respected. A review of the facility's current policy and procedure titled, Restorative Nursing Services, last reviewed on 4/2022, indicated that residents will receive restorative nursing care as needed to help promote optimal safety and independence restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. A review of the facility's current policy and procedure titled, Assisting the Resident with In-room Meals, last reviewed on 4/2022, indicated that the purpose of this procedure is to provide appropriate assistance for resident who chose to receive meals in their rooms Review the resident's care plan and provide for any special needs of the resident. 46008 b. A review of Resident 93's Admission Record indicated the facility originally admitted the resident on 3/29/2022 and readmitted on [DATE] with diagnosis including type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing related problems), and end stage renal (kidneys) disease dependent on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). A review of Resident 93's MDS, dated [DATE], indicated the resident had moderate cognitive impairment (damaged or is not working properly). The MDS indicated Resident 93 required total assistance with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 93's Physician Orders, dated 9/26/2022, indicated Enteral (a route by way of tube to deliver nutrition to the stomach or intestines) Formula Nepro 1.8 at 50 milliliters (ml) per hour (hr) over 20 hours to provide 1000 ml/2160 kilocalories (kcal) in 24 hours. On at 7 p.m. and off at 11 a.m. Infuse feeding until total volume is infused via a pump. A review of Resident 93's Physician Orders, dated 10/24/2022, indicated Enteral Formula Nepro 1.8 at 75 ml per hr over 16 hours to provide 1200 ml/2160 per kcal in 24 hours. On at 7 p.m. and off at 11 a.m. Infuse feeding until total volume is infused via a pump. During an observation on 10/25/2022 at 7:59 a.m., in Resident 93's room, observed GT feeding pump off. On 10/25/2022 at 8:33 a.m., during a concurrent observation and interview in Resident 93's room, ADON turned on the GT pump and the GT pump indicated 457 ml volume infused. The ADON stated Resident 93 was supposed to have his GT feeding still on because the resident had not met the ordered 1200 ml for the day. The ADON stated Resident 93 not getting his GT feeding according to physician's orders placed the resident at risk for weight loss, not getting his nutrients, feelings of hunger, and dehydration. The ADON further stated the resident is diabetic which placed him at risk for low blood sugar that could cause confusion or alteration in mental status, and possible hospitalization . On 10/26/2022 at 9:16 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated Resident 93's GT feeding order was to be on at 7 p.m. and off at 11 a.m. or when the dose had been completed. The DON stated dose complete means the pump will stop running when it reached the set dose. The DON calculated Resident 93's GT feeding that was infused from 10/24/2022 at 7 p.m. to 10/25/2022 at 8 a.m., the DON stated Resident 93 should have received 975 ml; the DON stated the pump indicating 457 ml on 10/25/2022 at 8:33 a.m. was not accurate and was less than what the resident should have received at the time. The DON stated Resident 93's GT feeding being left off was not following physician's orders and placed Resident 93 at risk for weight loss and hypoglycemia (low blood sugar). On 10/26/2022 at 11:27 a.m., during a concurrent observation and interview, in Resident 93's room, Licensed Vocational Nurse 3 (LVN 3) turned the GT feeding pump on and the pump indicated 1000 ml infused, observed LVN 3 pressed the run/stop button, and the pump began to make a beeping sound. LVN 1 stated the pump making a beeping sound meant that the dose had been completed. LVN 3 stated 1000 ml was not the correct order as Resident 93 should have received 1200 ml. LVN 3 stated the pump was probably set up incorrectly with the incorrect dose limit when the order was changed. LVN 3 stated Resident 93 not receiving his GT feeding as ordered placed him at risk for weight loss and weakness. A review of Resident 93's Physician Orders, dated 9/26/2022, indicated admission weight followed by weekly weights for three weeks and then monthly. A review of Resident 93's Weights and Vitals Summary from 9/7/2022 to 10/27/2022 indicated the following: - 9/7/2022: 176 pounds (lbs.); (did not indicate the source the weight was obtained from) - 9/19/2022: 177 lbs. (wheelchair) - Resident was transferred to the hospital on 9/18/2022. - 10/7/2022: 159 lbs. (did not indicate the source the weight was obtained from) - 10/18/2022: 171 lbs. (did not indicate the source the weight was obtained from) A review of Resident 93's weight recorded on 9/7/2022 and 10/7/2022 indicated the resident lost 17 pounds in 30 days or 9.7%, a severe weight loss. On 10/27/2022 at 10:35 a.m., during a concurrent interview and record review, the DON stated Resident 93 did not have a recorded weight upon readmission but should have had one. The DON stated not monitoring the resident's weight according to physician's orders and facility policies placed the resident at risk for inaccurate weight loss and inaccurate interventions. During a concurrent interview and record review, there was no documented evidence that nursing reported resident's weight loss on 10/7/2022 to the physician. The DON stated Resident 93's weight loss was a change of condition and should have been reported to the physician. A review of Resident 93's Nutrition Assessment completed by the Registered Dietician (RD), dated 9/29/2022, indicated the resident's most recent weight was 177 lbs with estimated nutritional needs of 2000-2400 kcal and 96-112 grams protein. The Nutrition Assessment indicated a recommendation to change to Nepro 1.8 at 75 ml per hr over 16 hours to provide 1200 ml per kcal. There was no documented evidence that this recommendation was reported to Resident 93's physician for approval or disapproval. A review of Resident 93's Medication Administration Record (MAR) from 9/26/2022 to 10/28/2022 indicated the resident received GT feeding as follows: - Nepro 1.8 at 50 ml per hr over 20 hours to provide 1000 ml/2160 kcal from 9/27/2022 to 10/17/2022 - Nepro 1.8 at 50 ml per hr over 20 hours to provide 2160 ml/2160 kcal from 10/18/2022 to 10/24/2022 - Nepro 1.8 at 75 ml per hr over 16 hours to provide 2160 ml/1800 kcal starting 10/25/2022 On 10/27/2022 at 11:18 a.m., during a concurrent interview and record review, the RD stated Resident 93's admission order was Nepro 1.8 50 ml/hr over 20 hours to provide 1000 ml/1800 kcal, but on 9/29/2022 she made a new recommendation Nepro 1.8 @ 75 ml/hr over 16 hours to provide 1200ml/2160 kcal. The RD stated she sends her recommendations to nursing department, then nursing department places the order. The RD stated the team meets for weekly weight meeting to discuss weight variances. During a concurrent interview and record review, there was no weekly weight meeting for Resident 93 on the week of 10/2/2022 to 10/8/2022. The RD stated the next meeting was on 10/11/2022 where she requested for Resident 93's dry weight (weight without the excess fluid that builds up between dialysis treatments) and recommended to continue to monitor the resident's weight weekly. The RD stated Resident 93's weight is much more manageable because he is on steady feeding which meant continuous feeding daily on schedule. The RD stated if Resident 93's GT feeding was being left off or not being run completely, then the resident was not getting the recommended amount which could result in weight loss. The RD stated the potential consequence of weight loss is muscle wasting. On 10/28/2022 at 10:55 a.m., during a concurrent interview and record review of Resident 93's weight records, Restorative Nursing Assistant 1 (RNA 1) stated RNAs are responsible for weighing the residents on a weekly or monthly basis. RNA 1 stated the facility was not weighing Resident 93 because he is on dialysis, instead the facility looked at post dialysis weight multiply by 2.2 and record the result on the RNA binder. There was no evidence recorded on the RNA binder of Resident 93's weekly weights; there were monthly weights recorded for the months of March, April, May, August, September, and October. RNA 1 stated Dietary Services Supervisor (DSS) is responsible for documenting the weights on the facility's electronic chart point click care (PCC). A review of the facility's policy and procedure (P&P), titled, Enteral Nutrition, dated 4/2022, indicated, Adequate nutritional support through enteral nutrition is provided to residents as ordered . 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include . f. The volume/rate goals and recommendations . A review of the facility's P&P, titled, Weight Assessment and Intervention, dated 4/2022, indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. 2. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 4. The Dietician will respond within 24 hours of receipt of written notification .

Based on observation, interview, and record review, the facility failed to provide a safe environment and supervision to one of three sampled residents (Resident 1). On 6/30/2022, at 2 p.m., Resident 1, while unsupervised, walked with a front wheeled walker (FWW) through an emergency exit door to the designated smoking patio and fell face down onto the floor as his FWW went forward due to a slanted floor by the emergency door. As a result, Resident 1 fell sustained a laceration (cut) on the right side of the forehead requiring transfer to General Acute Care Hospital 1 (GACH 1) for further evaluation and treatment. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 4/18/2022 with diagnoses including presence of right artificial hip joint (a surgeon removes the damaged sections of the hip joint and replaces them with parts usually constructed of metal, ceramic and very hard plastic), other abnormalities of gait (the manner of walking) and mobility. A review of Resident 1 ' s Care Plan initiated on 4/19/2022 for the resident ' s risk for falls and injury related to gait/balance problems due to limited mobility and used a FWW, indicated in the approaches the need of a safe environment such as even floors free from spills and/or clutter; adequate light; working and reachable call light, bed in low position at night; and personal items within reach were in effect. A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 4/25/2022, indicated the resident had the ability to make self-understood and has the ability to understand others. Resident 1 required extensive assistance in the activities of daily living (ADLs, such as walking, dressing, personal hygiene, bathing, and toilet use). Resident 1 ' s balance during transitions and walking was not steady and only stabilized with staff assistance. The resident was using a walker and wheelchair for mobility. A review of Resident 1 ' s Physical Therapy (PT) Discharge Summary, dated 6/2/2022, indicated the resident was independent with bed mobility and required supervision during transfers and walking on level and uneven surfaces. A review of Resident 1 ' s nursing Progress Notes, dated 6/30/2022, indicated the resident was last seen smoking outside the patio, and at around 2 p.m., the charge nurse was called outside because the resident fell . The charge nurse found the resident face down. The resident had blood on his face and an abrasion (scraping of the skin) on the right eyelid with bruising and swelling. The physician was informed and ordered to transfer Resident 1 to the GACH 1 via emergency medical services (EMS, transportation when life, health or safety is in danger). A review of Resident 1 ' s Change of Condition Evaluation, dated 6/30/2022, indicated the resident had a fall and sustained an abrasion on the face. The resident complaint of acute (sudden) musculoskeletal (having to do with muscles, bones, tendons, ligaments, joints, and cartilage) pain rated as 6/10 (a pain rating scale from zero to 10, zero indicating no pain and 10 the worst possible pain). A review of GACH 1 ' s Hospital Discharge Summary, dated 7/4/2022, indicated Resident 1 sustained a laceration on the right side of the forehead and also complained of right hip pain. A review of Resident 1 ' s re-admission record, indicated on 7/4/2022, the facility readmitted the resident with order for physical therapy evaluation. A review of Resident 1 ' s Care Plan Conference Summary, dated 7/5/2022, indicated an Interdisciplinary Team Meeting (IDT) was held for the fall. In attendance was Resident 1, the Director of Social Services, the Case Manager, and the Activities Director. Resident 1 was educated on the use of correct exit door to access the smoking patio and not the emergency exit door. Resident 1 was restarted on physical therapy/ occupational therapy (PT/OT) skilled services five times per week. On 7/18/2022, at 9:50 a.m., during an interview, Resident 1 stated on the day he fell , he unknowingly used the emergency door, and nobody was watching him or assisted him to go through the correct door. Resident 1 stated he fell when going through the door and his walker went forward causing him to lose balance. On 7/18/2022, at 12:21 p.m., during an interview, Charge Nurse 1 (CN 1) stated he found Resident 1 by the emergency exit face down on the floor with a gash on the forehead. CN 1 stated he was not aware Resident 1 could not walk on uneven floor surfaces. On 7/18/2022, at 1 p.m., during an interview, Activities Aid 1 (AA 1) stated he was not aware Resident 1 could not walk on uneven floor surfaces. On 7/18/2022, at 1:26 pm., during a concurrent observation and interview with Maintenance Supervisor 1 (MS 1), the floor by the emergency exit door leading to the smoking patio was noted slanted and uneven. MS 1 confirmed the floor was slanted. During a concurrent observation and interview on 7/18/2022, at 1:33 p.m., the Housekeeping Supervisor 1 (HS 1), HS 1 stated the floor was uneven in front of the emergency exit door where Resident 1 fell . A review of the facility ' s current policy and procedure titled, Safety and Supervision of Residents, revised date of 7/2017, indicated that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Monitoring the effectiveness of interventions shall include the following: (a) Ensuring that interventions are implemented correctly and consistently; (b) Evaluating the effectiveness of interventions; (c) Modifying or replacing interventions as needed; and (d) Evaluating the effectiveness of new or revised interventions. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased where there are temporary hazards in the environment or if there is a change in the resident's condition. A review of the facility ' s current policy and procedure titled, Falls and Fall Risk, Managing, revised date of 3/2018, indicated that the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with history of falls. A review of the facility ' s current policy and procedure titled Care Plans, Comprehensive Person-Centered, revised date of 12/2016, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from accidents and hazards by: 1. Certified Nursing Assistant 1 (CNA 1) not completing a competency check for assisting residents with feeding prior to feeding Resident 1. 2. Not supervising Resident 1 while eating and observe for pocketing of food in the cheeks. 3. Not adhering to its policy on Emergency Procedure-Choking (choking, the partial or complete obstruction of the airway due to a foreign body such as food, water, a toy, etc.) and immediately and correctly perform the [MEDICATION(S)] maneuver (emergency rescue procedure for application to someone choking on a foreign object, in which the rescuer places a fist between the victim's lower ribs or upper abdomen from behind and exerts sudden pressure in the form of thrusts of sufficient force to help eject the object from the windpipe) on Resident 1. 4. Licensed Vocational Nurse 1 (LVN 1) performing a deep finger sweep inside Resident 1's mouth when the resident experienced signs and symptoms of choking which could result on further pushing the food into the throat. 5. Not ensuring staff did not leave Resident 1 alone to call for help while the resident was experiencing signs and symptoms of choking. 6. Not adhering to Resident 1's plan of care to monitor and report signs and symptoms of dysphagia (difficulty swallowing) including pocketing food in the cheeks, choking, coughing, drooling, holding food in mouth. As result, on [DATE], Resident 1 experienced a choking episode during dinner and soon after the resident expired. On [DATE] at 6:55p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident; §483.25(d) Accidents) situation was identified in the presence of the facility's Director of Nursing (DON) and Director of Staff Development (DSD) for the facility's failure to implement measures to ensure the safety of the residents, prevent choking and not providing immediate assistant to open the resident's airway. On [DATE] (three days later) at 2:47 p.m., the State Survey Agency (SSA) removed the IJ situation in the presence of the DON and the DSD after an on-site verification of the implementation of the written IJ Removal Plan (interventions to immediately correct the deficient practice) through observation, interview, and record review. The acceptable Removal Plan included the following: 1. On [DATE], the DSD provided one on one in-service training to CNA 1 on the facility's Emergency procedure - Choking policy. 2. On [DATE], the DON provided one on one in-service training to LVN 1 on the facility's Emergency procedure - Choking policy. 3. On [DATE], the DON conducted skills competency for LVN 1 about assistance and supervision during resident's feeding, identification and provision of immediate emergency procedures for residents experiencing signs and symptoms of chocking including [MEDICATION(S)] maneuver training. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a [AGE] year-old female, on [DATE] with diagnoses including dysphagia (difficulty swallowing) and dementia (group conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). A review of the Physician's Order for Resident 1, dated [DATE], indicated Resident 1 had an order for speech therapy evaluation and treatment. A review of Resident 1's History and Physical (H&P) exam completed by the attending physician on [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's ST Evaluation and Plan of Treatment dated [DATE], indicated the resident needed ST for dysphagia and to assess and evaluate least restrictive oral intake and reduce signs and symptoms of aspiration (a person accidentally inhaling an object or fluid into their windpipe and lungs) by: A review of Resident 1's Care Plan dated [DATE], developed for the resident's potential nutritional problem such as weight loss, aspiration, dysphagia, and dementia. The goals were for resident not to develop complications related to nutritional problem including ineffective breathing pattern. The interventions included monitoring, documenting, and reporting any sign and symptoms of dysphagia; pocketing, choking, coughing, drooling, holding food in the mouth, several attempts at swallowing, refusing to eat and appearing concerned during meals. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had severely impaired cognition (mental action of acquiring knowledge and understanding through thought and the senses), required extensive assistance with one-person physical assist with eating, toilet use and personal hygiene. A review of Resident 1's Physician's Order dated [DATE] indicated resident had an order for low fat, low cholesterol diet, finely chopped texture with honey thickened liquids consistency. A review of Resident 1's Speech Therapy evaluation and plan of treatment, dated [DATE], indicated resident needed speech therapy for dysphagia and assess and evaluation least restrictive oral intake and reduce signs and symptoms of aspiration. A review of Resident 1's speech therapy progress notes dated [DATE], indicated resident had modified [MEDICATION(S)] swallow (MBS-special x-ray that allows the doctor to check problems regarding swallowing) on ,d+[DATE], and was noted to have silent aspiration and at high risk and complications of aspiration. A review of Resident 1's Physician's Order dated [DATE] indicated resident had an order for low fat, low cholesterol diet, finely chopped texture with honey thickened liquids consistency. A review of Resident 1's ST Progress Notes, dated [DATE], indicated the resident had modified [MEDICATION(S)] swallow study (MBS - is a study using X-rays to obtain real-time moving images to determine whether food or liquid is entering a person's lungs. It permits observe the coordination of anatomical structures in the mouth and throat, as they are actively functioning when chewing, drinking, and swallowing) on ,d+[DATE], and was noted to have silent aspiration and at high risk and complications of aspiration. A review of Resident 1's ST Progress Notes, dated [DATE], indicated the resident was refusing solid food trails and the Speech Therapist was unable to fully assess resident and spoke with Case Manager (CM) to schedule the MBS study as soon as possible. A review of Resident 1's Change of Condition form, dated [DATE], indicated Resident 1 was sitting up in the wheelchair and front of the nursing station. Resident 1 ate about 40% of dinner and started coughing. The Charge Nurse (LVN 1) noticed Resident 1 coughing and tried opening the mouth and take food from the mouth. 911 (emergency number to request for immediate medical assistance) was called since resident did not have a pulse. On [DATE] at 3:10 p.m. during an interview, LVN 1 stated that on [DATE] around 5:30 p.m., Resident 1 was in front of the nursing station. LVN 1 stated that she told the CNA 1 to feed resident slowly and carefully because resident had difficulty swallowing. LVN 1 heard Resident 1 coughing sounds, told the CNA to stop feeding the resident, but resident kept making coughing and throat clearing sounds. LVN 1 stated she opened the resident's mouth and swept the mouth (LVN 1 motioning circling with her left index finger pointed straight and motioning to back of mouth and near the neck) several times and a yellow liquid came out. LVN 1 stated she did not do [MEDICATION(S)] Maneuver. LVN 1 stated she was taught to stick the finger down deeper into the throat to trigger the resident to spit out. LVN 1 stated she should have not put her finger inside resident mouth and should have done [MEDICATION(S)] maneuver right away. On [DATE] at 3:30 p.m., during an interview, the DON stated on [DATE], Resident 1 passed away. DON stated the resident was high risk for aspiration. DON further stated that if a resident was coughing and possibly choking, staff should check for response, check if there is anything inside the mouth and do [MEDICATION(S)] Maneuver to try to expel the food. DON stated that staff can look around the mouth and try to get food out but should not do a deep finger sweep because it can cause the food or the object to lodge further back into the throat and make the situation worse. On [DATE] at 7:10 p.m., during a telephone interview, Registered Nurse Supervisor (RNS) stated on [DATE], around 5:30 p.m., CNA 1 called him to the nursing station by CNA 1 and told him Resident 1 was choking. RN 1 stated that resident was sitting alone in the reclining chair and LVN 1 was in the nursing station calling 911. RN stated when he got to the resident, Resident 1 was unresponsive, no pulse (heartbeat) with her fingernails already bluish black so he started a [MEDICATION(S)] Maneuver, then place the resident in the floor and initiated cardiopulmonary resuscitation CPR (a lifesaving technique that is useful in many emergencies, such as a [CONDITION(S)] or near drowning, in which someone's breathing, or heartbeat has stopped). On [DATE] at 7:10 p.m., during a telephone interview, CNA 1 stated that on [DATE] at dinner time (between 5 p.m. to 6 p.m.), Resident 1 was in front of the Nursing Station and was eating dinner. CNA 1 stated Resident 1 was on mechanical soft diet and thickened liquid. Resident 1 started coughing so she called the attention of LVN 1. Resident 1 started spitting some food and LVN 1 tried to remove some of the food inside the resident's mouth. LVN 1 told her to call RNS. On [DATE] at 12:45 p.m., during an interview with the DSD and a concurrent review of CNA 1's skills competency, DSD stated CNA 1 was hired on ,d+[DATE] and the performance checklist included feeding residents requiring assistance and care to a resident choking was only conducted on [DATE], after Resident 1's incident of choking and death ([DATE]). DSD stated skills competency should have been done upon hire or during orientation to determine competency to take care of residents. DSD also stated that during any emergency such as choking, resident should not be left alone and should have called for help instead. On [DATE] at 2:35 p.m., during an interview, the DON stated all nursing staff should have been evaluated for their competency and performance including feeding residents who were at risk for aspiration/choking prior to allow the staff to take care of the residents. On [DATE] at 11:07 a.m., an interview with Speech Therapist 2 (ST 2) and a concurrent review of Resident 1's speech therapy evaluation, treatment, and progress notes for the month of ,d+[DATE] was conducted. ST 2 stated ST 1 evaluated Resident 1 on [DATE] because of dysphagia. ST 2 stated the plan for the resident was speech therapy five times a week for one week. ST 2 stated during the treatment, Resident 1 was inconsistent with the food and fluid trials. On [DATE], resident had a weak cough and had difficulty clearing fluids out of the throat. ST 2 further stated that on [DATE], ST 1 recommended a Modified [MEDICATION(S)] Swallow (MBS) because of inconsistent food and fluid trials and the resident's responsible party agreed. ST 2 stated ST 1 should have created a care plan, so the nursing staff would know the precautions to be taken for Resident 1. On [DATE] at 11:35 a.m., during an interview, the DON stated there was no care plan for speech therapy treatment, there was no order for MBS. The DON stated the ST recommended the treatment, should have called the doctor for orders, and notify the Case Manager (CS) who would arrange the appointment for the procedure. DON stated there was no documentations regarding the MBS order from the CM or the licensed nurses. During an interview on [DATE] at 12:48 p.m., CM stated ST 1 did not notify her about her recommendation for Resident 1 to have a MBS study, therefore, she did not call the insurance for authorization and to arrange an appointment. CM stated ST 1 should have obtained the physician's order and then notify her (CM) about it. A review of facility's policy and procedure titled safety and supervision of residents' with revised date of ,d+[DATE], indicated that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. It also indicated that employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. It also indicated that the facility uses resident-oriented approach to safety to addresses safety and accident hazards for individual residents. it also indicated that the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risk for that resident. the care team shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risk and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. ensuring that interventions are implemented; and 3. documenting interventions. A review of facility's policy and procedures titled, Choking-Emergency procedure with revised date of ,d+[DATE], indicated trained staff will assist the resident who is chocking by attempting to expel the foreign body from the airway. For conscious residents-standing or sitting 1. Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breath and needs your help immediately. 2. Ask the resident to cough or speak, if at all possible, to determine if his or her airway is obstructed. 3. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object. 4. Call for help but stay with the resident. 5. Quickly assure the resident that you are going to stay and assist him or her. 6. If the resident cannot cough, only then should abdominal thrusts be performed as follows: a. Stand behind the resident b. Wrap your arms around the resident's waist c. Make a fist with one hand. d. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel. e. Grasp your clenched first with your other hand. f. Press your first into the resident's upper abdomen with a quick upward thrust. g. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. Unconscious resident-lying down 1. Ease the resident as gently as possible to the floor. 2. Call for help if assistance is not already present but do not leave the resident unattended. 3. Position the resident on his or her back with the arms at his or her side. 4. Perform abdominal thrust 5. Perform the finger sweep maneuver to check for foreign body as follows: a. Keep the resident's face up b. Perform the tongue jaw lift to open the resident's mouth c. Perform the finger sweep using your index finger as a hook. (1) Insert index finger into the resident's mouth alongside of the cheek and across the base of the tongue. (2) Try to remove the foreign objects (3) Avoid pushing foreign objects deeper into the throat (4) Turn the resident's head to one side if needed to sweep an object form the mouth.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) had the specific competencies and skill sets necessary to care for one of three sampled residents (Resident 1). On [DATE], around 5:30 p.m., Resident 1 was choking (partial or complete obstruction of the airway due to a foreign body such as food, water, a toy, etc.) and LVN 1 and CNA 1 left the resident alone instead of starting [MEDICATION(S)] Maneuver (lifesaving procedure, manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea [windpipe]). This deficient practice resulted in delayed interventions to open Resident 1's airway and subsequent death of Resident 1. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, a [AGE] year-old female, on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's History and Physical (H&P) exam completed by the attending physician on [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's ST Evaluation and Plan of Treatment dated [DATE], indicated the resident needed ST for dysphagia and to assess and evaluate least restrictive oral intake and reduce signs and symptoms of aspiration (a person accidentally inhaling an object or fluid into their windpipe and lungs) by: A review of Resident 1's Care Plan dated [DATE], developed for the resident's potential nutritional problem such as weight loss, aspiration, dysphagia, and dementia. The goals were for resident not to develop complications related to nutritional problem including ineffective breathing pattern. The interventions included monitoring, documenting, and reporting any sign and symptoms of dysphagia; pocketing, choking, coughing, drooling, holding food in the mouth, several attempts at swallowing, refusing to eat and appearing concerned during meals. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had severely impaired cognition (mental action of acquiring knowledge and understanding through thought and the senses), required extensive assistance with one-person physical assist with eating, toilet use and personal hygiene. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Speech Therapy evaluation and plan of treatment, dated [DATE], indicated resident needed speech therapy for dysphagia and assess and evaluation least restrictive oral intake and reduce signs and symptoms of aspiration. A review of Resident 1's speech therapy progress notes dated [DATE], indicated resident had modified [MEDICATION(S)] swallow (MBS-special x-ray that allows the doctor to check problems regarding swallowing) on ,d+[DATE], and was noted to have silent aspiration and at high risk and complications of aspiration. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's ST Progress Notes, dated [DATE], indicated the resident had modified [MEDICATION(S)] swallow study (MBS - is a study using X-rays to obtain real-time moving images to determine whether food or liquid is entering a person's lungs. It permits observe the coordination of anatomical structures in the mouth and throat, as they are actively functioning when chewing, drinking, and swallowing) on ,d+[DATE], and was noted to have silent aspiration and at high risk and complications of aspiration. A review of Resident 1's ST Progress Notes, dated [DATE], indicated the resident was refusing solid food trails and the Speech Therapist was unable to fully assess resident and spoke with Case Manager (CM) to schedule the MBS study as soon as possible. A review of Resident 1's Change of Condition form, dated [DATE], indicated Resident 1 was sitting up in the wheelchair and front of the nursing station. Resident 1 ate about 40% of dinner and started coughing. The Charge Nurse (LVN 1) noticed Resident 1 coughing and tried opening the mouth and take food from the mouth. 911 (emergency number to request for immediate medical assistance) was called since resident did not have a pulse. On [DATE] at 3:10 p.m. during an interview, LVN 1 stated that on [DATE] around 5:30 p.m., Resident 1 was in front of the nursing station. LVN 1 stated that she told the CNA 1 to feed resident slowly and carefully because resident had difficulty swallowing. LVN 1 heard Resident 1 coughing sounds, told the CNA to stop feeding the resident, but resident kept making coughing and throat clearing sounds. LVN 1 stated she opened the resident's mouth and swept the mouth (LVN 1 motioning circling with her left index finger pointed straight and motioning to back of mouth and near the neck) several times and a yellow liquid came out. LVN 1 stated she did not do [MEDICATION(S)] Maneuver. LVN 1 stated she was taught to stick the finger down deeper into the throat to trigger the resident to spit out. LVN 1 stated she should have not put her finger inside resident mouth and should have done [MEDICATION(S)] maneuver right away. During an interview on [DATE] at 3:30 p.m., Director of Nursing (DON) stated on [DATE], Resident 1 passed away. DON stated that resident was high risk for aspiration. DON further stated that if a resident was coughing and possibly choking, staff should check for response, check if there is anything inside the mouth and do [MEDICATION(S)] Maneuver to try to expel the food. DON stated that staff can look around the mouth and try to get food out but should not do a deep finger sweep because it can cause the food or the object to lodge further back into the throat and make the situation worse. During a telephone interview on [DATE] at 6:30 p.m. with Registered Nurse Supervisor (RNS) stated on [DATE], around 5:30 p.m., CNA 1 called him to the nursing station by CNA 1 and told him Resident 1 was choking. RN 1 stated that resident was sitting alone in the reclining chair and LVN 1 was in the nursing station calling 911. RN stated when he got to the resident, Resident 1 was unresponsive, no pulse (heartbeat) with her fingernails already bluish black so he started a [MEDICATION(S)] Maneuver, then place the resident in the floor and initiated cardiopulmonary resuscitation CPR (a lifesaving technique that is useful in many emergencies, such as a [CONDITION(S)] or near drowning, in which someone's breathing or heartbeat has stopped). During a telephone interview on [DATE] at 7:10 p.m., Certified Nursing assistant 1 (CNA 1) stated that on [DATE] at dinner time (5 p.m. to 6 p.m.), Resident 1 was in front of the nursing station and was eating dinner. CNA 1 stated Resident 1 was on mechanical soft diet and thickened liquid. Resident 1 started coughing so she called the attention of LVN 1. Resident 1 started spitting some food and LVN 1 tried to remove some of the food inside the resident's mouth. LVN 1 told her to call RNS. During an interview on [DATE] at 12:45 p.m., during an interview with Director of Staff development (DSD) and a review of CNA 1's skills competency, DSD stated CNA 1 was hired on ,d+[DATE] and the performance checklist included feeding residents requiring assistance and care to a resident choking was only conducted on [DATE], after Resident 1's incident of choking and death ([DATE]). DSD stated skills competency should have been done upon hire or during orientation to determine competency to take care of residents. DSD also stated that during any emergency such as choking, resident should not be left alone and should have called for help instead. A review of facility's policy and procedure titled safety and supervision of residents' with revised date of ,d+[DATE], indicated that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. It also indicated that employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was free from abuse, after a certified nurse assistant (CNA)1 hit Resident 1's right arm with the mechanical lift remote control and covered Resident 1's mouth with her hands to keep her from screaming on two separate occasions. This deficient practice resulted in Resident 1's transfer to a General Acute Care Hospital (GACH) for an evaluation and complaints of a headache and pain in her right arm. This failure had the potential to cause Resident 1 emotional distress and/or fear due to the abusive treatment. Findings: A review of Resident 1's Admission Record, dated 11/4/19, indicated an original admission to the facility on [DATE] and a readmission on 10/15/19, with [DIAGNOSES REDACTED].(mood disorder that affects daily life). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 7/27/19, indicated a Brief Interview for Mental Status (used to assess cognitive status in the elderly and may provide useful information as a possible referral for dementia diagnosis) score of zero, indicating severe cognitive (having a very hard time remembering things, making decisions, concentrating, or learning) impairment. Resident 1 required extensive assistance with bed mobility, eating and was totally dependent on staff members, for transferring, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 also needed the physical assistance of two people to transfer from surface to surface (bed to wheelchair, etc.). A review of Resident 1's Nurses' Progress Note, dated 10/14/19, indicated two certified nurses' assistants (CNAs) 2 and 3, on Friday 10/11/19, saw CNA 1 transferring Resident 1 from the bed to the Geri-chair (a reclining chair). Resident 1 was screaming loudly during the transfer. CNAs 2 and 3 heard the screams and came to Resident 1's room to help CNA 1. CNAs 2 and 3 told the director of staff development (DSD), CNA 1 hit Resident 1's right arm with the mechanical lift remote control and CNA 1 used her hand to cover Resident 1's mouth to prevent the resident from screaming. A review of Resident 1's physician's telephone order, dated 10/14/19, indicated to transfer the resident to the general acute care hospital (GACH) for further evaluation. A review of Resident 1's GACH emergency department (ED) notes, dated 10/14/19, indicated the resident presented in the ED, from a skilled nursing facility, for an evaluation for generalized weakness and injury status [REDACTED]. Resident 1 complained of a mild headache and right forearm pain. A review of the facility's Investigation and Interview Record, dated 10/15/19, documented another incident involving CNA 1 again putting her hands over Resident 1's mouth. CNA 4 stated, The last week of September, around 10:00 a.m., I (CNA 4) saw CNA 1 put her hand on Resident 1's mouth. During an observation, on 11/4/19, at 11:06 a.m., Resident 1 was in her room, lying in bed, screaming loudly and unintelligibly while the CNAs were getting her ready for the day. According to the Director of Nursing (DON), Resident 1 has behaviors of screaming and laughing uncontrollably. On 11/4/19, at 11:11 a.m., during an interview CNA 2, a witness to the incident on 10/14/19, stated on a Friday (date not specified), Resident 1's door was closed. CNA 2 and CNA 3 thought they could assist, because Resident 1 was screaming. When CNA 2 entered Resident 1's room, CNA 1 had Resident 1 in the mechanical lift. CNA 2 asked CNA 1 if she needed help, because Resident 1 needs more help. While CNA 1 and CNA 2 were transferring Resident 1 to the chair, Resident 1 tried to grab CNA 1. CNA 1 used the mechanical lift remote control to hit Resident 1 on the right bicep (upper arm) twice. During concurrent interviews, on 11/4/19, at 11:33 a.m., the DON and DSD stated on 10/14/19, CNA 3 reported (to the DSD) that she saw CNA 1 put both hands, on Resident 1's mouth to prevent her from screaming. The DON and DSD acknowledged the incident as physical abuse; stating, Placing your hands over Resident 1's mouth is not appropriate. The DON also admitted , in September (date not indicated), CNA 4 also witnessed CNA 1 placing her hands over Resident 1's mouth to prevent her from screaming. During an interview on 11/4/19, at 12:39 p.m., CNA 4 confirmed in September (date not indicated) around 10:00 a.m., she witnessed CNA 1 placing her hands over Resident 1's mouth to keep her quiet. A record review of the facility's investigation, for the incident on 10/14/19, the facility suspended CNA 1 pending an investigation. A review of the facility's policy, titled Abuse Prevention Program, revised November 2019, indicated our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion.

Based on interview and record review, the facility failed to follow its policy on Fall and Fall Risk Management, Safety and Supervision of Residents and resident's plan of care to ensure one of three sampled residents (Resident 1), was provided safety devices, consistent visual monitoring or close supervision to prevent falls and or minimize injury. The facility also failed to update Resident 1's plan of care based on the fall risk assessment and first fall incident by not identifying the specific need of the resident for close supervision. As a result, Resident 1 had a second fall incident on [DATE], at 8:30 p.m., causing severe pain on the resident's right leg, and was transferred to a GACH (general acute care hospital) where Resident 1 was identified as having right [MEDICAL CONDITION] (break) and was confined for a week. Resident 1 required extensive surgery for [REDACTED]. Resident 1 was transferred to another skilled nursing facility (SNF), where she expired on [DATE], with the immediate cause of death as complications from periprosthetic hip (a broken bone that occurs around the implants of a total hip replacement) fracture sustained from a fall. Findings: On [DATE], at 11:58 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. A review of Resident 1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1s Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired based on her brief interview for mental status (BIMS), with a score of 12. The MDS indicated Resident 1 required limited assistance with one-person physical assist in transferring to and from the bed, wheelchair/chair or a standing position, walking in the room and with activities of daily living (ADLs)such as dressing, toilet use and personal hygiene. The MDS also indicated the resident uses a walker or wheelchair for mobility. A review of Resident 1's admission Fall Risk assessment dated [DATE], indicated a risk score of 9. According to assessment tool, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A review of Resident 1's care plan titled, The resident is at moderate risk for falls related to gait/balance problem initiated on [DATE], included interventions such as anticipating and meeting the resident's need, ensuring the resident's call light is within reach, encouraging the resident to use the call light and following the facility fall protocol (not specified). A review of Resident 1's SBAR ((Communication tool used in healthcare) Situation-Background-Assessment-Request) completed on [DATE], at 9:42 p.m. indicated the following documentation: At 6:30 p.m., Charge Nurse called the Registered Nurse to the room and informed her that Resident 1 was on the other side of the bed, stood up trying to reach the call light and slid. Two persons helped the resident to get up and sat her in bed. A full body check was done and there were no visible injuries noted. Will continue to monitor, call light within reach and visually monitor at all times. A review of the Accident/Investigation Report and Post Fall Interdisciplinary Review dated [DATE], indicated Resident 1 stood up from her wheelchair in her room and slid while reaching for her call light. A review of another care plan for Resident 1 titled, At Risk for Falls related to a fall when resident tried to stand up reaching for her call light, poor safety judgement/awareness and impaired cognition was initiated on [DATE]. The approach plan included to maintain a safe and hazard free environment (no wet floor, adequate lighting, no items that may cause tripping), ensure adequate lighting including night light, visual checks during medication pass and ADL care. A review of Resident 1's Post Fall Fall Risk assessment dated [DATE], indicated Resident 1 scored a 17, now considered high risk for potential falls. A review of another SBAR for Resident 1 dated [DATE], at 8:30 p.m. indicated the following: Resident 1 was found on the floor sitting next to her bed, in her room. Resident told staff she was reaching for her sweater in the wheelchair and slid from bed. Bilateral ,[DATE] siderails were up in bed and the bed was at low level. The resident was bare foot without socks in the dark. The resident complained of pain with a pain scale of ,[DATE] (10 being the worst pain) and was screaming while staff was touching her right leg. 911 (emergency response) was called at 8:35 p.m., arrived at 8:40 p.m., and transferred Resident 1 to GACH by 8:45 p.m. A review of Resident 1's GACH emergency records dated [DATE], at 9:30 p.m. indicated the following: Resident 1 was brought in, complaining of severe right lower extremity (leg) pain due to status [REDACTED]. Resident 1 was Unable to complete exam secondary to pain. Resident 1 received an additional 2 milligrams of IV [MEDICATION NAME] to relieve pain. The resident's right lower extremity (RLE) was noted to be shortened and externally rotated A review of the History and Physical Reports dated [DATE], from the acute hospital indicated Resident 1, who presented from the Skilled Nursing Facility (SNF) after a mechanical fall and a right leg pain, was found to have a right periprosthetic (a broken bone that occurs around the implants of a total hip replacement) [MEDICAL CONDITION]. A review of Resident 1's Diagnostic Radiology form dated [DATE], revealed a mildly displaced periprosthetic right femur (thigh bone closest to the hip joint) fracture A review of Resident 1's Discharge Documentation from GAUCHE dated [DATE], indicated the following: Repair of the [MEDICAL CONDITION] requires extensive surgery that carries extensive risk in this frail patient (Resident 1) with multiple comorbidities (the presence of one or more medical condition or disease in addition to an initial diagnosis). Per discussion with the patient and family. ortho and palliative care (a specialized medical care for people with serious illness, focused in providing relief from symptoms, pain and stress), the patient and family decided that palliative care with hospice (involves a team-oriented approach to expert medical care, pain management, emotional and spiritual support tailored to the patient's needs and wishes) would be preferable to surgery. The patient and her family would like to focus on pain control and tranfer back to a preferred SNF with hospice. The notes also indicated Resident 1 has persistent pain on the right leg from the hip to her feet at rest and worse with movement. The physical examination revealed the resident's right lower leg was externally rotated and shortened and with severe pain on light palpation. The resident was discharged to SNF 2 for palliative care. A review of Resident 1's Interdisciplinary Progress Notes from SNF 2 dated [DATE], indicated the resident is in extreme pain when repositioning even with [MEDICATION NAME] (pain medication). The medical doctor (MD) met with the family and discussed the resident's prognosis and plan of care. The risk of skin breakdown versus the risk of increased pain was discussed and the family agreed to focus on pain management. The MD stated the resident is nearing the end of life process. A review of Resident 1's Certificate of Death issued on [DATE], indicated the resident expired on [DATE], with the immediate cause of death as complications of right periprosthetic [MEDICAL CONDITION]. On [DATE], at 12:08 a.m., during a telephone interview, Certified Nurse Aide 1 (CNA) stated that Resident 1 had an unwitnessed fall and there was no mat on the floor. She said the resident was trying to get her sweater and fell on the right side of the bed and did not press the call light. CNA 1 further stated that after the incident she heard that the resident was the type to get out of bed unassisted. On [DATE], at 4:35 p.m., during an interview, CNA 2 stated he was called to help stand Resident 1 up after the fall. He said nobody touched the resident to get her up because she was in pain. CNA 2 further stated that the resident's bed was in low position and there was no floor mat. On [DATE], at 4:55 p.m., during an interview, Registered Nurse 1 (RN) stated, For Resident 1, when we touched her right leg, she was screaming in pain. RN 1 added, I don't remember a floor mat. I'm sure, I don't remember a floor mat. She also said she wrote in the SBAR, In the dark room. She further stated, she recalled asking the question, Hey, why so dark? when entering Resident 1's room after the fall. RN 1 concluded by stating, For me, it's no floor mat. On [DATE], at 4:15 p.m., during an interview, RN 2 stated, For residents at high risk for falls, we put them near the nursing station, provide landing pads (floor mats), an alarm if ordered by the doctor, and do frequent visual checks. She also stated , If we say we'll monitor, we document to prove it was done. During a concurrent record review, RN 2 noted that Resident 1's fall risk score of 17 placed her for high fall risk. RN 2 stated that for high fall risk residents, fall precaution devices are initiated, low bed, floor mat and place the resident in a room closer to the station. When asked if any updates were done for Resident 1's care plan, RN 2 confirmed that nothing was added to the resident's care plan after the initial fall ([DATE]), and that records showed no implementation of the care plan. She said Resident 2 encountered a second fall on [DATE], and went to the hospital, never came back. On [DATE], at 1:07 p.m., during a telephone interview, the director of Nurses (DON) stated that visual monitoring meant checking on the resident based on a time frame. She stated the CNAs and the licensed nurses should do the visual checks when doing their rounds. She added that if recorded, visual monitoring should have a time frame, like hours and for how many days and should be reflected on the Medication Administration Record (MAR). The DON also stated that for residents who require supervision, such as trying to climb out of bed, the licensed nurse do nursing measures and visual checks on residents and also document on the MAR. She said frequent visual checks would need an order. A review of Resident 1's medical record revealed no documentation that the facility staff consistently monitored or closely supervised the resident after the first fall, nor was the resident being placed close to the nursing station as part of the care plan. Additionally, the care plan did not identify the resident's need for close supervision after the initial fall. A review of a facility policy titled, Falls and Fall Risk, Managing, last revised (MONTH) 2007, states, If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The policy also states The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. A review of a facility policy titled Safety and Supervision of Residents, last revised (MONTH) (YEAR), states resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy, under the topic of Individualized, Resident-Centered Approach to Safety also indicates that Implementing interventions and Monitoring the effectiveness of interventions to reduce accident risks and hazards shall include the following: 1. Ensuring that all interventions are implemented correctly and consistently. 2. Documenting interventions. 3. Evaluating the effectiveness of interventions. 4. Modifying or replacing interventions as needed. The policy under, Systems Approach to Safety indicates the resident supervision is a core component of the systems approach to safety and the type and frequency of resident supervision is determined by the individual resident's assessed needs.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) did not received unnecessary medication. Resident 1 received Bumetadine and [MEDICATION NAME] (medication designed to increase the amount of water and salt expelled from the body as urine) a medication with same action and same therapeutic effects from (MONTH) 6 to 12, (YEAR). As a result on 9/12/18, Resident 1 was transferred and admitted to general acute care hospital (GACH) for altered mental status and found to be hypotensive ((SBP 77) decreased systolic blood pressure. Resident 1 was worked up for shock and ultimately determined to be in hypovolemic shock (result of massive fluid loss). Findings On 9/27/18 at 2:10 p.m., an unannounced visit was made to the facility to investigate allegations of Quality of Care. A review of Resident 1's Admission Record (Facesheet) indicated the resident was initially admitted to the facility on [DATE] with the latest readmission date of [DATE]. Resident 1's [DIAGNOSES REDACTED]. due to plaque buildup), pacemaker (device placed on the chest or abdomen to regulate abnormal heart rhythms), type ll Diabetes (uncontrolled high blood sugar). A review of Resident 1's discharge instructions from the General Acute Care Hospital (GACH) dated 9/5/18, indicated that the resident was started on the medication Bumetadine ([MEDICATION NAME] - medication designed to increase the amount of water and salt expelled from the body as urine) 3 milligrams (mg) by mouth (orally) two times per day. The Discharge Instructions included for Resident 1 to stop taking the medication [MEDICATION NAME] (medication designed to increase the amount of water and salt expelled from the body as urine) 20 mg two times a day. A review of Resident 1's Skilled Nursing Facility Physician's admitting orders by phone, dated 9/5/18, indicated [MEDICATION NAME] tablet, 1 mg, give 3 tablets by mouth two times a day for [MEDICAL CONDITION] (swelling) lower extremities. The admitting orders included [MEDICATION NAME] tablet, give 80 mg by mouth two times a day for [MEDICAL CONDITION]. According to DailyMed, an online reference by the National Library of Medicine/National Institutes of Health, the medication [MEDICATION NAME] ¹ is a potent loop diuretic, which, if given in excessive amounts, can lead to a profound diuresis of water and electrolyte depletion. For the medication [MEDICATION NAME] ², another loop diuretic, excessive diuresis may cause potentially symptomatic dehydration, blood volume reduction and [MEDICAL CONDITION] (abnormally low blood pressure) and worsening renal (kidney) function. On 10/24/18 at 2:24 p.m., during a phone interview with the facility's Pharmacist, (Pharm-D1), he stated, For the medications [MEDICATION NAME] or [MEDICATION NAME], they are both loop diuretics and considered it is a duplicate therapy, especially for heart failure patients. He also added, These are both loop diuretics. It is rarely used together. [MEDICATION NAME] is a strong diuretic. On 10/24/18 at 4:20 p.m., during an interview with the admitting Registered Nurse (RN 1) regarding the medications [MEDICATION NAME] and [MEDICATION NAME], he stated he called the admitting physician for orders for Resident 1. A review of Resident 1's Medication Administration Record [REDACTED]. [MEDICATION NAME] was documented administered 14 times. On 10/24/18 at 4:48 p.m., during an interview and record review with Licensed Vocational Nurse 1 (LVN 1), she stated the medication [MEDICATION NAME] was in the medication cart with other Resident 1 medications. LVN 1 further stated the initials in the Resident 1's MAR for [MEDICATION NAME] from 9/6/18 and 9/7/18 was hers, and she signed it after giving the medication. LVN 1 stated, If the pharmacy does not deliver the medications, we will get the medication from the old medicine cards. On 11/1/18 at 3:25 p.m., during an interview with LVN 2, she confirmed working with Resident 1 on (MONTH) 8 and 9, (YEAR), which the MAR indicated [REDACTED]. On 10/26/18 at 9:22 a.m., during a phone interview with the Director of Nurses (DON), she stated RN supervisors do admissions with help of LVN. She further stated the admitting licensed nurse will verify medication with the admitting physician. Review of the nurses notes dated 9/12/18 at 3:30 p.m., Resident 1 was described as appearing lethargic (sluggish) but arousable when spoken to, B/P (blood pressure) 89/64. Picked up by paramedics and transferred to GACH. A review of Resident 1's GACH records with admission date of [DATE], indicated on arrival to emergency department, patient's BP was 77/46. The GACH records indicated that Resident 1 received both previous order of [MEDICATION NAME] and new dose of [MEDICATION NAME] over the last week while at nursing facility. That Resident 1 presented from the nursing facility with altered mental status and found to be hypotensive ((SBP 77) decreased systolic blood pressure). A cardiologist (heart doctor) was consulted and had low suspicion for cardiogenic shock (shock resulting from acute heart failure). Resident 1 was worked up for shock and ultimately determined to be in hypovolemic shock (result of massive fluid loss). Between 9/12/18 and 9/14/18, Resident 1 received [MEDICATION NAME] drip (medication used to increase heart rate and blood pressure administered directly into the vein for immediate action). A review of an undated facility provided policy titled Unnecessary Medications, states Each resident must receive and the Facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The policy includes Each resident's medication regimen must be free from unnecessary drugs. An unnecessary drug is any drug used: in excessive doses, including duplicate therapy. Also, The consultant pharmacist, in cooperation with the Interdisciplinary Team (group of healthcare providers who work together for the common goal of providing the best outcome for a patient), will identify medications that may be considered 'unnecessary' as defined. The attending physician will be notified for clarification or alteration of the medication order. [MEDICATION NAME] ¹- [MEDICATION NAME] Tablet https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=32dfbea3-eb2b-4070-8605-57ce3e6d5a2f [MEDICATION NAME]² - [MEDICATION NAME] Tablet https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3c8f1c0b-8a44-4ca0-b2cf-3c591f8878fd DailyMed is a site provided by The National Library of Medicine (NLM) and is the official provider of FDA drug label information (package inserts).

Based on interview and record review, the facility failed to ensure one of four sampled residents (Residents 1) who was [DIAGNOSES REDACTED] (paralysis of one side of the body) and required extensive assistance from staff with activities of daily living was provided with escort during medical transport to clinic appointment as ordered by the physician. As a result, on [DATE] around 7:30 a.m., Resident 1 was transported without having his wheelchair properly buckle and not having a seatbelt on him. Resident 1 fell and sustained a large laceration to his nose and under his left eye, when the transport company (TC) driver slammed the break and resident fell from the wheelchair face down and hit the floor, moved forward and ended up nearby the driver seat. Findings: On [DATE], at 8:30 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care. A review of Resident 1's Admission Record indicated the resident was re-admitted to the facility on [DATE]. Resident 1 [DIAGNOSES REDACTED].). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated [DATE], indicated the resident cognitive (a mental process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and he had the ability to understands and understood by others. The MDS indicated, Resident 1 required extensive assistance and one-person physical assist for activities of daily living (dressing, toilet use, personal hygiene, and bathing) and occasionally incontinent (inability to control) of bowel and always continent (ability to control) of bladder. The MDS indicated, Resident 1 required limited assistance and one-person physical assist on locomotion (how resident moves) on unit and off unit. A review of Resident 1 Medical Doctor (MD's) history and physical examination [REDACTED]. A review of Resident 1's Fall Risk assessment dated [DATE] indicated the resident had a balance problem while standing, jerking or unstable when making turns, and required use of assistive device. Resident 1 was identified high risk for fall. A review of Resident 1 MD's order dated [DATE] indicated the resident was scheduled for an eye appointment at the Clinic Building (CB) on [DATE] at 9 a.m. The MD order indicated Resident 1 must have escort and wheelchair. A review of Resident 1's appointment notification form indicated TC picked up Resident 1 on [DATE] at 6:30 a.m. from the facility going to CB. During an interview on [DATE], at 11:30 a.m., Resident 1 stated TC driver picked him up from the facility for eye clinic appointment and facility did not provide an escort. Resident 1 stated TC driver put him at the back of the van and did not properly buckle his wheelchair and did not put a seatbelt on him. Resident 1 stated on the way to the clinic, TC driver slammed the break and resident fell from the wheelchair face down and hit the floor, moved forward and ended up nearby the driver seat. Resident 1 stated TC driver pulled over at the side of the highway and wiped the blood dripping from his face and replaced his bloodied shirt with driver's shirt. Resident 1 stated TC driver dropped him off in the CB unattended and left. During an interview with Clinic Social Worker (CSW) on [DATE], at 2 p.m., CSW stated found Resident 1 sitting in the wheelchair, alone in the CB's waiting area, noted with blood dripping down from the nose with a large laceration (skin tear) on his nose and under left eye. CSW stated drips of blood all over Resident 1's jeans. CSW wheeled Resident 1 right away to the Emergency Department (ED) located at the other building. CSW stated clinic requested for escort to ensure Resident 1's safety due to unsteady gait, high fall risk, and uses wheelchair. CSW stated she called the facility on [DATE] early a.m. prior to Resident 1's transport to CB to make sure escort will be provided and facility confirmed that Resident 1 would have an escort. A review of General Acute Care Hospital (GACH) Mental Health Intensive Case Management progress notes, dated [DATE], at 9:30 a.m., indicated Resident 1 sustained an injury (large laceration to his nose and under left eye) during transportation from facility to eye clinic appointment on [DATE] approximately between 7:30 am to 8:30 a.m. A review of GACH MD's ED notes, dated [DATE], at 11:22 a.m., indicated Resident 1 chief complaint was facial laceration. ED notes indicated the laceration over the bridge of the nose was repaired with steri-strips (wound closure strips) as it was deemed too dangerous for the patient (resident) to undergo suturing with a needle due to his uncontrolled tremors and the superficial skin tear underneath the left eyelid was repaired with dermabond (skin glue). On [DATE], at 2:50 p.m., during clinical record review and concurrent interview with facility Social Service Assistant 1 (SSA 1), SSA 1 stated she did not arrange for an escort for Resident 1 because the appointment notification form indicated escort not needed. During a clinical record review and concurrent interview with Registered Nurse 1 (RN 1), on [DATE], at 1:45 p.m., RN 1 stated Resident 1 has an order to have an escort. RN 1 stated that MD order should be followed. RN 1 stated that the escort is a facility staff, arranged to attend to resident's needs in case there will be a sudden change of condition on the way to the clinic and for resident's safety. During an interview with Director of Staff Development (DSD), on [DATE], at 3:30 p.m., DSD stated facility should provide an escort to resident as ordered by MD. DSD stated if resident's family member not available, she will designate/assign a facility staff to accompany the resident if escort needed. A review of facility's policy and procedure titled Safety and Supervision of Residents, dated ,[DATE], indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview and record review, the facility failed to ensure the resident receives adequate supervision and assistance devices to prevent accidents and injury for one of 14 sampled residents (Resident 36), who was at risk for falls and required two-person assistance with transfers, including, 1. Failure to develop a comprehensive resident centered plan of care that included in the interventions the method of transferring Resident 36, the need to provide two-person physical assist, and the use of a mechanical or electronic lifting device to safely transfer Residents 36 in and out of bed or chair 2. Failure to implement the plan of care that indicated the use of two-person assist during Resident 36's transfers. 3. Failure to implement the facility's policy and procedure on Safe lifting and Movement of Residents by not using appropriate techniques and devices (mechanical lifting devices) to lift and move residents and by not documenting in the plan of care Resident 36's transferring and lifting needs. As a result, on September 25, 2017, when Certified Nursing Assistant 10 (CNA 10) was transferring Resident 36 without another staff assistance and without the use of a mechanical transferring device, Resident 36 fell to the floor, requiring emergency transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. Resident 36 was diagnosed with [REDACTED]. Findings: On October 11, 2017, at 11:40 a.m., Resident 36 was observed with arm sling on her left arm, sleeping in a low-position bed with a landing pad on the floor at the right side of the bed. A review of the Admission Record indicated Resident 36 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated August 12, 2017, indicated Resident 36 had limited ability to communicate, was unable to walk, and was totally dependent (full staff performance) with two or more persons physically assisting with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfers (how resident moves between surfaces including to and from: bed, chair, wheelchair, standing position). A review of Resident 36's Fall Risk assessment dated [DATE], indicated Resident 36 had moderate risk for fall. A review of Resident 36's nursing Weekly Summary dated September 5, 2017, indicated the resident's functional status for transfer (how resident moves between surfaces including to or from bed, chair, standing position) was totally dependent. A review of the Care Plan initiated on August 11, 2015, for Resident 36's fall risk re-evaluated every three months, had a goal for Resident 36 not to have incidents of falls/injury. The interventions included to supervise/assist with transfers and ambulation, and to use transfer/lift equipment as indicated. A review of a care plan for dated August 12, 2017, for Residents 36's risk for fall related to stroke with left sided weakness, had a goal for the number of falls to decrease during the next 90 days. The interventions included assist Resident 36 with transfers/mobility as needed. The care plan did not specify a method of transfer to be used by the nursing staff based on Resident 36's size, weight, mobility status, and weight bearing ability, in order to ensure safety during transfers. A review of Resident 36's SBAR (Situation - Background - Assessment - Recommendation) communication form and Progress Note dated September 25, 2017, with no unspecified time, indicated Resident 36 had an incident of a fall while Certified Nursing Assistant 10 (CNA 10) was transferring the resident alone from the bed to a shower chair. A review of the Nurse Progress notes dated September 25, 2017, timed at 8:50 a.m. indicated Resident 36 complained of severe pain to the left shoulder and right hip after the incident, was observed having facial grimaces and grunting when trying to touch the affected area. Resident continuously complained of severe pain and paramedics (911) was called. Resident 36 was transferred to a GACH. According to a review of the clinical record from the GACH, x-rays of the left shoulder, arm and wrist, dated September 25, 2017, timed at 12:58 p.m., indicated Resident 36 sustained fracture of the left humeral neck (shoulder). Resident 36 had an arm sling on her left arm and returned to the facility on [DATE] with order of Norco 5-325 mg every 6 hours for moderate pain. Since readmission to September 26, 2017, Resident 36 has received Norco 20 times for moderate pain to the left shoulder. On October 11, 2017, 2:42 p.m., during an interview, CNA 10 stated she was assigned to Resident 36 on the day of the fall. Resident 36 was scheduled for shower on that day and at around 8:30 a.m. she tried to transfer Resident 36 from bed to shower chair by herself. However, when she lifted Resident 36 from the bed, was too heavy for her and she, CNA 10, could not complete the transfer and Resident 36 fell to the floor. CNA 10 stated she was not sure how the resident was previously transferred. On October 11, 2017, at 3:30 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she was the charge nurse on duty when Resident 36 fell . LVN 4 stated at the start of the shift she gave endorsement to her CNAs regarding their assigned residents. LVN 4 stated she told to CNA 10, Resident 36 needs two-person assist with transfers. LVN 4 stated CNA 10 should have used a mechanical lift. On October 12, 2017 at 8:46 a.m., during a record review and concurrent interview, Physical Therapist 1 (PT 1) stated Resident 36 required maximum assistant for bed mobility and two-person assist and she usually recommends the use of a mechanical lift for totally dependent and heavy residents. On October 12, 2017 at 9:40 a.m., during a record review and an interview, the Assistant Director of Nursing (ADON) stated she could not find in Resident 36's clinical record documentation addressing the need to use of the mechanical lift with two-person assistance when transferring Resident 36 in and out of bed or chair. The ADON stated the plan of care did not reflect transfer and lifting needs as indicated in the facility policy. A review of the facility's policy and procedure titled, Safe lifting and Movement of Residents, dated December 2013, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this uses appropriate techniques and devices to lift and move residents. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Staff will document resident transferring and lifting needs in the care plan. Such assessment include resident's preferences for assistance, resident's mobility, size, and weight bearing ability.

Based on observation, interview, and record review, the facility failed to ensure all injuries of unknown source were reported in accordance with State law through established procedures, have evidence that violations are thoroughly investigated, and report results of all investigations to the administrator and to other officials in accordance with State law for one resident of 24 sample residents (Resident 16), by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) immediately reported to Licensed Vocational Nurse 6 (LVN 6) Resident 16 had a fall during an assisted transfer, in order to provide an assessment of Resident 16 who had an injury. 2. Promptly conduct a thorough assessment and investigation into Resident 16's right hip pain, to help identify the extent to which underlying causes of pain could be addressed as indicated in the Clinical Protocol for Pain. 3. Thoroughly and promptly complete an investigation of Resident 16's injury of unknown origin to determine the events leading up to the incident as per the facility's policy and procedure. 4. Report immediately to the Administrator of the facility and to the state survey and certification agency (Department of Public Health), (as soon as possible but not to exceed 24 hours after discovery of the incident) or within 24 hours of the knowledge of an injury of unknown origin. 5. Ensure the Administrator provided a written report of the results of all abuse investigations to the state survey and certification agency (Department of Public Health), within five working days of the incident as per the facility policy. These deficient practices resulted in a delay of 20 hours for a medical evaluation of Resident 16's right hip pain and to identify the resident had a comminuted (multiple bone splinters) mildly displaced (abnormal position) right femoral neck (right hip) fracture (broken bone). (If left untreated, a comminuted fracture can lead to further injury to the area surrounding the fracture and produce severe pain). This also resulted in a delay of 4 days for providing a written report of the results of an abuse (injury of unknown origin) investigation to the state survey and certification agency (Department of Public Health). On August 5, 2017, the Department of Public Health received an Entity Reported Incident (ERI) regarding an injury of an unknown origin. A review of the ERI indicated on July 25, 2017, at an unspecified time, 1. Resident 16 was noted to exhibit right leg pain. 2. On July 26, 2017, according to the physician's orders [REDACTED]. 3. The pain was identified as a [MEDICAL CONDITION] hip. 4. The facility had no fall incident reported and Resident 16 had no report of an incident, 5. The fracture was of unknown cause. 6. The facility initiated an investigation and will submit more information once the investigation was completed. The ERI was initiated and investigated by the Department of Public Health during the Recertification Survey starting on August 8, 2017. A review of the admission record, Resident 16 was originally admitted on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 16's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated May 5, 2017, indicated the resident's cognitive skills for daily decision making were severely impaired, no mood and behavioral signs and symptoms, needed total assistance from staff members for transfers, dressing, toilet use, personal hygiene, and bathing. The resident had impairment on both sides of upper and lower extremities with functional limitation in range of motion (full movement potential). A review of the Certified Nursing Assistant (CNA) - ADL (activities of daily living) tracking form indicated Resident 16 was last transferred into a wheelchair on July 25, 2017, during the 7 a.m. to 3 p.m. shift. There were no entries on the C N A tracking form of July 25, 2017, to indicate a fall or accident took place or was reported to the licensed nurses. A review of the Resident 16's physician's orders [REDACTED]. A review of Resident 16's Nurse's Notes dated July 25, 2017, at 11:10 p.m., indicated Resident 16 was monitored for leg pain. The resident was noted with pain during the shift. PRN (as needed) medications were given as ordered for pain and was noted with relief with no grimace noted. Pain scale rating assessment was one out of 10, (on a pain rating scale zero being no pain, and 10 being the worst pain possible). The pain assessment form of July 25, 2017, indicated Resident 16's right leg pain was relieved by Tylenol 325 milligrams 2 tablets. A review of the Nurse's Notes dated July 26, 2017, at 5 a.m., indicated Resident 16's pain scale rating assessment was of two out of 10. The resident was monitored for right leg pain. There was no indication in Resident 16's Licensed Nurses Notes, Progress Notes or Pain Assessment form of July 25, 2017 or July 26, 2017, to indicate the staff attempted to determine if the resident's right leg pain was a result of an injury (such as a fracture) or accident (such a as fall). A review of Resident 16's physician's orders [REDACTED]. A review of the GACH record (History and Physical) dated July 26, 2017, at an unspecified time, indicated Resident 16 had a chief complaint of acute right hip pain. The resident was seen and evaluated due to the significant pain to the hip area as well as abnormal laboratory findings. X-ray was obtained which had appeared to be positive with a comminuted mildly displaced right femoral neck (hip) with fracture. A comminuted fracture is an injury resulting to several pieces of broken bones. This fracture will cause an unbearable pain because of various reasons. (Comminuted Fracture - Definition, Causes, Symptoms, Treatment and Recovery. Retreived on August 15, 2017 from http://www.actforlibraries.org/comminuted-fracture/). A review of GACH's physician's progress note dated July 31, 2017, indicated Resident 16's family members wanted to treat this injury with non-operative means. On August 10, 2017, at 7:10 a.m., during an observation and interview with Resident 16, she was alert and oriented to name and place, lying in bed on her left side. The resident stated CNA 1 was with her when she fell to the floor from her wheelchair. Resident 16 did not state the date of the fall. On August 10, 2017, at 8:37 a.m., during an interview with LVN 6, he stated on July 25, 2017 at 1 p.m., Resident 16 was holding her right leg and was moaning. The resident stated pain, pain, pain repeatedly. The physician was called and ordered a venous doppler. On July 26, 2017, at 10 a.m. the physician stated to transfer the resident to the hospital. LVN 6 stated I did not know of an occurrence of a fall. CNA 1 was working here until Resident 16 was transferred to the hospital. On August 10, 2017, at 9 a.m., during an interview with the Director of Nurses (DON), he stated he was not aware of falls that occurred with Resident 16. The DON stated the resident had an injury of an unknown origin. On August 10, 2017, at 10 a.m., during an interview with the Administrator, when asked for a copy of the facility's investigated report, she stated the investigation was initiated and was reported to the Department, but was not completed yet. It is still in progress. The Administrator submitted a copy of the investigation August 10, 2017, that indicated Resident 16 had a fracture of unknown origin. A review of Resident 16's investigation report did not indicate interviews with the resident, resident's roommates, other residents, and licensed staff members were conducted as indicated in the facility's policy and procedure titled Abuse Investigations. On August 10, 2017, at 3 p.m., during an interview with the Administrator, when asked why the investigation report was not completed within five days, she stated it was still in progress. A review of Resident 16's facility's investigation report dated August 11, 2017, (9 days after the resident was readmitted to the skilled nursing facility with a [DIAGNOSES REDACTED]. 1. On July 25, 2017, CNA 1 was assigned and provided care for Resident 16. CNA 1 transferred the resident to the wheelchair. In mid-morning, the resident appeared to be in pain. The charge nurse (LVN 6) was informed and directed staff to put resident back in bed. 2. On July 26, 2017, the CNA was directed by the charge nurse (LVN 6) to leave Resident 16 in bed. 3. All staff interviewed report they did not witness Resident 16 fall on any of the shifts between July 24, 2017 and July 26, 2017. Staff interviews reflect this resident was completing her normal routine throughout the previous weekend as well. 4. During the investigation, a change was noted: Resident 16's leg pain started to occur mid-morning on July 25, 2017. CNA 1 was assigned to this resident at this time. 5. CNA 1 was questioned again concerning what occurred during his work shift and assignment with Resident 16 on July 24, 2017, July 25, 2017 and July 26, 2017. CNA 1 stated he did not work with the resident on July 24, 2017. CNA 3, she stated that during the morning on July 24, 2017, CNA 1 did to come and assist CNA 3 with transferring the resident from the bed to wheelchair. 6. On August 11, 2017, approximately 9 a.m., Resident 16 allowed the Administrator to speak with her. The outcome of the interview was the resident acknowledged CNA 1 was with her when she fell (on an unspecified date). CNA 1 transferred her to the wheelchair, and her foot slipped on the agua (water) and she fell to the floor. Resident 16 stated CNA 1 put her back on the bed. C N A 1 transferred the resident a second time to the wheelchair. The resident stated when she was transferred back to the bed that day, she felt pain. 7. The findings of the facility investigation indicated: on July 25, 2017, C N A 1 transferred Resident 16 to the wheelchair and the resident fell during this transfer. CNA 1 did not report the accident to his charge nurse or supervisor. This employee will be terminated effective immediately as a result of the findings of the investigation. On August 11, 2017 at 2 p.m., during an interview with the Administrator, she stated she acknowledged the investigation was not completed in a timely manner and the results of the investigation were not completed within five days. The facility's policy and procedure titled Abuse Investigations dated April 2014, indicated all reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigated by facility management. The individual conducting the investigation will as a minimum included to review the resident's medical record to determine events leading up to the incident, interview any witnesses to the incident, interview the resident (as medically appropriate), interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, interview other residents to whom the accused employee provides care or services, and review all events leading up to the alleged incident. The results of the investigation will be recorded on approved documentation forms. The investigator will give a copy of the completed documentation to the Administrator. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five working days of the reported incident. Should the investigation reveal that a false report was made/filed, the investigation will cease. Residents, family members, ombudsmen, state agencies, etc. will be notified of the findings. A review of the facility's Clinical Protocol for Pain revised June 2013, indicated as a part of the medical assessment the physician will help identify the extent to which underlying causes of pain can be addressed or reversed.

Based on observation, interview and record review, the facility failed to ensure the resident receives adequate supervision and assistance devices to prevent accidents and injury for one of 14 sampled residents (Resident 36), who was at risk for falls and required two-person assistance with transfers, including, 1. Failure to develop a comprehensive resident centered plan of care that included in the interventions the method of transferring Resident 36, the need to provide two-person physical assist, and the use of a mechanical or electronic lifting device to safely transfer Residents 36 in and out of bed or chair 2. Failure to implement the plan of care that indicated the use of two-person assist during Resident 36's transfers. 3. Failure to implement the facility's policy and procedure on Safe lifting and Movement of Residents by not using appropriate techniques and devices (mechanical lifting devices) to lift and move residents and by not documenting in the plan of care Resident 36's transferring and lifting needs. As a result, on (MONTH) 25, (YEAR), when Certified Nursing Assistant 10 (CNA 10) was transferring Resident 36 without another staff assistance and without the use of a mechanical transferring device, Resident 36 fell to the floor, requiring emergency transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. Resident 36 was diagnosed with [REDACTED]. Findings: On (MONTH) 11, (YEAR), at 11:40 a.m., Resident 36 was observed with arm sling on her left arm, sleeping in a low-position bed with a landing pad on the floor at the right side of the bed. A review of the Admission Record indicated Resident 36 was originally admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated (MONTH) 12, (YEAR), indicated Resident 36 had limited ability to communicate, was unable to walk, and was totally dependent (full staff performance) with two or more persons physically assisting with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfers (how resident moves between surfaces including to and from: bed, chair, wheelchair, standing position). A review of Resident 36's Fall Risk assessment dated (MONTH) 12, (YEAR), indicated Resident 36 had moderate risk for fall. A review of Resident 36's nursing Weekly Summary dated (MONTH) 5, (YEAR), indicated the resident's functional status for transfer (how resident moves between surfaces including to or from bed, chair, standing position) was totally dependent. A review of the Care Plan initiated on (MONTH) 11, (YEAR), for Resident 36's fall risk re-evaluated every three months, had a goal for Resident 36 not to have incidents of falls/injury. The interventions included to supervise/assist with transfers and ambulation, and to use transfer/lift equipment as indicated. A review of a care plan for dated (MONTH) 12, (YEAR), for Residents 36's risk for fall related to stroke with left sided weakness, had a goal for the number of falls to decrease during the next 90 days. The interventions included assist Resident 36 with transfers/mobility as needed. The care plan did not specify a method of transfer to be used by the nursing staff based on Resident 36's size, weight, mobility status, and weight bearing ability, in order to ensure safety during transfers. A review of Resident 36's SBAR (Situation - Background - Assessment - Recommendation) communication form and Progress Note dated (MONTH) 25, (YEAR), with no unspecified time, indicated Resident 36 had an incident of a fall while Certified Nursing Assistant 10 (CNA 10) was transferring the resident alone from the bed to a shower chair. A review of the Nurse Progress notes dated (MONTH) 25, (YEAR), timed at 8:50 a.m. indicated Resident 36 complained of severe pain to the left shoulder and right hip after the incident, was observed having facial grimaces and grunting when trying to touch the affected area. Resident continuously complained of severe pain and paramedics (911) was called. Resident 36 was transferred to a GACH. According to a review of the clinical record from the GACH, x-rays of the left shoulder, arm and wrist, dated (MONTH) 25, (YEAR), timed at 12:58 p.m., indicated Resident 36 sustained fracture of the left humeral neck (shoulder). Resident 36 had an arm sling on her left arm and returned to the facility on (MONTH) 26, (YEAR) with order of Norco 5-325 mg every 6 hours for moderate pain. Since readmission to (MONTH) 26, (YEAR), Resident 36 has received Norco 20 times for moderate pain to the left shoulder. On (MONTH) 11, (YEAR), 2:42 p.m., during an interview, CNA 10 stated she was assigned to Resident 36 on the day of the fall. Resident 36 was scheduled for shower on that day and at around 8:30 a.m. she tried to transfer Resident 36 from bed to shower chair by herself. However, when she lifted Resident 36 from the bed, was too heavy for her and she, CNA 10, could not complete the transfer and Resident 36 fell to the floor. CNA 10 stated she was not sure how the resident was previously transferred. On (MONTH) 11, (YEAR), at 3:30 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she was the charge nurse on duty when Resident 36 fell . LVN 4 stated at the start of the shift she gave endorsement to her CNAs regarding their assigned residents. LVN 4 stated she told to CNA 10, Resident 36 needs two-person assist with transfers. LVN 4 stated CNA 10 should have used a mechanical lift. On (MONTH) 12, (YEAR) at 8:46 a.m., during a record review and concurrent interview, Physical Therapist 1 (PT 1) stated Resident 36 required maximum assistant for bed mobility and two-person assist and she usually recommends the use of a mechanical lift for totally dependent and heavy residents. On (MONTH) 12, (YEAR) at 9:40 a.m., during a record review and an interview, the Assistant Director of Nursing (ADON) stated she could not find in Resident 36's clinical record documentation addressing the need to use of the mechanical lift with two-person assistance when transferring Resident 36 in and out of bed or chair. The ADON stated the plan of care did not reflect transfer and lifting needs as indicated in the facility policy. A review of the facility's policy and procedure titled, Safe lifting and Movement of Residents, dated (MONTH) 2013, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this uses appropriate techniques and devices to lift and move residents. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Staff will document resident transferring and lifting needs in the care plan. Such assessment include resident's preferences for assistance, resident's mobility, size, and weight bearing ability.

Based on observation, interview and record review, the facility failed to ensure the resident receives adequate supervision and assistance devices to prevent accidents and injury for one of 14 sampled residents (Resident 36), who was at risk for falls and required two-person assistance with transfers, including, 1. Failure to develop a comprehensive resident centered plan of care that included in the interventions the method of transferring Resident 36, the need to provide two-person physical assist, and the use of a mechanical or electronic lifting device to safely transfer Residents 36 in and out of bed or chair 2. Failure to implement the plan of care that indicated the use of two-person assist during Resident 36's transfers. 3. Failure to implement the facility's policy and procedure on Safe lifting and Movement of Residents by not using appropriate techniques and devices (mechanical lifting devices) to lift and move residents and by not documenting in the plan of care Resident 36's transferring and lifting needs. As a result, on (MONTH) 25, (YEAR), when Certified Nursing Assistant 10 (CNA 10) was transferring Resident 36 without another staff assistance and without the use of a mechanical transferring device, Resident 36 fell to the floor, requiring emergency transfer to a General Acute Care Hospital (GACH) for evaluation and treatment. Resident 36 was diagnosed with [REDACTED]. Findings: On (MONTH) 11, (YEAR), at 11:40 a.m., Resident 36 was observed with arm sling on her left arm, sleeping in a low-position bed with a landing pad on the floor at the right side of the bed. A review of the Admission Record indicated Resident 36 was originally admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated (MONTH) 12, (YEAR), indicated Resident 36 had limited ability to communicate, was unable to walk, and was totally dependent (full staff performance) with two or more persons physically assisting with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and transfers (how resident moves between surfaces including to and from: bed, chair, wheelchair, standing position). A review of Resident 36's Fall Risk assessment dated (MONTH) 12, (YEAR), indicated Resident 36 had moderate risk for fall. A review of Resident 36's nursing Weekly Summary dated (MONTH) 5, (YEAR), indicated the resident's functional status for transfer (how resident moves between surfaces including to or from bed, chair, standing position) was totally dependent. A review of the Care Plan initiated on (MONTH) 11, (YEAR), for Resident 36's fall risk re-evaluated every three months, had a goal for Resident 36 not to have incidents of falls/injury. The interventions included to supervise/assist with transfers and ambulation, and to use transfer/lift equipment as indicated. A review of a care plan for dated (MONTH) 12, (YEAR), for Residents 36's risk for fall related to stroke with left sided weakness, had a goal for the number of falls to decrease during the next 90 days. The interventions included assist Resident 36 with transfers/mobility as needed. The care plan did not specify a method of transfer to be used by the nursing staff based on Resident 36's size, weight, mobility status, and weight bearing ability, in order to ensure safety during transfers. A review of Resident 36's SBAR (Situation - Background - Assessment - Recommendation) communication form and Progress Note dated (MONTH) 25, (YEAR), with no unspecified time, indicated Resident 36 had an incident of a fall while Certified Nursing Assistant 10 (CNA 10) was transferring the resident alone from the bed to a shower chair. A review of the Nurse Progress notes dated (MONTH) 25, (YEAR), timed at 8:50 a.m. indicated Resident 36 complained of severe pain to the left shoulder and right hip after the incident, was observed having facial grimaces and grunting when trying to touch the affected area. Resident continuously complained of severe pain and paramedics (911) was called. Resident 36 was transferred to a GACH. According to a review of the clinical record from the GACH, x-rays of the left shoulder, arm and wrist, dated (MONTH) 25, (YEAR), timed at 12:58 p.m., indicated Resident 36 sustained fracture of the left humeral neck (shoulder). Resident 36 had an arm sling on her left arm and returned to the facility on (MONTH) 26, (YEAR) with order of Norco 5-325 mg every 6 hours for moderate pain. Since readmission to (MONTH) 26, (YEAR), Resident 36 has received Norco 20 times for moderate pain to the left shoulder. On (MONTH) 11, (YEAR), 2:42 p.m., during an interview, CNA 10 stated she was assigned to Resident 36 on the day of the fall. Resident 36 was scheduled for shower on that day and at around 8:30 a.m. she tried to transfer Resident 36 from bed to shower chair by herself. However, when she lifted Resident 36 from the bed, was too heavy for her and she, CNA 10, could not complete the transfer and Resident 36 fell to the floor. CNA 10 stated she was not sure how the resident was previously transferred. On (MONTH) 11, (YEAR), at 3:30 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she was the charge nurse on duty when Resident 36 fell . LVN 4 stated at the start of the shift she gave endorsement to her CNAs regarding their assigned residents. LVN 4 stated she told to CNA 10, Resident 36 needs two-person assist with transfers. LVN 4 stated CNA 10 should have used a mechanical lift. On (MONTH) 12, (YEAR) at 8:46 a.m., during a record review and concurrent interview, Physical Therapist 1 (PT 1) stated Resident 36 required maximum assistant for bed mobility and two-person assist and she usually recommends the use of a mechanical lift for totally dependent and heavy residents. On (MONTH) 12, (YEAR) at 9:40 a.m., during a record review and an interview, the Assistant Director of Nursing (ADON) stated she could not find in Resident 36's clinical record documentation addressing the need to use of the mechanical lift with two-person assistance when transferring Resident 36 in and out of bed or chair. The ADON stated the plan of care did not reflect transfer and lifting needs as indicated in the facility policy. A review of the facility's policy and procedure titled, Safe lifting and Movement of Residents, dated (MONTH) 2013, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this uses appropriate techniques and devices to lift and move residents. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Staff will document resident transferring and lifting needs in the care plan. Such assessment include resident's preferences for assistance, resident's mobility, size, and weight bearing ability.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and modify the care plan interventions when necessary for one of four sampled residents (Resident 4). For Resident 4, who was assessed as a moderate risk for fall, the facility failed to: 1. Implement the fall care plan interventions of visual checks during care or during medication pass. 2. Implement the cognitive loss care plan interventions by monitoring Resident 4 for unsteadiness in gait and balance. 3. Implement the facility's policy titled, Falls - Clinical Protocol, dated 4/2013, to report a recent injury, pain, or precipitating factors and details on how Resident 4's fall occurred. These deficient practices resulted in Resident 4 suffering a fall, with progressively worsening, severe pain, being transferred to a general acute care hospital (GACH), nine days after the complaints of severe pain, a decline in mobility, Resident 4 becoming bed bound, unable to do most activities, and required total care. Findings: A review of the Admission Face Sheet indicated Resident 4 was admitted to the facility, on 6/25/16, with [DIAGNOSES REDACTED]. A review of the Fall Risk Assessment, dated 6/25/16, indicated Resident 4 received anti-hypertensive medications (used to treat high blood pressure), psychotropic medication (medication capable of affecting the mind, emotions, and behavior of a resident), and diuretics (medication that increases production of urine). The assessment indicated Resident 4 had difficulty in recalling the location of the facility, his room, staff names/faces, and days of the week. In addition, Resident 4 was unable to stand independently and had decreased muscle coordination. The fall risk assessment form indicated Resident 4 scored a 13 which indicated a moderate risk for fall. A review of the Fall Care Plan, dated 6/25/16, indicated Resident 4 was at risk for fall related to poor balance and weakness. The goal indicated to not have any incident of falls or injury. The care plan approaches included to provide visual checks during care and medication pass, to assist the resident with transfer as needed. However the Minimum Data Set (MDS - an assessment and care screening tool), dated 7/8/16, indicated Resident 4 required supervision during transfer and toilet use, which was a discrepancy) and to encourage the resident to ask for assistance. The MDS indicated Resident 4 had moderate cognitive impairment, required supervision during transfer and toilet use, and extensive assistance during personal hygiene / bathing with one person physical assistance. A review of the SBAR Communication Form (SBAR - Situation, Background, Assessment, Recommendation), dated 8/19/16, indicated Resident 4 complained of pain on both sides of the hip related to an unwitnessed fall. The SBAR form indicated a neuro check (neurological assessment to identify early signs of trauma or brain injury) was initiated on 8/19/16, at 9:15 a.m. A review of the physician's orders [REDACTED]. A review of the Fall Care Plan, dated 6/25/16, indicated there was no updated or revised goals or approaches / interventions to address the unwitnessed fall on 8/19/16. During an interview with Registered Nurse Supervisor 2 (RN 2), on 9/2/16, at 12:45 p.m., she stated Resident 4's care plan should have been updated or revised after the unwitnessed fall, but it was not done. A review of the clinical record for Resident 4 indicated there was no documentation of visual checks during care or during medication pass, per the plan of care. In addition, there was no documentation Resident 4 was being supervised during transfer and toilet use. During an interview with the Director of Nursing (DON), on 12/27/16, at 9:45 a.m., she stated providing visual checks to Resident 4 during care or medication pass, and providing supervision during transfer and toilet use should have been documented by the licensed nurses, but it was not. The DON stated it was important Resident 4 received the visual checks to assess for any changes in condition, provide prompt intervention, and to assess the safety of the environment. A review of the Cognitive Loss Care Plan, dated 6/25/16, indicated Resident 4 had potential for increasing confusion related to memory problem and impaired decision making. The goal was to be able to meet Resident 4's daily needs. The care plan approaches included to provide reality orientation while giving care, to provide verbal cues and reminders, to monitor for unsteady gait and balance, and to keep the environment free of hazard. A review of the clinical record for Resident 4 indicated there were no documentation of verbal cues or reminders provided to the resident. There was also no documentation that Resident 4 was monitored for unsteadiness in gait and balance. During an interview with the DON, on 12/27/16, at 9:48 a.m., she stated providing verbal cues or reminders and monitoring Resident 4 for unsteadiness in gait and balance should have been documented by the licensed nurses, but it was not done. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 9/2/16, at 12:40 p.m., she stated Resident 4 informed her that he fell on [DATE], at around 8:30 a.m. Resident complained of pain at this time, rated at 7 on a scale of 10 (moderate pain). LVN 1 stated she did not notify the supervisor of the fall, and was unable to explain her reasoning for not reporting. LVN 1 stated she should have reported it to her supervisor. During an interview with RN 2, on 9/2/16, at 12:50 p.m., she stated LVN 1 informed her that Resident 4 was complaining of pain to the lower back and both sides of the hip. RN 2 stated there was no investigation or interviews conducted related to Resident 4's unwitnessed fall, that LVN 1 should have reported the unwitnessed fall. RN 2 stated the importance of reporting any fall incidents was to ensure facility staff performed an investigation to prevent further episodes of fall. A review of the clinical record indicated there were no Interdisciplinary Team meetings conducted regarding Resident 4's fall on 8/19/16. A review of Resident 1's Medication Administration Record (MAR), dated 8/9/16, indicated to administer Norco 5/325 milligrams (mg - a unit of measure), a narcotic medication used to relieve moderate pain, one tablet by mouth every four hours as needed for moderate pain (rated five to seven out of ten). The physician's orders [REDACTED]. A review of the Pain Assessment Flow sheet, dated 8/18/16, Resident 4 had no complaints pain and did not receive any pain medication. A review of the Pain Assessment Flow sheet, dated 8/19/16, indicated Resident 4 received Norco 5/325 milligram (mg) one tablet by mouth at 2 p.m. (over five hours after initial complaints of pain from the fall). The pain assessment form indicated Resident 4's pain was rated an eight out of ten on the pain intensity scale (ten being the worst possible pain). This indicated Resident 4 did not receive the physician ordered Morphine for severe pain after the fall. During an interview with LVN 1, on 12/27/16, at 9:10 a.m., she stated she administered Norco as ordered after Resident 4 complained of moderate pain on 8/19/16 around 9 a.m., but she forgot to document it on the MAR. LVN 1 stated she should have documented it. LVN 1 stated she did not administer the appropriate medication which was the Morphine Sulfate 0.25 ml when resident complained of eight out of ten pain indicating severe pain on 8/19/16 at 2 p.m. A review of the Pain Assessment Flow Sheet, dated 8/19/16 through 8/28/16 (for 10 days) indicated Resident 4 had generalized pain, rated eight to nine out of 10, indicating very severe pain. The assessment flow sheet indicated Resident 4 received Norco 5/325 mg one tablet a total of six times and Morphine Sulfate 0.25 ml a total of 18 times. A review of the physician's orders [REDACTED]. During an interview with the DON, on 12/27/16, at 9:30 a.m., she stated LVN 1 should have documented in the MAR administration of the pain medication. The DON stated she reviewed the Incident Log Book and there was no incident report completed on Resident 4's unwitnessed fall and there was no investigation done. The DON stated during an unwitnessed fall the resident should be assessed immediately for any injuries including the pain level. She stated appropriate pain medication should be administered immediately and pain reassessment should have been done. The care plan should have been revised or updated indicating new goals and interventions. The DON stated LVN 1 should have reported the incident to the RN Supervisor and the DON to be able to conduct an investigation to prevent further episodes of fall. A review of the GACH's History and Physical, dated 8/29/16, indicated Resident 4 was observed to have progressively worsening back pain since the fall on 8/19/16 with a decline in mobility. A review of the GACH's Performance Scale, dated 9/2/16, indicated Resident 4 was bed bound, unable to do most activities, and required total care. A review of the facility's policy and procedure titled, Falls - Clinical Protocol, dated 4/2013, indicated a licensed nurse shall assess and report any recent injury, pain, and precipitating factors and details on how fall occurred. A review of the facility's policy and procedure titled, Care Plans, dated 9/2010, indicated a licensed nurse and/or other Interdisciplinary Team member should develop, update and revise a care plan upon identification of a change of condition and/or any new needs. A review of the facility's policy and procedure titled, Pain-Clinical Protocol, dated 6/2013, indicated a licensed nurse should assess a resident whenever there was a significant change in condition and when there was onset of new pain or worsening of existing pain. Appropriate non-pharmacologic and medication interventions to address the pain should be provided and administered timely.

Based on observation, interview, and record review, the facility failed to provide supervision and assistance devices to prevent injury from avoidable accidents for 4 of 24 sample residents (3, 11, 29, 6), and failed to ensure the enviroment was safe for all residents, by failing to: 1. Monitor and provide close and frequent supervision to Resident 3, and evaluate and update the plan of care interventions when not effective to prevent multiple falls and injury, one of which resulted in a fracture to the resident's right hip; and by failing to follow the facility policies. Resident 3 required hip surgery under general anethesia and suffered avoidable pain, suffering, and risk from the surgery. 2. Monitor and provide adequate supervision to Resident 11 who was assessed as being a high risk for falls, had a history of [REDACTED]. Resident 11 had multiple falls, two that resulted in a displaced fracture (the two ends of the broken bone are separated from one another) of the left humerus (upper arm bone). 3. Ensure Resident 29 was provided the physician-ordered tilt-in space wheelchair. Resident 29 was provided with a standard manual regular wheelchair that resulted in the resident falling from the wheelchair and fracturing the left tibia (lower leg bone). Resident 29 required surgery to repair the fractured bone. 4. Provide liquid thickener to Resident 16, who had a [DIAGNOSES REDACTED]. 5. Ensure full fire extinguisher tanks were securely stored to prevent accidental discharge, and not kept on the floor in the maintenance office. Findings: a. On March 30, 2015, at 5:40 p.m., Resident 3 was observed eating independently in the Station I ' s dining room. She had a self-release belt (positioning belt to improve safety while seated in the wheelchair) applied around her waist. The director of nursing (DON) checked and released the belt and it alarmed loudly. The DON stated the self-release belt was an intervention implemented after the resident fell multiple times. According to the skilled nursing facility (SNF) admission record Resident 3 was a [AGE] year-old- female, who was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. and hardening of the blood vessels that supply the legs and feet). The Minimum Data Set (MDS), an assessment and care screening tool, dated March 10, 2014, indicated Resident 3 usually made herself understood and sometimes understood others, required one person physical assistance with transferring to her bed, chair, wheelchair, and to a standing position, and for toileting and walking in her room. The MDS Care Area Assessment (CAA) indicated that falls was an area of concern requiring further assessment and care planning. The documentation in the CAA notes indicated that Resident 3 had a " previous fall " on February 13, 2014. However there was no care plan in the current medical record reflecting this actual fall. According to a primary care physician ' s History and Physical (H&P) Examination report dated September 24, 2014, Resident 3 did not have the capacity to understand, make decisions, and her rehabilitation potential was poor. Resident 3 had a plan of care (care plan) in the medical record initiated on September 11, 2014, and updated December 2014, for at risk for falls as a problem related to poor balance, unsteady gait, weakness, and use of drugs (not indicated, left blank). The goal was that Resident 3 would have no incident of falls/injury every shift for three months. The interventions included to assist the resident with transfers/mobility as needed and encourage asking for assistance if able to, and "frequent" visual checks. There was no documentation on the current care plan that indicated how the resident was expected to ask for assistance if " not " able to since she did not have the capacity to understand or make decisions. There was no indication as to what time frame was meant by "frequent visual checks" or by whom the frequent visual checks were to be done for the resident ' s safety. The care plan did not incorporate or include information about the actual fall circumstances that occurred previously on February 13, 2014 (whether the fall was from bed or from the wheelchair). A review of the Fall Risk Assessment (an assessment tool used for screening fall risk) dated January 5, 2015, indicated that Resident 3 was a high risk for falls. A review of the clinical record indicated Resident 3 had recurrent falls after the February 13, 2014, incident as follows: A review of the facility's investigation report indicated that on January 15, 2015, during rounds, a Registered Nurse (RN) Supervisor found Resident 3 sitting on the floor next to her bed at 12 a.m. A body assessment was done and the resident complained of pain to bilateral (both) hips. The physician was notified who ordered an immediate X-ray of hips and pelvis. A review of the X-ray results dated January 15, 2015, indicated Resident 3 had a right hip acute minimally displaced femoral neck (a bone located near the top of the long bone of the thigh) fracture (broken bone). There was no fracture, dislocation, or degenerative changes present to the left hip. A review of Resident 3's Pain assessment dated [DATE] indicated she had signs and symptoms of pain upon movement. According to the assessment it was determined by the resident's facial grimace, the pain was very severe at a level of (8/10) 8 out of 10 (a pain scale rating from 0 to 10 where 0 is no pain and 10 is the most severe pain). Resident 3 had physician orders [REDACTED]. The physician had ordered her to be transferred to the general acute care hospital emergency room (GACH ER) for the hip fracture. Resident 3 had a plan of care developed for an actual fall on January 15, 2015, related to poor safety awareness, weakness, and the use of drugs such as Dilaudid, Tramadol (narcotic-like pain reliever used to treat moderate to severe pain), Seroquel (used to treat the symptoms of mental disorders), and Ativan (used to treat anxiety disorders), all with side effects that may cause falls. There were updated interventions to "closely" monitor Resident 3, keep the resident's bed in a low position with floor landing pads, to apply an alarm on the bed and wheelchair (alerts staff if a resident attempts to get out of bed or out of the wheelchair without assistance). There was no documentation that indicated the interdisciplinary team (IDT) was involved in the development of the plan interventions as indicated in the facility's policy to prevent further injury from falls. A review of the GACH history and physical (H&P) dated January 16, 2015, indicated Resident 3 was admitted with a right hip fracture after a fall. She had dementia, memory loss, did not remember falling, and was an unreliable historian. A review of the literature indicated the post-operative risk and complications associated with a surgery under general anesthesia included bleeding, infection, heart attack, pneumonia, kidney failure (during or after an operation), deep venous thrombosis (DVT - occurs when blood clots from in the large veins of the leg. If the blood clots in the veins break apart, they travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a pulmonary embolism) (Save, Richard H., "Postoperative Care." Hospital Medicine, 2nd Edition, Philadelphia: Lippincott, Williams, & Wilkins, 2005, 261-269). According to the SNF readmission Evaluation record, Resident 3 returned to the SNF on January 18, 2015 at 5 p.m., after repair of her fractured hip. The reason for readmission was for continuation of care and rehabilitation with physical and occupational therapy. A Resident Status skin assessment report dated January 19, 2015, indicated Resident 3 had a right upper thigh surgical wound that measured 9.0 centimeters long with 15 surgical staples, with skin discoloration to the area. On February 3, 2015, Resident 3 was discharged from rehabilitation, according to a March 30, 2015, at 3:10 p.m., interview with the Physical Therapist ((PT 1) trained individuals who help people improve their physical movement and manage their pain). It was stated that Resident 3 was discharged with a physical functional status that required contact guard assist to help steady the body or help with balance, but no walking because the resident could not comprehend that she could not put full weight on her right leg after the January 15, 2015 hip repair. A review of the medication administration record (MAR) and physician orders [REDACTED]. The medications included Dilaudid 2 milligrams (mg), and Tramadol (pain relieving medication) 50 mg. The Pain Assessment Flowsheet indicated that from February 1 to February 28, 2015, Resident 3 had pain daily ranging from a pain level of 5/10 to 8/10, requiring pain medications for relief. A change of condition Communication Form dated February 14, 2015 (Saturday), 10 a.m., indicated Resident 3 had another fall, unwitnessed. She was found on the floor sitting by the restroom with her wheelchair behind her; the "resident consistently tries to get out of bed." The form indicated that things that make the condition better were "staying with the resident." Resident 3 complained of pain to the right knee and ankle, determined to be at a level of 3/10. The primary care physician was notified, who ordered an X-ray of the right knee and right ankle. The X-ray results dated February 14, 2015, indicated there was no fracture or dislocation. There was no documented evidence that indicated the physician was notified regarding the resident's behavior of consistently trying to get out of bed, or that the IDT was involved with evaluating and updating the care plan interventions given the current interventions were not working, to create a safer environment for the resident and to prevent further injury from falls as indicated in the facility's policy. There was no documentation on the form to indicate that the immediate environment was assessed and documented as to whether the bed or wheelchair alarms were in place or not, or operating. There was no evidence that the information that made the condition better, "staying with the resident" (one-to-one supervision), was considered and incorporated when updating the care plan to prevent injury from falls. According to a change of condition Communication Form dated February 15, 2015 (Sunday), 10:20 a.m., Resident 3 was in the activity room when she was found on the floor by the Activity Director; the resident slid off the wheelchair. The resident was assessed and found to have slight pain on the right knee determined to be 3/10. Resident 3 was able to move the lower extremities. The form indicated at 10:25 a.m., the physician was called, new orders received and carried out. There was no documentation indicating the conditions surrounding the fall were assessed, such as whether the wheelchair alarm was applied or not, or whether the alarm sounded. On March 30, 2015, at 12:45 p.m., when the DON was questioned about the conditions surrounding this fall, she stated that the Activity Director no longer worked at the facility, therefore no interview could be done. She stated that the wheelchair alarm had been applied incorrectly on top of the wheelchair cushion, and should have been under the cushion, and that was the reason the wheelchair alarm didn't sound when the resident slid out of the wheelchair. A review of Resident 3's X-ray results of the lumbar-sacral (lower back) area, dated February 15, 2015, indicated there was no fracture or subluxation (bones of the spine that move out of position and irritate the spinal nerves) seen. Resident 3's plan of care was updated on February 15, 2015, to include a self- release belt to be applied to the resident while in her wheelchair. A plan of care was developed February 17, 2015, for Resident 3's two fall incidents during the weekend of February 14 and February 15, 2015. The interventions included re-checking the wheelchair and bed alarms for functionality every shift and escalate interventions by adding a self-release belt while in the wheelchair with alarm. There was no evidence that the information that made the condition better, "staying with the resident" (one-to-one supervision), was considered and incorporated when updating the care plan to prevent injury from falls. A review of Resident 3's Restraint Evaluation dated February 17, 2015, indicated the resident attempted continuous wandering behavior. The resident was diagnosed with [REDACTED]. The resident did not have any safety awareness and would attempt to function beyond her abilities. According to the evaluation Resident 3 would be safe from potential body injuries related to falls. A change of condition Communication Form dated March 15, 2015, 10:55 p. m., indicated Resident 3 had another fall, and was found by a Certified Nursing Assistant ((CNA) CNA ' s name is not available) lying on the floor pad. An assessment was done, Resident 3 denied any pain and there were no injuries documented. The vital signs recorded were normal. A review of Resident 3 ' s physician's orders [REDACTED]. 1. Tramadol 50 mg by mouth to be administered every six hours as needed for moderate pain level 3-6/10 (pain scale of zero to ten; zero indicating no pain and 10 indicating worse pain) dated January 19, 2015. (Tramadol is a pain medication with adverse drug reactions that included dizziness, vertigo, confusion, and anorexia Nursing Drug Handbook 2015, Pages 1407-1408). 2. Tramadol 50 mg two tablets by mouth to be administered every six hours as needed for severe pain level 7-10/10 dated January 19, 2015. 3. Dilaudid 2 mg by mouth every six hour as needed times three weeks for severe pain level 7-10/10, dated January 19, 2015. (Dilaudid is an opioid pain medication with adverse drug reactions that included dizziness, sedation, confusion, nausea, and weight loss (per care plan of January 26, 2015 the resident lost 8 pounds in one week) Nursing Drug Handbook 2015, Pages 711-713). 4. Seroquel 12.5 mg by mouth to be administered every other night at bed time for schizo-affective disorder (a mental condition that causes both a loss of contact with reality and mood problems) manifested by continuous wondering dated, January 19, 2015. (Seroquel is an antipsychotic medication with adverse drug reactions that included dizziness, lowering or raising blood pressure Nursing Drug Handbook 2015, Pages 1203 - 1206). 5. Ativan 1 mg by mouth to be administered every six hours as needed for anxiety manifested by constant attempting getting out of bed dated, January 20, 2015. (Ativan is an anti-anxiety medication with adverse drug reactions that included dizziness, weakness, unsteadiness, disorientation Nursing Drug Handbook 2015, Pages 874 - 875). 6. Remeron 15 mg by mouth to be administered at bed time for depression manifested by isolation and poor appetite dated, January 28, 2015. (Remeron is an anti-depressant medication with adverse drug reactions that included dizziness, and confusion Nursing Drug Handbook 2015, Pages 958 - 960). On April 1, 2015 at about 1:55 p.m., during an interview with the DON, the February 13, 2014, fall was not mentioned. When asked what was done differently after Resident 3's fall incident on January 15, 2015, she stated that they put the resident's bed in a low position with floor landing pads, applied an alarm to the resident's bed and wheelchair, and did frequent visual checks. She stated that frequent meant during rounds, during the time the staff provided care, and when medications were given. However, the DON could not provide documented evidence that staff provided Resident 3 with consistent close and frequent monitoring to prevent her recurrent falls and injuries. During this interview, the DON stated that the facility had a program where facility staff were assigned a group of rooms to monitor during the day. However, the staff member who was assigned to monitor Resident 3 did not work on the weekends, which was when most of the incidents occurred, and the January 15, 2015, incident occurred on the night shift just after midnight. The DON could not provide evidence that there was someone assigned to consistently monitor Resident 3 when the "assigned" staff person was not working or present. During this interview, the DON stated that considering the resident's behavior of attempting to function beyond her abilities, and considering her injuries and needs, new interventions and a revised plan of care should have been put into place to prevent recurrent falls and further injuries. She stated that Resident 3 had recurrent falls that could have been avoided if the care plans would have been "escalated and revised" such as nursing staff taking turns physically monitoring the resident (one-to-one supervision) and documenting the residents whereabouts. A review of the facilities policy titled Fall Prevention and Incident Management undated, indicated the Interdisciplinary Team (IDT), based on the identified potential risk factors, develops and implements an individualized plan of care as necessary, evaluates, monitors and revises the individualized plan of care as necessary. The IDT conducts an evaluation of each incident/accident and implements appropriate interventions to protect the resident(s) and prevent recurrence. During interviews with the DON and the facility administrator on April 1, 2015, between 3 p.m. and 4 p.m., they were asked to provide documented evidence that each fall incident was investigated thoroughly, and that the January 15, 2015, fall with fracture was reported to the Department as required. They were not able to provide the information as requested, and it was stated that Resident 3's fall that resulted in fracture was not reported to the Department. b. According to the admission record Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a comprehensive assessment and screening tool) assessment dated [DATE], indicated Resident 16 was moderately impaired with cognitive skills for daily decision making and required extensive to total assistance from staff for eating and for positioning. The MDS also indicated the resident received nutrition both via feeding tube (a flexible tube placed into the stomach wall to provide nutrition and fluids) and oral intake and was on a mechanically altered diet (foods that are altered so they are soft and easy to chew and swallow). Resident 16 had the following physician's orders [REDACTED]. 1. Diet no added salt, pureed texture and nectar thick fluid consistency diet, dated January 19, 2015. 2. Medications may be taken oral or via Gastrostomy tube (GT- a feeding tube placed in the abdominal wall to provide nutrition to individuals who cannot swallow safely.), dated January 19, 2015. On March 25, 2015, 9:10 a.m., during the medication pass observation with Licensed Vocational Nurse 5 (LVN 5) LVN 5 did not reposition Resident 16 during medication administration. Resident 16 was slumped in bed with the head of the bed up, and was not sitting all the way up which may put the resident at risk for aspiration (the entry of material food, drink or stomach contents from the oral tract into the windpipe and into the lungs) while attempting to swallow. On March 25, 2015, at 4:35 p.m., during an interview LVN 5 stated it is easier for the resident to take his medications if he is sitting up properly so as not to be at risk for aspiration. A review of the facility's policy titled General Dose Preparation and Medication Administration, dated 2013, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, including, positioning the resident properly, if necessary. c. On March 24, 2015, a review of the admission record indicated Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS- comprehensive assessment and care screening tool) dated January 6, 2015, indicated Resident 11 was able to express ideas and wants, had clear speech and was able to understand others, severely impaired but had the ability to recall after cues were given and required limited assistance with one person physical assist with bed mobility, transferring, toilet use, personal hygiene and bathing. There were three separate care plans developed for fall risk dated October 1, 2014, January 14, 2015, and March 8, 2015. On March 31, 2015 at 10:15 a.m.. During an interview, the director of nursing (DON) stated the nursing staff members were using three different care plans. The DON was unable to identify updated interventions that would have prevented the third fall. The DON also stated the resident turns off his bed alarm. The DON could not provide evidence of interventions to be implemented to address the resident's behavior of turning off the bed alarm. When asked who was assigned to monitor the resident, the DON stated there is a log for the bed alarm, and the licensed nurses are responsible for checking the log. A review of Resident 11's care plans revealed a plan of care dated January 14, 2015, that identified a problem that the resident was at risk for fall or injury due to unsteady gait. The plan had interventions that included call light within reach and answered promptly, during activities keep close observation to minimize potential for falls. A review of the Fall Risk Evaluation dated January 15, 2015, and March 8, 2015, indicated Resident 11 had a high risk for falls. A review of the physician's orders [REDACTED]. The orders indicated for the staff to check functionality of the alarm every shift, so that the alarm alerts the staff when the resident attempts to transfer without assistance. According to the Medication Administration Record (MAR) Resident 11 had the following medications with adverse effects to cause falls that placed him at risk for injuries from a fall: 1. Seroquel 50 milligrams (mg) by mouth to be administered twice daily for psychosis manifested by continuous wandering and delusional striking dated September 24, 2014 (Seroquel is an antipsychotic medication with adverse drug reactions that included dizziness, lowering or raising blood pressure Nursing Drug Handbook 2015, Pages 1203 - 1206). 2. Ativan 1 mg by mouth to be administered every six hours as needed for anxiety manifested by constant attempting getting out of bed dated, January 20, 2015. (Ativan is an anti-anxiety medication with adverse drug reactions that included dizziness, weakness, unsteadiness, disorientation Nursing Drug Handbook 2015, Pages 874 - 875). A review of the facility's investigation of the incident report indicated Resident 11 had three falls: the first fall was on December 29, 2014, that resulted in no physical injuries (reported and investigated by the Department on a separate visit). The second fall was on December 31, 2014, that resulted in a left upper arm fracture. The third fall occurred on March 8, 2015, at 8:30 p.m. A review of the investigation report indicated that on December 31, 2014, at 6:25 p.m., Resident 11 was found on the floor, lying on the landing mat on his left side with his left arm under him. He was sent to the general acute care hospital (GACH) at 8:00 p.m., and was diagnosed as having a fracture to the left humerus bone. The resident was admitted to the GACH and was treated with immobilization of the fracture and discharged back to the skilled nursing facility on January 1, 2015, at 12:20 a.m. According to the x-ray report dated January 26, 2015, the resident's fracture showed early healing of the fracture without displacement. According to the situation, background, assessment and request form (SBAR-a licensed staff communication tool) dated March 8, 2015, and timed at 8:35 p.m., Resident 11 got up from the bed and walked towards the door of the room, lost his balance and fell at 8:30 p.m.. This resulted in a displaced fracture of the left humerus bone. According to the x-ray report dated March 9, 2015, Resident 11 had a displaced fracture of the left humerus with displacement contrary to the previous x-ray showing healing of the fracture of the left humerus. This was complicated by the March 8, 2015, fall that caused displacement of the fractured left humerus. There was a Short Term Care Plan for the actual fall dated March 8, 2015, with interventions that included the resident will be monitored every shift, check for bed alarm placement every shift, observe resident and call light within reach. On March 24, 2015, at 1:30 p.m., during an observation in the presence of Housekeeper 1 (HK 1), Resident 11 was standing by the door of his room. The resident had an unsteady gait and was bare footed. HK 1 assisted the resident back to bed. Resident 11's bed alarm was not heard triggered when he got out of bed and stood by the door. During an interview at 1:35 p.m., HK 1 stated she saw Resident 11 at the door. When asked if she had heard his bed alarm go off to alert the facility staff she stated "No." On March 24, 2015 at 1:35 p.m., during an interview with Certified Nurse Assistant 1 (CNA 1) regarding Resident 11's injuries, she stated the resident sustained [REDACTED]. When asked when and how the resident fell , CNA 1 stated the resident's bed alarm should have been checked if it was applied and not turned off by the resident. When asked if the bed alarm sounds when the resident gets out of the bed, CNA 1 stated that the bed alarm is very loud (when it is applied) and it stays on until someone turns it off. A review of the facility's policy dated October, 2014, titled Fall Prevention and Incident Management indicated to provide an environment that is free from hazards over which the community has control. The community identifies residents who are at risk for accidents or falls, and adequately assesses and plans care to reduce the injuries associated with the resident's risk to the extent possible. A review of the facilities undated policy titled Fall Prevention and Incident Management, indicated the Interdisciplinary Team (IDT), based on the identified potential risk factors, develops and implements an individualized plan of care as necessary, evaluates, monitors and revises the individualized plan of care as necessary. The IDT conducts an evaluation of each incident/accident and implements appropriate interventions to protect the resident(s) and prevent recurrence. d. On March 30, 2015, a review of the admission record indicated Resident 29 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED].(tightening of muscles that prevents normal movement). A review of the plan of care for falls dated October 24, 2014, did not include intervention for a specialty assistive device. A review of the physician's orders [REDACTED]. A review of the occupational therapy discharge summary notes dated January 7, 2015, indicated to maintain correct anatomical alignment while seated in the wheelchair using leg rests, specialty wheelchair back support and specialized cushion in order to facilitate intact skin integrity, eliminate risk for falls, enhance comfort, and achieve proper joint alignment. A review of the full Mimimum Data Set (MDS) assessment and screening tool, dated March 16, 2015, indicated Resident 29 had severely impaired cognitive skills and was not able to make decisions, required total assistance with one person physical assistance with bed mobility, transferring, toilet use, personal hygiene and bathing. According to the physician's history and physical exam (H&P) dated March 4, 2014, Resident 29 did not have the capacity to understand and make decisions. A review of the physician's progress note dated February 5, 2015, indicated Resident 29 was slowly, more confused. On March 30, 2015 at 9:55 a.m., during an interview, Resident 29's family member stated that the resident fell from the wheelchair on March 28, 2015 which resulted in a fractured left tibia; the resident had underwent surgery to repair the fractured lower leg as a result of the fall. The family member stated that Resident 29 has advanced stages of Alzheimer's disease, and was unable to walk independently or with assistance. According to the family member Resident 29 was normally in a wheelchair, and described the resident as "dead weight" while being repositioned or moved. The resident was found on the floor and the fall was unwitnessed by the nursing staff. A review of the Fall Risk Evaluation with dates of September 18, 2014, October 23, 2014, December 16, 2014, and March 16, 2015, indicated Resident 29 had a score of 20. According to the Fall Risk Evaluation a score of 10 or higher indicated the resident was at high risk for falls. A review of the Situation, Background, Assessment and Request (SBAR- a licensed staff communication tool) form dated March 28, 2015, and timed at 11:20 a.m. indicated Resident 29 was found on the floor lying on the right side. The resident fell from the wheelchair with slight discoloration of the skin at the right temple and the right elbow area. A review of the nurses' notes dated March 28, 2015 timed at 12:30 p.m., indicated Resident 29's left leg was swollen. During an interview on March 30, 2015 at 3:05 p.m., a licensed vocational nurse (LVN 1) stated that she was passing medications and heard a cry for help from the laundry staff that Resident 29 was on the floor lying on her right side with discoloration to the right

Based on interviews, and record review, the facility failed to ensure Resident 1 was provided sufficient fluids to prevent dehydration by failing to: 1. Ensure that Resident 1, who was admitted to the facility with [DIAGNOSES REDACTED]. 2. Ensure that the licensed nursing staff followed monitored Resident 1's hydration status by means of accurate and continuous intake and output (I&O) records, and prompt communication between nursing staff, as indicated in the facility's policy and procedures for the prevention of dehydration. 3. Promptly notify the physician when Resident 1's 24-hour fluid intake was not met for several days, and inquire of further medical interventions as necessary to prevent dehydration. These deficient practices resulted in Resident 1's hospitalization on [DATE], at 2: 35 p.m., nine days after being admitted from the general acute care hospital (GACH 1). Resident 1 became unresponsive and was transferred via paramedics (emergency personnel) to GACH 2. She was diagnosed with [REDACTED]. Resident 1 died on [DATE], five days after she was transferred to the GACH 2. Findings: On [DATE], the Department received a complaint that alleged Resident 1 was unresponsive, with fast breathing, low blood pressure, and was transferred to GACH 2 by paramedics (emergency personnel) on [DATE]. A review of the skilled nursing facility (SNF) admission record indicated Resident 1 was admitted from GACH 1 on [DATE], with [DIAGNOSES REDACTED]. The discharge instructions sent with the resident to the SNF from GACH 1 indicated upon discharge, Resident 1 had [DIAGNOSES REDACTED]. A review of the Resident 1's Dehydration Risk Assessment Tool dated [DATE], indicated she had a moderate risk for dehydration, and the tool indicated a plan of care was required. However, on [DATE], at 3: 50 p.m., during a record review and an interview, Registered Nurse 1 (RN 1) was asked to provide a plan of care to address interventions for Resident 1's risk for dehydration. RN 1 stated there was a nutritional care plan developed by the Registered Dietician (RD), but the licensed nursing staff did not develop a plan of care that included interventions to prevent dehydration. A review of the Registered Dietician's Nutritional assessment dated [DATE], indicated Resident 1 had a height and weight of 65 inches and 149 pounds respectively. The RD's assessment also indicated the resident was confused, had swallowing difficulties and her daily fluid requirement (fluids needed to maintain proper hydration) was 2010 cc of fluid per day. There was no indication on the assessment of the resident's moderate risk for dehydration. There was a care plan for "Alteration in Nutrition" dated [DATE], that indicated to maintain adequate hydration for 3 months. The approaches included to monitor meal intake, offer/encourage fluids, and to assist/feed as needed. The care plan was not specific for dehydration and did not incorporate the [DATE], fluid needs assessment of 2010 cc per day, completed by the RD. For example, the licensed nursing staff did not incorporate interventions that indicated how the 2010 cc of fluid per day would be provided to Resident 1; there was no indication as to the responsible persons to provide the fluids, and how the resident's intake of fluids would be monitored. The care plan did not indicate alternative interventions to be taken if the resident did not consume the 2010 cc of required fluid needs as assessed by the RD. A review of the Minimum Data Set, a comprehensive assessment tool, dated [DATE], indicated the resident had long and short-term memory problems, and was totally dependent on staff for toileting, eating, and drinking. On [DATE], during an interview with Family Member 1 she stated she is a registered nurse and knew the conditions of Resident 1 when discharged from GACH 1 to the skilled nursing facility on [DATE]. According to FM 1, Resident 1 had normal vital signs and no fever. FM 1 stated that on [DATE], she received a call from the facility informing her Resident 1 was transferred to GACH 2 because she was unresponsive, had a low blood pressure and fast breathing. When FM 1 arrived at GACH 2 she was informed by the physician the resident was unresponsive and had abnormal labs. The labs were: Sodium was 176 (normal range is 135 to145), BUN (blood urea nitrogen test shows how well the kidneys and liver are working) was 93 (normal range is 8 to 20), Creatinine 4.41 (test to show how well your kidneys work), and had dehydration and kidney failure. During the interview, FM 1 stated that in her entire career as a registered nurse, she had never seen a sodium level that high. The intake and output record ((I&O) a record to monitor how much liquid was consumed and eliminated as urine) initiated on [DATE], was reviewed with RN 1. The I&O record from [DATE], to [DATE], indicated the resident did not receive and consume 2010 cc of fluid per day in accordance with the RD's assessment. According to the I&O record Resident 1 consumed between 1050 cc and 1320 cc of fluids per day. For example, the intake from [DATE] through [DATE] was as follows according to documentation on the I&O sheet: [DATE] was 1340 cc; [DATE] was 1320 cc; [DATE] was 1080 cc; [DATE] was 1100 cc; [DATE] was 1050 cc; [DATE] was 1070 cc; [DATE] was 570 cc with no 7 a.m. to 3 p.m. intake recorded, and no 24 hour total recorded; [DATE] was 1120 cc; and [DATE] was 1170 cc. The total fluids consumed daily was recorded between 690 cc to 960 cc per day less than what Resident 1 required for her daily hydration needs according to the RD's assessment. The comment section indicated "adequate". There was no indication the physician or RD had been notified of the intake. In addition, the I&O record under the section of Weekly Evaluations did not indicate the licensed nursing staff consistently recorded the resident's fluid output to ensure the resident's hydration status was adequate. The urine output was recorded as the number of times the resident urinated, such as 2 X, however the totals were not totaled correctly to ensure an accurate evaluation. The consistency of the urine, the color and the odor were not recorded as indicated on the discharge instruction received from GACH 1. On [DATE], at 3: 50 p.m., during an interview with RN 1, she was asked why the physician was not contacted when the resident wasn't getting the required fluids necessary as assessed by the RD. RN 1 stated there was lack of documentation or communication from the certified nursing assistants indicating the resident was not drinking the required fluids. She was unable to provide the reason why the resident's I&O record was incomplete and inaccurate. The Medication Administration Record [REDACTED]. It was signed off as being given, however there is not indication what amount was consumed. A review of the CNA - ADL Tracking Form from [DATE] through [DATE], revealed the daily documentation was illegible and inconsistent in the areas of "Dietary Supplement Offered" and "Fluids Offered". In the supplements area the documentation for all three shifts is either "0" of "8" meaning none or did not occur. The fluids offered and consumed was not legible for most days and did not match the I&O recording. The resident's refusal or inability to take fluids was not reported to a licensed nurse according to RN 1's statement on [DATE]. The facility's policy titled, "Resident Hydration and Prevention of Dehydration" dated 2013, indicated the RD will assess all residents for hydration adequacy, nursing will assess for signs and symptoms of dehydration during daily care, nursing will monitor and document fluid intake and output in the medical record. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be incorporated into the care plan, and the physician will be notified. The RD, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Orders may be written for extra fluids to be encouraged between meals. A specific minimum amount should be included ...., "force fluids" or "encourage fluids" are not adequate orders. There was no documented evidence in the clinical record that indicated the licensed nursing staff consistently monitored the resident's hydration status. This would include monitoring clinical signs and symptoms of hypovolemia /dehydration such as skin turgor (skin's ability to change shape and return to normal), dry skin, dry mucus membranes (moist openings such as the mouth, nose, eyes), coated tongue, irrregular bowel movements and its consistency, and the urine output (color, amount, odor). Other monitoring would include consistent documentation and communication regarding the resident's refusal or inability to drink fluids, and notification of the physician to obtain alternative treatment instructions such as tube feeding and/or IV fluid replacement as indicated in the facility's undated policies and procedures (a set of principles, rules, and guidelines formulated or adopted by an organization to reach its goals) as stated above. On [DATE], at 3: 50 p.m., during an interview RN 1 stated, on [DATE], at approximately 2:30 p.m., Licensed Vocational Nurse 1 (LVN 1) called stat (a code for emergency) to the resident's room. On arrival to the room, Resident 1 was observed with excessive sweating, fast breathing, unresponsive but arousable. The vital signs were: blood pressure ,[DATE], pulse 76, respiration 32, and had a temperature of 102.2 taken under the arm; cooling measures were provided. Oxygen Saturation was not readable due to excessive sweating. Oxygen was given at 15 liters per minute via a non-re-breather mask. A review of the Licensed Nurse Progress Note dated [DATE], at 2:30 p.m., indicated Resident 1 was diaphoretic (sweating), breathing too fast and unresponsive. The blood pressure was ,[DATE] (normal ,[DATE]), temperature 102.2 degree Fahrenheit (normal 98.6?F) taken under the arm, respiration 32 breaths per minute (normal ,[DATE]). The physician was notified of the resident's change of condition and an order was obtained to transfer the resident to GACH 2 via paramedics, which occurred at 2:35 p.m. A review of the emergency room Note (ER) obtained from GACH 2 dated [DATE], indicated upon arrival Resident 1 had an altered mental status, no pulse, a fever of 104 ?F, was hypovolemic and hypotensive (low blood pressure) requiring [MEDICATION NAME] drip (medication to raise blood pressure) and CPR (cardiopulmonary resuscitation- compressing over the chest and blowing air into the lungs). Resident 1 was intubated (insertion of breathing tube into the windpipe) and placed on a ventilator (tube connected to a breathing machine to help breath). The resident was also given 6.4 liters of IV fluid replacement (to compensate fluid loss) and two units of fresh frozen plasma, and was admitted to an intensive care unit. A review of the History and Physical (H&P) examination record dated [DATE], indicated the resident went into acute [MEDICAL CONDITION]. The record indicated the x-ray of the abdomen results on [DATE], indicated the resident had a very large fecal impaction (a large lump of dry, hard stool that stuck in the rectum (often seen in resident's with low fluid intake and constipated for a long time)) of at least "16 by 819 centimeters." A review of Resident 1's laboratory test results obtained from GACH 2 dated [DATE], indicated the following: 1. An elevated blood sodium level of 176 mEq/L (reference range ,[DATE] mEq/L). A blood sodium level of more than 150 mEq is an indicator for dehydration (American Journal of Nursing [DATE], Vol. 106 No. 6 Pages ,[DATE]). According to the history and physical examination [REDACTED]. The H&P also indicated the resident had episodes of [MEDICAL CONDITION] secondary to high sodium. 2. An elevated Creatinine (Cr) level of 4.41 mg/dl (reference range 0XXX,[DATE].30 mg/dL). Resident 1's BUN/Cr ratio (BUN divided by creatinine) was 26.3. (A BUN/Cr ratio of 20 to 24 is an indicator for impending dehydration and a BUN/Cr ratio of 25 and above is an indicator for dehydration ("Ranges of Laboratory Test Results for Determining Hydration Status," American Journal of Nursing [DATE], Vol. 106 No. 6 Pages ,[DATE])). BUN and Cr are waste products in the blood filtered by the kidneys and removed in the urine. The decrease blood flow to the kidneys due to reduced blood volume would affect the filtration process which in turn causes the accumulation of waste products such as BUN and Cr leading to acute [MEDICAL CONDITIONS], decreased cardiac output (heart failure-[MEDICAL CONDITION] (AJN diagnostic clinical indicators and laboratory values [DATE]- Vol. 99-Issue 5 Pages ,[DATE],71,73,75). Delayed treatment or delayed hydration may lead to acute [MEDICAL CONDITION] a sudden decrease in kidney function that can lead to irreversible tubular necrosis (premature death or damage to the kidney cells). American Journal of Nursing [DATE] Vol. 99- issue 5 Pages ,[DATE]. 3. An increased white blood cell count (WBC) of 18.7 (reference range 3XXX,[DATE].1 mg/dL). An increased WBC may be an indicator for infection. According to GACH 2's Physician's Progress Notes and the Discharge Summary Notes dated [DATE], Resident 1 died this fifth day of hospitalization . The causes of death were [MEDICAL CONDITION] (heart failure), [MEDICAL CONDITION] (infection), meningitis (brain infection), [DIAGNOSES REDACTED] (a condition where the body cannot regulate itself), and multiple organ failure (a life threatening condition when more than one body organ stops functioning).