Every finding on record at Maple Healthcare Center

Based on observations, interviews, and record reviews, the facility failed to ensure the safe storage and labeling of emergency potable (safe to drink or suitable for human consumption) water reserve for 204 out of 204 bottled waters, 34 six-pack bottled water cases (of which 12 six-packs with Niagara brand and 22 six-packs with [NAME] brand). By failing to:Ensure all emergency potable water was not stored past the facility applied label indicating a use by date (peak freshness and container integrity, not that the water itself has spoiled. Water does not expire, but plastic bottles can degrade over time and leach chemicals which affect the taste and safety) of 11/28/2025, as per facility policy and procedure (P&P) titled Emergency and Disaster Procedures dated 11/25/2025. This failure had the potential for all facility residents and staff consuming outdated emergency potable water in the event of an emergency, which could result in illness.Findings:During an interview on 7/6/2026 at 12:33 P.M., with the Dietary Supervisor (DS), the DS stated that the emergency water was used by the staff for drinking and was provided to residents as part of their meals during an emergency. The DS stated that emergency water was safe for consumption when it was labeled with the manufacturer's best by or use by date and was consumed in accordance with that date. The DS stated that the emergency water supply was an essential part of meeting resident's nutritional and hydration needs during an emergency. During an observation on 7/6/2026 at 12:40 P.M. in the facility's kitchen storage closet, the drinking emergency bottled water supplies were observed. 12 six -pack cases (72 one-gallon bottles) of Niagara (brand) purified drinking water were observed to have a manufacturer's date best by 3/30/2023 printed on the packaging with facility use by label dated 11/28/2025 and 22 of six-pack pack [NAME] (brand) 22 six-pack cases (132 one-gallon bottles) without manufacturer's date with facility label use by dated 11/28/2025. During a concurrent observation and interview on 7/6/2026 at 12:43 P.M., the DS stated it was unusual for the emergency bottled water to have a label indicating a date beyond the manufacturer's use by date. The DS stated that the manufacturer's Best if Used by date of March 30, 2023, indicated the water was approximately three years past that date. The DS stated that the facility applied labels indicated a use by date of November 28, 2025, and were not safe for use. The DS stated that emergency drinking water supplies had to be verified to ensure the water bottles were within the manufacturers' acceptable use by date before being provided to residents or staff. The DS stated that using emergency drinking water beyond the acceptable date could potentially harm residents and staff which could result in symptoms such as diarrhea, nausea, vomiting and stomach pain. The DS stated that all emergency water supply with a use by date 11/28/2025 had to be replaced as soon as possible. During a concurrent interview and record review on 7/6/2026 at 1:25 P.M. with the Infection Preventionist Nurse (IPN), photographs of the emergency water supply taken on 7/6/2026 were reviewed. The IPN stated that the emergency drinking water supply was intended for use by the residents and staff during an emergency. The IPN stated that the emergency drinking water had to be labeled to identify water intended for drinking, water intended for general use, and the applicable expiration or use by date. The IPN stated that the facility applied label indicated a use by date of 11/28/2025. The IPN stated that she agreed with the DS that all emergency water supplies stored in the kitchen storage area had to be replaced. The IPN stated if emergency water with a facility-applied use by date of 11/28/2025 were served, it could potentially cause gastrointestinal illness. The IPN stated that the facility failed to maintain a safe emergency drinking water supply. During a review of the facility's P&P titled Emergency and Disaster Procedures dated 11/25/2025, the P&P indicated the facility would have a written plan of action which included emergency menus to be used in the event of an emergency or disaster and indicated the procedure of rotating emergency water every year or longer. During a review of the facility's P&P titled Infection Prevention and Control Committee dated 11/25/2025, the P&P indicated that the facility had infection prevention and control program. The P&P indicated the duty of the committee included to assist in monitoring and assessing facility- wide environmental infection prevention and control practices. During a review of the facility's P&P titled Meals for All dated 11/25/2025, the P&P indicated meals for all plus a water supply was needed for emergency feeding.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accidental hazards for one of five sampled days (7/10/2026) by failing to ensure the facility's front door was locked. This failure had the potential to result in residents wandering out of the facility, elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) and vulnerability to external intruders entering the facility.Findings:During a concurrent observation and interview on 7/10/2026 at 8:16 AM with Registered Nurse 1 (RN 1), in front of the facility entrance, the front door was observed to be unlocked, and the surveyor was able to enter the facility. RN 1 observed surveyor entered the facility and asked how the surveyor was able to enter the facility from the outside. RN 1 also stated that the front door was supposed to be locked and was supposed to alarm when opened without a code. During a follow up interview on 7/10/2026 at 9:50 AM with RN 1, RN 1 stated the facility front door was supposed to be locked due to having psychiatric residents (residents with mental health conditions that affect their ability to think and act normally). RN 1 stated facility staff were supposed to let all visitors in using the facility code. RN 1 also stated that the front door could not be opened without the facility code and did not know why the front door was unlocked that morning (7/10/2026). During an interview on 7/10/2026 at 10:17 AM with the Director of Nursing (DON), the DON stated that the front door was supposed to be locked and visitors were to be let in by the facility staff using the code, which unlocked and opened the door. The DON stated that if the door was locked and was opened from the inside, the front door alarm turned on to alert staff. The DON stated the facility was a secured facility (locked or protected living environment designed to keep residents with memory loss from wandering) and residents could wander out of the facility if the door was unlocked and did not alarm. During a review of the facility's policy and procedure (P&P), titled, Behavioral Health Services, reviewed on 11/25/2025, the P&P indicated that it was the facility's policy to maintain a safe, secure and therapeutic environment for residents residing in the behavioral/dementia (a decline in mental abilities such as memory, thinking, and reasoning, that is severe enough to interfere with daily life) unit and that doors leading into and out of the building had to be locked when necessitated by the clinical needs of the residents or to prevent security threats. During a review of the facility's P&P, titled, Wandering and Elopements, reviewed on 11/25/2025, the P&P indicated that the facility would identify residents who were at risk of unsafe wandering and elopement and strived to prevent harm. During a review of the facility's P&P, titled, Safety and Supervision of Residents, reviewed on 11/25/2025, the P&P indicated that facility strived to make the environment as free from accident hazards as possible and that resident safety and supervision and assistance to prevent accidents were facility-wide priorities.

Based on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the possible spread of infections for one of two sampled medication carts (medication cart 1-med cart 1). By failing to ensure the incinerator container (medication disposal container) was kept clean, closed and/or changed as needed. This failure had the potential to result in the spread of disease and infection to residents, visitors, and staff.Findings:During a concurrent observation and interview on 7/8/2026 at 10:20 AM with Licensed Vocational Nurse 2 (LVN 2) of med cart 1, the bottom drawer was observed with an opened incinerator container, which was more than 80% full of reddish, and brownish unknown substance with some pieces of capsules in it. The incinerator container was also observed unclean, with reddish and brownish residuals and dried spills all over the top lid. LVN 2 stated that the incinerator container should have been closed due to possible spillage of the unknown substance and should have been clean for infection control. LVN 2 stated that since the incinerator container was almost full, she (LVN 2) was supposed to have changed the container. During an interview on 7/8/2026 at 10:41 AM with the Infection Preventionist Nurse (IPN), the IPN stated that the incinerator had to be closed and clean for possible infection control and contamination issues. During an interview on 7/9/2026 at 8:04 AM with the Director of Nursing (DON), the DON stated that the observed incinerator container in med cart 1 had to be closed, cleaned and changed as needed. During a review of the facility's policies and procedures (P&P) titled Infection Prevention and Control Program, reviewed on 11/25/2025, the P&P indicated that the facility an established and maintained infection prevention and control program that provided a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. During a review of the facility's P&P titled Discarding and Destroying Medications, reviewed on 11/25/2025, the P&P indicated that medications that could not be returned to the dispensing pharmacy were disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. The P&P indicated that for unused, non-hazardous controlled substances not disposed of by an authorized collector, EPA (Environmental Protection Agency-United States government agency that protect human health and environment) recommended destruction and disposal of the substance with other solid waste by mixing medication, either liquid or solid, with an undesirable substance such as sand, coffee grounds, kitty litter or other absorbent materials.

Based on interview and record review the facility failed to clarify physician orders for Eliquis (a prescription blood thinner) as recommended by the facility's consultant pharmacist (a healthcare professional who provides specialized expertise to healthcare facilities, typically focusing on ensuring the safe and effective use of medications) during the monthly Medication Regimen Review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) for one of six sampled residents (Resident 2). This failure had the potential for Resident 2 to experience adverse effects (undesired and harmful effects that occur because of a medication, treatment, or procedure) from Eliquis such as bruising, balance issues, and hemorrhage (uncontrolled bleeding).Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 1/9/2025 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), and depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 4/27/2026, the MDS indicated Resident 2 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and could not make daily decision for self-requiring total assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).During a review of Resident 2's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 5/18/2026 for Eliquis 5 milligrams (mg, a metric unit of volume) by mouth daily for CVA PPX (Cerebrovascular [stroke; death of brain tissue] prophylaxis [preventative treatment]). During a review of Resident 2's Consultant Pharmacist's Medication Regimen Review (CPMRR) Prescriber note, dated 6/5/2026, CPMRR Prescriber note indicated a recommendation to re-evaluate Resident 2's Eliquis and clarify CVA PPX due to a possibility of an unnecessary therapy. The CPMRR Prescriber note indicated a need to explain how benefits outweighed the risk of the therapy. During a concurrent interview and record review on 7/10/2026 at 1:30 PM, Resident 2's physician order for Eliquis (Apixaban) dated 5/18/2026 and the facility's document titled Consultant Pharmacist's Medication Regimen Review dated 7/6/2026 were reviewed with the Director of Nursing (DON). The DON verified the facility's pharmacy consultant recommended to clarify the intended indication for use of Eliquis for CVA Prophylaxis. The DON stated Resident 2's current physician order should have been clarified. The DON stated she did not know why Resident 2's physician order for Eliquis was not clarified. The DON stated that when the pharmacist recommends changes to the resident's medication, the recommendation had to be followed through because medications had adverse effects. The DON stated there could have been potential for Resident 2 to experience adverse effects if the pharmacist recommendations are not followed. The DON further stated following the pharmacist recommendations could help prevent the resident from experiencing adverse effects of medications. During a concurrent interview and record review on 7/10/2026 at 2:05 PM, Resident 2's facility document titled Consultant Pharmacist's Medication Regimen Review dated 6/5/2026 were reviewed with Licensed Vocational Nurse (LVN) 2. LVN 2 verified and confirmed the consultant pharmacist recommended to clarify the reason for usage of Eliquis. LVN 2 stated Resident 2's current physician order for Eliquis was unchanged and had not been clarified. LVN 2 stated that when the consultant pharmacist made a recommendation, the resident's physician had to be notified of the recommendation. LVN 2 stated Resident 2's physician order should have been clarified with the resident's physician as recommended by the consultant pharmacist. LVN 2 stated consultant pharmacist recommendations had to be followed to help prevent the resident from having unwanted side effects. During a review of the facility's Policy and Procedure (P&P) titled Drug Regimen Review reviewed 11/25/2025, the P&P indicated Facility must ensure that a pharmacist reviews each resident's medical chart every month and perform a drug regimen review.During their monthly drug regimen review, pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports will be acted upon by the facility.

Based on observation, interview and record review, the facility failed to update and post daily the actual hours or projected hours worked by licensed and unlicensed staff providing direct care to the residents per shift on one of five sampled days (7/6/2026), as per the facility's policy and procedures (P&P) titled Posting Direct Care Daily Staffing Numbers, reviewed on 11/25/2025. This failure had the potential to prevent residents and visitors from knowing the accurate nurse staffing hours and had the potential to cause inadequate staffing and had the potential for the residents' needs to go unmet.Findings:During an observation on 7/6/2026 at 7:44 AM, in front of the nursing station, a facility document titled Census (number of residents currently staying or residing at the facility) and Direct Care Services Hours Per Patient Day (DHPPD-amount of hands-on nursing time each patient gets within a 24-hour period) was observed posted and dated 7/2/2026 with only the estimated direct care services hours and DHPPD. During an interview on 7/10/2026 at 10:17 AM with the Director of Staff Development (DSD), the DSD stated projected nursing hours were supposed to be posted daily and updated as needed if there were any changes with the census and staffing. The DSD stated that the charge nurse on the weekend should have updated the nursing hours to be able to provide the most recent staffing hours. During an interview on 7/10/2026 at 12:04 PM with the Director of Nursing (DON), the DON stated importance of updating and posting nursing hours daily and added that facility missed posting the nursing hours from 7/3/2026 to 7/5/2026. During a review of the facility's P&P, titled, Posting Direct Care Daily Staffing Numbers, reviewed on 11/25/2025, the P&P indicated the facility would post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The P&P indicated that within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses [RNs], Licensed Vocational Nurses [LVNs]) and the number of unlicensed nurses (certified nursing assistants [CNAs] and nursing assistants [Nas]) directly responsible for resident care was to be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs of two of 14 sampled residents (Resident 8 and Resident 10) by failing to:1. Develop a care plan for Resident 8's post-traumatic stress disorder (PTSD-a mental health condition triggered by experiencing or witnessing a terrifying event) diagnosis and Zyprexa (antipsychotic [medication that help calm the brain] medication) use.2. Develop a care plan for Resident 10's delusional (holding a strong, false belief that is completely out of touch with reality) thoughts of somatic (related to the body) symptoms behavior.These failures had the potential to result in a negative impact on Resident 8 and 10's health, as well as the quality of care and services received.Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 3/23/2026 with diagnoses including PTSD, anxiety and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive [period of feeling sad, hopeless or empty] lows to manic [being in a state of extreme, elevated energy and emotion] highs). During a review of Resident 8's Order Summary Report, dated 3/23/2026, the Order Summary Report indicated Resident 8 had a physician order for Zyprexa 5 milligram (mg) by mouth one time a day for psychosis (mental disorder) manifested by auditory/visual hallucinations. During a review of Resident 8's History and Physical (H&P) dated 3/24/2026, the H&P indicated Resident 8 had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 8 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and mostly moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 8 had an active diagnosis of psychotic disorder and PTSD and taking high risk drug medication such as an antipsychotic medication. During a concurrent interview and record review on 7/9/2026 at 1:33 PM with Minimum Data Set Nurse (MDSN), Resident 8's care plan was reviewed. Resident 8's care plan indicated a missing PTSD care plan. MDSN stated Resident 8 was supposed to have had a care plan for PTSD to be able to provide individualized and specific care to Resident 8. During a concurrent interview and record review on 7/10/2026 at 11:03 AM with Director of Nursing (DON), Resident 8's care plan was reviewed. Resident 8's care plan indicated missing Zyprexa care plan. The DON stated importance of having Zyprexa care plan was to be able to provide and monitor Resident 8's Zyprexa use. The DON stated importance of needing to have PTSD care plan for Resident 8. During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted Resident 10 on 10/28/2025 and was re-admitted on [DATE] with diagnoses including schizophrenia (mental disorder in which people interpret reality abnormally), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and insomnia (sleep disorder). During a review of Resident 10's H&P dated 11/29/2025, the H&P indicated Resident 10 had the capacity to understand and make decisions. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had intact cognition for daily decision-making and independent with ADLs. The MDS also indicated Resident 8 had an active diagnosis of schizophrenia and taking high risk drug medication such as an antipsychotic medication. During a review of Resident 10's Order Summary Report, dated 7/7/2026, the Order Summary Report indicated Resident 10 had a physician order for the following: Seroquel (antipsychotic medication) 12.5 mg by mouth one time a day and Seroquel 1 mg by mouth at bedtime for schizophrenia manifested by delusional thoughts of somatic symptoms. Resident 10's Order Summary Report also indicated a physician order to monitor behaviors of schizophrenia manifested by delusional thoughts of somatic symptoms, tally with numerical value and document interventions such as rest/reposition; cues/prompt/reassure; redirection/diversion/reorientation and other every shift. During a concurrent interview and record review on 7/10/2026 at 11:03 AM with the DON, Resident 10's care plan was reviewed. Resident 10's care plan indicated missing behavior of delusional thoughts of somatic symptoms care plan. The DON stated that the physician had recently changed the behavior manifestation and that the care plan should have been updated as well in Resident 10's care plan. The DON stated importance of care planning Resident 10's behavior to be able to provide proper care to Resident 10. During a review of facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered reviewed on 11/25/2025, the P&P indicated that a comprehensive care plan had to be developed and implemented for each resident including measurable objectives and timetables to meet a resident's physical, psychosocial and functional needs. During a review of facility's P&P titled Behavioral Assessment, Interventions and Monitoring reviewed on 11/25/2025, the P&P indicated that facility was to provide and residents would receive behavioral health services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with comprehensive assessment and plan of care. P&P indicated that the care plan was to incorporate findings from the comprehensive assessment and be consistent with the current standards of practice.

Based on observation, interview, and record review, the facility failed to protect private health information for two of two sampled residents (Resident 30 and Resident 31), by failing to ensure confidential medical information was not easily visible and accessible. This failure had the potential to result in a violation of Resident 30 and 31's right to personal privacy and confidentiality of their medical records.Findings:During a review of Resident 30's admission Record, the admission Record indicated the facility originally admitted Resident 30 on 10/21/2013 and re-admitted the resident on 10/3/2025 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and dysphagia (difficulty swallowing food or liquid). During a review of Resident 30's History and Physical (H&P) dated 11/28/2025, the H&P indicated Resident 30 had the capacity to make medical decisions. During review of Resident 30's Minimum Data Set (MDS, a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 30 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 31's admission Record, the admission Record indicated the facility admitted Resident 31 on 6/5/2021 with diagnoses including schizophrenia (mental disorder in which people interpret reality abnormally), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During review of Resident 31's MDS, dated [DATE], the MDS indicated Resident 31 had moderately impaired cognition for daily decision-making and mostly independent for ADLs. During a review of Resident 31's H&P dated 6/22/2026, the H&P indicated Resident 31 did not have the capacity to understand and make decisions. During a concurrent observation in the nursing station and interview on 7/8/2026 at 11:16 AM with the Director of Nursing (DON), Resident 30 and 31's electronic medical records (EMR-digital, computer-based version of patient's paper medical record) were left open and unattended on two computer screens. The DON was observed looking for the nurses and stated that the two nurses were busy attending to other residents. During an interview on 7/9/2026 at 8:04 AM with the DON, the DON stated importance of closing the EMR when walking out of the computer due to confidentiality and privacy issues. During a review of the facility's policy and procedure (P&P), titled, Resident Rights, reviewed on 11/25/2025, the P&P indicated that any unauthorized release, access, or disclosure of resident information was prohibited and had to be in accordance with current laws governing privacy of information issues. During a review of facility's P&P, titled, Confidentiality of Information and Personal Privacy, reviewed on 11/25/2025, the P&P indicated that the facility would protect and safeguard all resident personal and medical records.

Based on interview and record review, the facility failed to implement its' policy and procedures (P&P) titled Abuse Investigation and Reporting dated 11/25/2025 by failing to report the misappropriation of property (Debit Card) for one of three sampled residents' (Resident 1).This deficient practice resulted in multiple unauthorized transactions on 6/1/2026 on Resident 1's debit cards. During a review of Resident 1's admission Record, dated 4/7/2026, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), depression (a mood disorder that may cause persistent sadness or loss of interest in activities), and anxiety (persistent feeling of dread or panic that can interfere with daily life) .During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 5/5/2026, indicated Resident 1 had severe impaired cognition (ability to think, remember and reason) . Resident 1 required supervision (oversight, encouragement, or cueing) for eating, oral hygiene, toileting, shower/bath, upper and lower body dressing, putting on footwear, and personal hygiene. Resident 1 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfer, and walk 10 feet.During a review of Resident 1's Resident's Clothing and Possessions Inventory Checklist on Admission, dated 4/7/2026, indicated Resident had presented with 2 ATM (debit) cards to the facility, and CNA1 had verified these cards.During a review of Resident 1's Chase Bank Report, dated 6/4/2026, indicated Resident 1 reported unauthorized transactions on 6/1/2026 which included the following disputed transactions:5/1/2026 El [NAME] Loco in Los Angeles CA $13.715/1/2026 Popeyes in Gardena CA $48.585/7/2026 Kwik Serv Gas in Inglewood CA $18.375/7/2026 El [NAME] Loco in Inglewood CA $18.765/9/2026 VIP Bargain Center in Los Angeles CA $111.695/10/2026 Apparel women's ready to wear stores in Inglewood CA $94.615/12/2026 Acai Republic in [NAME] Beach CA $13.095/12/2026 Salvation Army in [NAME] Beach CA $30.975/12/2026 Ramen and Poke in [NAME] Beach CA $15.315/12/2026 Hobby Lobby in [NAME] CA $135.055/18/2026 Walmart subscription $7.105/19/2026 [NAME] Service Station in Los Angeles CA $12.505/19/2026 [NAME] Service Station in Los Angeles CA $40.005/23/2026 Ono fast food restaurants in Diamond Bar CA $21.93Total unauthorized purchases equaled to $581.67.During a phone interview on 6/25/2026 at 9 AM, the Care Coordinator (CC) for Resident 1, stated on 6/1/2026, she visited Resident 1 in the facility and noticed that Resident 1's debit card was missing from her wallet. The CC stated she assisted Resident 1 in paying her bills which includes paying her monthly rent for Resident 1's apartment, and she had come to assist Resident 1 in doing so on 6/1/2026. However, upon revision of Resident 1's inventory list, the CC noted that despite Resident 1's debit card being listed on the facility's inventory, her debit card was missing from her wallet, and the debit card had been unaccounted for from 5/15/2026 through 6/1/ 2026, and the debit card had been used without authorization from Resident 1. The CC stated she helped Resident 1 file a fraudulent report with the bank institution on 6/1/2026 to cancel Resident 1's debit card, and she notified the Social Services Director of the facility.During an interview on 6/25/2026 at 9:37 AM, the Social Services Director (SSD) stated that upon admission nursing staff are responsible for completing an inventory of resident belongings when Social Services is unavailable. The SSD stated valuables including money, jewelry, Social Security cards, credit cards, debit cards, and important documents are to be secured in the business office. The SSD stated if residents are confused, staff must use a witness and explain that valuables will be kept secured in the business office for safekeeping. If admission occurs on weekends, nursing staff are expected to secure the valuables until Social Services is available. The SSD stated she met with Resident 1 within two days of admission and recognized Resident 1 was confused and lacked the ability to independently manage her affairs. The SSD stated she referred Resident 1 to the Public Guardian for conservatorship due to concerns regarding the resident's inability to manage finances and absence of available family or responsible representatives. The SSD stated Resident 1 does not have privileges to go out on pass, nor does she drive, therefore Resident 1 could not have made the purchases that were made starting 5/1/2026 through 6/1/2026. During an interview on 6/25/2026 at 9:54 AM with Resident 1, Resident 1 was seated outside her room and stated that after learning her ATM card was missing, she wanted to cry and no longer felt safe in the facility. Resident 1 stated she could not think of anyone who would have taken the card, had not witnessed anyone searching through her belongings, and had not given the card to anyone. Resident 1 stated she believed she had kept her wallet with her and thought it was safe in her room. Resident 1 stated she became aware the ATM card was missing only after her case worker requested the card to make a payment for her apartment and the card could not be located. Resident 1 stated her Case Worker helped her report the debit card missing to her bank to cancel further unauthorized transactions. During a phone interview on 6/25/2026 at 10:01 AM, Certified Nursing Assistant (CNA) 1 stated he completed Resident 1's admission inventory independently. CNA 1 stated Resident 1 wanted to keep her wallet, and because he believed she was oriented, he allowed her to retain possession of it. CNA 1 stated he documented the inventory and provided the inventory sheet to the charge nurse but did not inform nursing that Resident 1 retained possession of her wallet or valuables. CNA 1 further stated he later realized Resident 1 was confused and acknowledged no one informed him of her cognitive impairment during admission. During an interview on 6/25/26 at 10:14 AM, the Social Services Director (SSD) stated Resident 1's debit card was listed on the admission inventory but was later discovered missing while Resident 1 resided in the facility, which constituted financial abuse. The SSD stated she reported the allegation to Adult Protective Services and the Ombudsman on 6/1/26, contacted law enforcement, and requested bank statements documenting unauthorized transactions. During an interview on 6/25/26 at 11:21 AM, the Administrator stated he was aware of the missing debit card and suspected financial exploitation beginning on 6/1/26. The Administrator acknowledged and stated he did not report the allegation to the California Department of Public Health because he believed the Social Services Director had already completed the required reporting. The Administrator stated he did not have an internal investigation documented nor had the investigation been initiated at the time the allegation was identified on 6/1/2026. During a review of the facility's P&P titled Abuse Investigation and Reporting dated 11/25/2025 indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source shall be reported immediately but not later than 2 hours if alleged violation involves abuse OR has resulted in bodily injury, or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury to local, state, and federal agencies and thoroughly investigated by facility management. The administrator will assign the investigation to an appropriate individual. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator.The individual conducting the investigation will as a minimum:Review the completed documentation formsReview the resident's medical record to determine events leading up to the incidentInterview the person reporting the incidentInterview any witnessesInterview residentInterview staff members who have had contact with the resident during the period of the alleged incidentReview all events leading up to the alleged incident.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was protected from misappropriation of personal property by failing to safeguard Resident 1's debit card after identifying Resident 1 lacked the capacity to safely manage finances.This deficient practice resulted in Resident 1's debit card going missing while residing in the facility, unauthorized financial transactions, and psychosocial harm, as evidenced by Resident 1 reporting feeling upset, wanting to cry, and no longer feeling safe in the facility.During a review of Resident 1's admission Record, dated 4/7/2026, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), depression (a mood disorder that may cause persistent sadness or loss of interest in activities), and anxiety (persistent feeling of dread or panic that can interfere with daily life) .During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 5/5/2026, indicated Resident 1 had severe impaired cognition (ability to think, remember and reason) . Resident 1 required supervision (oversight, encouragement, or cueing) for eating, oral hygiene, toileting, shower/bath, upper and lower body dressing, putting on footwear, and personal hygiene. Resident 1 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfer, and walk 10 feet.During a review of Resident 1's Resident's Clothing and Possessions Inventory Checklist on Admission, dated 4/7/2026, indicated Resident had presented with 2 ATM (debit) cards to the facility, and CNA1 had verified these cards.During a review of Resident 1's Chase Bank Report, dated 6/4/2026, indicated Resident 1 reported unauthorized transactions on 6/1/2026 which included the following disputed transactions:5/1/2026 El [NAME] Loco in Los Angeles CA $13.715/1/2026 Popeyes in Gardena CA $48.585/7/2026 Kwik Serv Gas in Inglewood CA $18.375/7/2026 El [NAME] Loco in Inglewood CA $18.765/9/2026 VIP Bargain Center in Los Angeles CA $111.695/10/2026 Apparel women's ready to wear stores in Inglewood CA $94.615/12/2026 Acai Republic in [NAME] Beach CA $13.095/12/2026 Salvation Army in [NAME] Beach CA $30.975/12/2026 Ramen and Poke in [NAME] Beach CA $15.315/12/2026 Hobby Lobby in [NAME] CA $135.055/18/2026 Walmart subscription $7.105/19/2026 [NAME] Service Station in Los Angeles CA $12.505/19/2026 [NAME] Service Station in Los Angeles CA $40.005/23/2026 Ono fast food restaurants in Diamond Bar CA $21.93Total unauthorized purchases equaled to $581.67.During a phone interview on 6/25/2026 at 9 AM, the Care Coordinator (CC) for Resident 1, stated on 6/1/2026, she visited Resident 1 in the facility and noticed that Resident 1's debit card was missing from her wallet. The CC stated she assisted Resident 1 in paying her bills which includes paying her monthly rent for Resident 1's apartment, and she had come to assist Resident 1 in doing so on 6/1/2026. However, upon revision of Resident 1's inventory list, the CC noted that despite Resident 1's debit card being listed on the facility's inventory, her debit card was missing from her wallet, and the debit card had been unaccounted for from 5/15/2026 through 6/1/ 2026, and the debit card had been used without authorization from Resident 1. The CC stated she helped Resident 1 file a fraudulent report with the bank institution on 6/1/2026 to cancel Resident 1's debit card, and she notified the Social Services Director of the facility.During an interview on 6/25/2026 at 9:37 AM, the Social Services Director (SSD) stated that upon admission nursing staff are responsible for completing an inventory of resident belongings when Social Services is unavailable. The SSD stated valuables including money, jewelry, Social Security cards, credit cards, debit cards, and important documents are to be secured in the business office. The SSD stated if residents are confused, staff must use a witness and explain that valuables will be kept secured in the business office for safekeeping. If admission occurs on weekends, nursing staff are expected to secure the valuables until Social Services is available. The SSD stated she met with Resident 1 within two days of admission and recognized Resident 1 was confused and lacked the ability to independently manage her affairs. The SSD stated she referred Resident 1 to the Public Guardian for conservatorship due to concerns regarding the resident's inability to manage finances and absence of available family or responsible representatives. The SSD stated Resident 1 does not have privileges to go out on pass, nor does she drive, therefore Resident 1 could not have made the purchases that were made starting 5/1/2026 through 6/1/2026. During an interview on 6/25/2026 at 9:54 AM with Resident 1, Resident 1 was seated outside her room and stated that after learning her ATM card was missing, she wanted to cry and no longer felt safe in the facility. Resident 1 stated she could not think of anyone who would have taken the card, had not witnessed anyone searching through her belongings, and had not given the card to anyone. Resident 1 stated she believed she had kept her wallet with her and thought it was safe in her room. Resident 1 stated she became aware the ATM card was missing only after her case worker requested the card to make a payment for her apartment and the card could not be located. Resident 1 stated her Case Worker helped her report the debit card missing to her bank to cancel further unauthorized transactions. During a phone interview on 6/25/2026 at 10:01 AM, Certified Nursing Assistant (CNA) 1 stated he completed Resident 1's admission inventory independently. CNA 1 stated Resident 1 wanted to keep her wallet, and because he believed she was oriented, he allowed her to retain possession of it. CNA 1 stated he documented the inventory and provided the inventory sheet to the charge nurse but did not inform nursing that Resident 1 retained possession of her wallet or valuables. CNA 1 further stated he later realized Resident 1 was confused and acknowledged no one informed him of her cognitive impairment during admission.During an interview on 6/25/2026 at 10:14 AM, the SSD stated the admission inventory documented Resident 1's debit card, confirming it was present upon admission. The SSD stated the missing debit card indicated it was lost while Resident 1 resided in the facility. The SSD further stated she initiated reports to Adult Protective Services (APS), the Ombudsman, law enforcement, and requested copies of Resident 1's bank statements after learning the debit card was missing. The SSD stated she did not report to California Department of Public Health, as she had notified the Administrator of the situation on 6/1/2025, who was the Abuse Coordinator for the facility. The SSD stated the facility was responsible for reimbursing Resident 1 for the total amount of purchases that were made without Resident 1's authorization after her debit card was stolen. During an interview on 6/25/2026 at 10:47 AM, CNA 2 stated CNAs are expected to inventory valuables with a witness and notify the charge nurse or Social Services if a resident wishes to retain money or valuables so that they can identify and account for those valuables. During an interview on 6/25/2026 at 10:51 AM, the Director of Staff Development (DSD) stated the admission inventory documented Resident 1's debit card upon admission. The DSD stated the debit card later went missing while Resident 1 resided in the facility. The DSD stated CNA 1 reported Resident 1 wanted to keep her wallet because he believed she was alert and oriented. The DSD stated CNA 1 should have notified nursing regarding the valuables, and licensed nursing staff should have verified which valuables Resident 1 retained. The DSD further stated valuables should have been secured in the business office and, if the resident refused, nursing staff should have documented the refusal. During an interview on 6/25/2026 at 11:04 AM, the Registered Nurse (RN) Supervisor stated licensed nurses are responsible for securing resident valuables in a locked narcotic drawer until transferred to the business office. The RN Supervisor stated CNA 1 did not report that Resident 1 wished to retain her wallet or debit cards. The RN Supervisor stated if a resident refuses to relinquish valuables, nursing staff should follow facility policy by attempting to secure the items and documenting the resident's refusal.During an interview on 6/25/2026 at 11:21 AM, the Administrator stated he was aware of Resident 1's missing debit card and suspected financial exploitation beginning on 6/1/2026. The Administrator acknowledged he did not report the allegation to the California Department of Public Health because he believed the SSD had already completed the required reporting. The Administrator stated this incident was a form of financial abuse and the facility would implement an internal investigation and plan of correction moving forward starting 6/25/2026. The Administrator did not indicate that an internal investigation had been initiated at the time the allegation was identified on 6/1/2026, as he was pending Bank Statement Reports from the Care Coordinator.During a review of the facility's policy and procedure (P&P) titled Personal Property, dated 11/25/2025, indicated a representative of the admitting office will advice the resident, prior to or upon admission, as to the types and amount of personal clothing and possessions that the resident may keep in his or her room. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.During a review of the facility's P&P titled Admitting the Resident: Role of the Nursing Assistant dated 11/25/2025, indicated to inventory the resident's personal effects ask the family member to remain in the room to witness the inventory of all clothing, valuables, and give the inventory of personal effects record to the nurse supervisor.

Based on interview and record review, the facility failed to implement its bed-hold policy for a resident who was transferred to general acute care hospital (GACH) by not reserving the resident's bed during hospitalization in accordance with the facility's policy and procedures (P&P) titled, Bed-Holds and Returns, reviewed 1/25/20 and regulatory requirements for one of three sampled residents, Resident 1. This deficient practice had the potential to result in the residents' delay returning to the facility and disruption in continuity of care. Findings: During a review of Resident 1's admission Records, Resident 1 was admitted to the facility on [DATE] with a diagnoses including hemiplegia (paralysis of one side of the body), major depressive disorder (characterized by a persistent feeling of sadness or a lack of interest in outside stimuli), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), malignant neoplasm of parietal lobe (the development and fast growing of cancer in the top middle part of the brain). During a review of Resident 1's Physician's order notes dated 3/20/2026, the physician's order notes indicated May transfer to GACH for further evaluation. A review of Resident 1's Discharge Summary indicated Resident 1 was transferred out to GACH via medical transport vehicle on 3/20/2026 a day after initial admission to the facility. During a review of the facility's census and Resident 1's transfer documentation on 3/24/2026, the census and transfer documentation indicated, a bed hold for Resident 1 was not initiated at the time the resident was transferred to GACH. During a concurrent telephone interview and record review on 3/24/2026 at 12:19 PM with the Director of Nursing (DON), facility census dated 3/23/2026 was reviewed. The facility Census did not indicate a bed-hold for Resident1. DON stated there should have been a seven-day bed hold when Resident 1 was transferred to GACH on 3/20/2026. DON stated Seven-day bed hold should have been held until 3/27/2026. DON agreed and stated that, it is a deficiency not holding a bed for seven days. During a concurrent interview and record review on 3/24/2026 at 12:43 PM with the Business Office Manager (BOM), facility census from 3/20/2026 to 3/24/2026 was reviewed. BOM stated, business office is responsible for bed-holds. Bed hold is indicated by placing a resident's name as a place holder on the resident census. The reviewed resident census did not indicate bed hold for Resident 1. BOM stated, seven-day bed hold is mandatory regardless of payment or insurance status. BOM further stated, I accidentally discharged Resident 1, it was an oversight. BOM stated, it will be a deficiency not placing a bed hold and can lead to delay or readmission to the resident and family. BOM corrected bed-hold errors and reflected seven-day bed hold for Resident 1. During an interview on 3/24/2026 at 1:20 PM with the facility Administrator (ADM), the ADM stated, Once a resident is sent out, we should hold the resident's bed for seven days regardless of the resident's status of coming back to us or not. During a review of the facility's policy and procedures (P&P) titled, Bed-Holds and Returns, reviewed 1/25/2025, the P&P indicated, The current bed-hold and return policy established by the state (if applicable) will apply to Medicaid residents in the facility. Prior to a transfer, written information will be given to the resident and the resident representatives that explains in detail: The rights and limitations of the resident regarding bed-hold. The reserved bed payment policy as indicated by the state plan (Medicaid residents)The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and The details of the transfer (per the notice of transfer).

Based on interview and record review the facility failed to report to the State Survey Agency (SSA) within two hours of a resident-to-resident altercation for two of four sampled residents (Resident 1 and Resident 2). On 2/6/26 at 10:47 a.m., Resident 1 and Resident 2 had a verbal and physical altercation. The facility reported the incident to the SSA on 2/6/26 at 4:05 p.m.This deficient practice had the potential to under report alleged cases of resident abuse to the SSA and may delay the investigation to ensure Resident 1 and Resident 2 were safe.1.During a review of the admission Record indicated the facility admitted Resident 1 on 5/25/23 and re-admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety disorder and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)During a review of the Minimum Data Set (MDS, resident screening tool) dated 11/16/25 indicated Resident 1 had severely impaired cognitive skills. Resident 1 needed substantial assistance 9helper does more than half the effort) with shower/bathe self, upper body dressing and personal hygiene. Resident 1 needed partial assistance (helper does less than half the effort) with putting on/taking off footwear. The same MDS indicated Resident 1 needed supervision with lower body dressing and was independent with eating, oral hygiene and toileting hygiene.2.During a review of the admission Record indicated the facility admitted Resident 2 on 12/4/24 with diagnoses including legal blindness, depression and generalized muscle weakness.During a review of the MDS dated [DATE] indicated Resident 2 was cognitively intact. Resident 2 needed set-up assistance (helper sets up or cleans up, resident completes activity) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. Resident 2 was independent with eating, oral hygiene and upper body dressing.During a review of the Behavior Related Incidents dated 2/6/26 at 10:47 a.m. indicated on 2/6/26 at 10:47 a.m., Resident 1 and Resident 2 were .noted to be speaking to one another in an elevated tone. Staff attempted to de-escalate the interaction between Resident 1 and Resident 2. Resident 1 grabbed Resident 2 while four staff members were present. The Behavior Related Incident indicated the paramedics and the police were notified. Resident 1 and Resident 2 refused medical care from the paramedics. At 11:28 a.m., the police arrived and at 12:18 p.m., the police transferred Resident 1 to the general acute hospital (GACH) for further evaluation.During a review of the initial report dated 2/6/26 sent by facsimile (fax) to the SSA, indicated Resident 1 and Resident 2 had physical altercation on 2/6/26.During a review of the fax transmission Verification Report indicated the facility sent the initial report to the SSA on 2/6/26 at 4:05 p.m.During a concurrent interview and record review on 2/19/26 at 1:24 p.m., the facility's initial report and the facility's Abuse Policy were reviewed with the administrator (ADM). The ADM stated allegations of abuse should be reported to the SSA within two hours of the incident. The ADM confirmed that Resident 1 and Resident 2's altercation was sent to the SSA on 2/6/26 at 4:05 p.m. The ADM stated because Resident 1 had a diagnosis that included dementia and there was no serious body injury, the incident between Resident 1 and Resident 2 could be reported to the SSA within 24 hours.During a review of the facility's policy an procedures (P&P) titled Abuse Investigation and Reporting reviewed on 11/25/25 indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The same Policy indicated all alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:A. Two hours if the alleged violation involves abuse or has resulted in serious bodily injury: orB. Twenty-four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.

Based on interview and record review, the facility failed to ensure that the resident had the capacity (a person's ability to make their own decisions about their healthcare) to understand and make decisions to be able to sign an advanced directive (AD -legal document that outlines your wishes for medical care if you become unable to communicate them yourself) acknowledgement form for one of one sampled resident (Resident 40).This deficient practice violated Resident 40's and Resident 40's representative the right to be fully informed of the option to formulate an AD and had the potential to cause conflict with health care wishes for Residents 40. During a review of Residents 40's admission Record indicated the facility admitted Resident 40 on 8/6/2024 and readmitted the resident on 11/1/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), altered mental status (AMS - a change in a person's level of awareness, thinking, or behavior.), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool) dated 5/15/2025, indicated Resident 40 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), a Brief Interview for Mental Status (BIMS score - a snapshot of how well someone is remembering things, knowing the date and time, and paying attention at that moment). The MDS indicated Resident 40 required supervisory or touch assistance from staff with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) During a review of Resident 40's history and physical (H&P -a thorough assessment of a patient's health, done by a healthcare provider) dated 11/1/2024, the H&P indicated Resident 40 does not have the capacity to make medical decision. During a concurrent interview and record review, on 7/15/2025, at 10:50 A.M., with Social Services Director (SSD), Resident 40's MDS, Advanced Directive (AD - is a legal document that outlines a person's wishes regarding their medical care in the event they become unable to make decisions for themselves due to illness, injury, or other incapacities) acknowledgment Form and H&P were reviewed. SSD stated that AD is a form gives the residents an opportunity to execute their wishes with the family member or guardian whom they choose in the event that they cannot make medical decisions. SSD stated that if the resident has the capacity to complete the AD acknowledgment form (ADAF) and/or the AD form, SSD will assist the residents to completing the AD and ADAF and then call the ombudsman (is a person who investigates, reports on, and helps settle complaints). SSD stated that ombudsman will then meet with the resident to verify the information on the AD form and cosign it. The SSD stated, if a resident does not have the capacity to make decisions, the resident is not able to indicate the name of a family member who can make decisions, then SSD does not execute/proceed with the ADAF/AD. SSD stated Resident 40 signed the AD acknowledgement form, Resident 40 has a BIMS score of 4 which means Resident 40 does not have the capacity to complete the ADAF/AD. The SSD further stated Resident 40's H&P indicates that Resident 40 does not have decision making capacity, and that the resident should not have signed the ADAF/AD. During an interview on 7/18/2025, at 2:10 P.M., with the Director of Nursing (DON), the DON stated Resident 40 has a BIMS score of 4, has fluctuating capacity, and that the resident's H&P indicates that the resident does not have the decision-making capacity. The DON further stated that Resident 40 is able to sign the ADAF, even though resident 40 has fluctuating capacity, a BIMS score of 4 and resident, and resident's H&P indicating that the resident does not have the decision making capacity. During a review of the facility policy and procedures titled Advanced Directive revised on 1/16/2025, indicated, The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment . Decision making capacity1. Upon admission the interdisciplinary team assesses the resident's decision making capacity and identifies the primary decision maker if the resident is determined not to have decision making capacity.2. The interdisciplinary team conducts ongoing review of the residents decision making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision making capacity. Changes are documented in the care plan and medical record.

Based on interview and record review, for one of one sampled resident (Resident 4), the facility failed to ensure that Resident 40 and or the resident's representative were:1. Notified timely in writing the reason for the transfer/discharge to the hospital and send a copy of the notice to the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities).2. Notified of the facility policy for bed hold (the facility agrees to keep a resident's bed available for them, even if they temporarily leave for a hospital stay or other leave of absence), including reserve bed payment in writing.This deficient practice resulted in Resident 4 and or the resident's representative not provided with options and rights regarding transfer and discharge by the facility.During a review of Resident 4's admission Record indicated the facility admitted Resident 4 on 6/13/2023, and readmitted Resident 4 on 4/1/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), paranoid schizophrenia (a mental illness that causes people to experience distorted perceptions of reality), and major depressive disorder (a serious mental health condition where a person experiences persistent feelings of sadness, hopelessness, and a loss of interest in activities they once enjoyed). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 6/18/2025, indicated Resident 4 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 4 was independent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 4's Physician Order dated 3/25/2025 at 10:28 P.M., the Physician Order indicated may transfer (Resident 4) to a general acute care hospital (GACH) with seven day bed hold. During a review of Resident 4's Nursing Progress Notes dated 3/26/2025 at 7:04 A.M., the Nursing Progress Notes indicated Resident 4 was transferred out to hospital . left in stable condition. During a review of Resident 4's Bed Hold Informed Consent Notification dated 3/26/2025, the Bed Hold Informed Consent Notification indicated that Resident/Legal representative notified by .how notified: telephone. During an interview, on 7/18/2025, at 1:43 P.M., with Licensed vocational nurse (LVN) 1, LVN 1 stated a bed hold needs to be completed in the midst of transferring the resident to the hospital. LVN 1 stated bed hold is initially completed on admission by the resident/responsible party (RP - someone chosen to act on behalf of a resident to help making decisions for the resident) and on the day the resident is transferred to the hospital. LVN 1 stated that the resident/resident presentative are notified of the bed hold and that a copy of the bed hold is either faxed or emailed to the resident/representative immediately. LVN 1 stated that bed hold notification is done so that the resident/RP are aware that the resident has a bed available to come back home to. LVN 1 stated, if not done (completing bed hold form), it means it did not happen. During an interview, on 7/18/2025, at 2:09 P.M., with the Director of Nursing (DON), the DON stated a bed hold is done for seven days depending on the resident's insurance. The DON stated, the facility does not provide written notification of the bed hold however, based on now reading the policy we should be providing written notification. During a review of the facility Policy &Procedure (P&P) titled Bed-Holds and Returns revised 1/16/2025, the P&P indicated, Policy statement: Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold.1. All resident/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice:a. Notice 1: well in advance of any transfer (e.g., in the admission packet); and b. Notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation) recommendation to obtain a PASRR level II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) evaluation for one of one sampled residents (Resident 18). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 18. During a review of Resident 18's admission record, the admission record indicated the facility admitted the resident on 2/7/2024 with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dementia (a progressive state of decline in mental abilities) and anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities). During a review of the Minimum Data Set (MDS- a resident assessment tool) dated 5/16/2025, the MDS indicated Resident 18's cognition (ability to think, understand, and reason was severely impaired. The MDS indicated Resident 18 required partial/moderate assistance from staff with showering, dressing and personal hygiene. The MDS also indicated Resident 18 had an active diagnoses of schizophrenia, anxiety disorder and dementia. During a review of Resident 18's Pre-admission Screening and Resident Review Level 1 (PASRR Level 1-is a preliminary assessment completed for all individuals prior to admission to determine whether an individual might have a mental illness or intellectual disability) screening results letter dated 4/23/2025, the letter indicated that due to the resident's serious mental illness, the resident required a PASRR Level II (is a person-centered evaluation that is completed for anyone identified by the Level 1 Screening as having, or suspected of having, a PASRR condition, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition (RC)). During a review of Resident 18's Notice of Attempted Evaluation letter dated 4/27/2025, the letter indicated a level II evaluation was not able to be completed due to Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 7/17/2025, Resident 18's Level 1 evaluation and Notice of Attempted Evaluation letters were reviewed. MDSC stated the Level 1 evaluation indicated Resident 18 required a level II evaluation. The MDSC stated the facility did not contact the appropriate state agency to reschedule an evaluation for Resident 18. During an interview on 7/18/2025 at 3:08 PM, the Director of Nursing (DON) stated the PASSR screened residents for mental disabilities and if not done could result in the resident not receiving the appropriate care. During a review of the facility's policy and procedures titled, PASRR Completion Policy, reviewed 1/16/2025, indicated, The center will make a sure that all admissions have the appropriate patient assessment and resident review completed.

Based on interview and record review, the facility failed to develop a comprehensive resident specific care plan in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered revised 1/16/2025 for one of one sampled resident (Resident 1). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 1.During a review of Resident 1's admission Record indicated the facility admitted Resident 1 on 6/5/2025 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), hepatic encephalopathy (a brain disorder that happens when a damaged liver can't properly filter toxins from the blood, leading to a buildup of these toxins in the brain), and diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/10/2025, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), and preferred language as Chinese. The MDS indicated Resident 1 required set up/clean up assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's care plan initiated on 6/16/2025 indicated a focus of altered thought process related to being Chinese speaking only. and interventions included Chinese translator when available. During a concurrent interview and record review, on 7/15/2025, at 1:09 P.M., with Licensed Vocation Nurse (LVN) 2, Resident 1's care plan was reviewed. LVN 2 stated Resident 1 is Chinese speaking and staff members use gestures and pointing to communicate. LVN 2 stated LVN 2 has not used the facility translator phone or number before and that the care plan indicated translator available when needed. LVN 2 stated the facility staff need to utilize a translator when Resident 1 does not understand what the facility staff are saying or when the facility staff does not understand what Resident 1 is saying. LVN 2 stated it is Resident 1's right to be able to understand the facility staff, free speech, and that Resident 1 needs to understand what is going on around him (Resident 1). LVN 2 stated Resident 1 is a resident at the facility and deserves to know what is going on in the facility and with his health. During an interview, on 7/18/2025, at 2:42 P.M., with the Director of Nursing (DON), the DON stated for residents that are non-English speaking, the facility staff use communication boards, and translator phones. The DON stated she does not know what language Resident 1 speaks, however, the communication board alone is enough to communicate with the resident even when it comes to medication pass. The DON stated that the facility staff do not tell the residents the medications they are getting during a medication pass and are only told what the residents are taking only if they ask. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 1/16/2025, the care plan indicated, Policy statement: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.4. Each residents comprehensive person centered care plan will be consistent with the residents rights to participate in the development and implementation of his or her plan of care, including the right to:g. receive the services and/or items included in the plan of care.

Based on interview and record review, the facility failed to follow its policy regarding laundry hot water temperature monitoring on a daily basis. This deficient practice had the potential to result in the spread infection throughout the facility.During a concurrent interview and record review, on 7/17/2025, at 3:39 P.M., with the Laundry Aid (LA) 1, the facility's temperature log for 7/2025 for the washer, dryer, and sink was reviewed. LA 1 stated that the temperature log is used to document the washer temperature and the dryer temperature. LA 1 stated, the Dryer temperature is checked every two hours, and the washer is checked every time when we do a new cycle. LA 1 stated temperature checking and logging is done to make sure that the temperature is normal or the right temperature is used to wash and dry residents' clothes. LA 1 stated the right temperature for the washer is 170 degrees Fahrenheit (unit of measure for temperature) and the dryer is between 160 Fahrenheit and 180 Fahrenheit. LA 1 stated for the month of 7/2025, the temperature log was incorrectly completed from 7/1/2025 to 7/17/2025 because the section for documenting the temperature was supposed to be recorded in numbers that represented time instead of temperature. LA 1 stated the appropriate temperature is supposed to kill bacteria or any infection and that if the temperature is not within range or not documented on the log, it will cause a problem. LA 1 stated it is important to make sure that the correct information/temperature is documented and the regulations are followed according to the policy, so everyone knows what the temperature was at a given time. During an interview with the Infection preventionist Nurse (IPN), on 7/18/2025, at, 11:34 A.M., the IPN stated that the temperature for the washer, dryer and sink is checked to make sure that when the facility staff are washing/drying clothes that the temperature is maintained within the correct range. IPN stated that the temperature log is a communication tool and if it is not completed facility staff may not know what the temperatures were during the times that were missed possible leading to infections. During an interview with the Administrator (ADM), on 7/18/2025, at 3:40 P.M., the ADM stated laundry washers and dryers need to have temperature checked three times a shift and documented on the temperature log located in the laundry room. The ADM stated the temperature log is important for infection control. The ADM stated the facility currently has the wrong temperature log in the room, we (facility staff) had an interdisciplinary meeting, we (facility staff) have fixed it and also updated our policy to say how often the log should be completed which was not in the policy we had. During a review of the facility policy and procedures (P&P) titled Departmental (Environmental Services) Laundry and Linen, revised 7/18/2025, the P&P indicated, Purpose: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen.d. Washer temperature to be checked and recorded every wash cycle and dryer temperature to be checked and recorded twice daily.

Based on observation, interview and record review, the facility failed to ensure 15 of 20 resident rooms (rooms 1, 2, 4, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, and 20) met the space requirements of 80 square feet for each resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the impacted residents.On 7/15/2025 at 1:50 PM during a general tour of the facility, Rooms 2, 4, 6, 7, 8, 9, 11, 14, 16, 17, 18, 19, and 20 were observed. room [ROOM NUMBER] and room [ROOM NUMBER] were observed with six residents each. The rooms were observed with enough space for nursing staff to provide care for the residents in the rooms. The rooms were observed with privacy curtains for each resident and with direct access to the corridors and the bathroom. During the resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life) on 7/17/2025 at 10 AM, there were no concerns brought up by residents who attended the meeting regarding the size of the residents' rooms. During a review of the facility Client Accommodations Analysis document dated 6/27/2025, the facility Client Accommodations Analysis document indicated the following rooms with their corresponding measurements: Room # # of beds Total Square Feet1 6 455.02 3 220.04 3 220.06 3 220.07 3 220.08 3 220.09 3 234.010 6 455.011 3 220.014 3 220.016 3 222.017 3 222.018 3 222.019 3 222.020 3 222.0 The Client Accommodation Analysis indicated the above rooms measured less than the required 80 square footage per resident in multiple resident bedrooms. For a three-bed capacity room, the square footage requirements would be at least 240 square feet. For a six-bed capacity room, the square footage requirements would be at least 480 square feet. During a review of a letter from the Administrator dated 6/27/2025, the letter indicated the Administrator was requesting a waiver for rooms 1, 2, 4, 6, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, and 20. The letter indicated that the rooms were in accordance with the special needs of the residents and would not have an adverse effect on residents' health and safety or impede the ability of any residents in the rooms to attain his or her highest practicable well-being. During an observation on 7/15/2025 at 2:03 PM in room [ROOM NUMBER], a total of six residents were in each room. During a concurrent interview Resident 32 stated he had no issues with his room and liked where he was. Resident 49 stated he had enough space for his belongings and did not have any complaints. During an interview on 7/15/2025 at 2:10 PM with the Certified Nurse's Aide (CNA) 2, CNA 2 stated CNA 2 was able to do all of CNA 2's nursing care in room [ROOM NUMBER] without any problems and that space was not a problem. During an interview on 7/15/2025 at 2:15 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the space in room [ROOM NUMBER] had enough space to do LVN 3's nursing care. During an interview on 7/15/2025 at 2:33 PM with the facility Administrator (ADM), ADM stated ADM never received any complaints from either the residents in rooms [ROOM NUMBERS] nor from the staff who cared for the residents in rooms [ROOM NUMBERS]. The room waiver was recommended to continue and was contingent with federal regulations at accommodation of needs (483.15 e) and Resident Rights (483.10).

Based on observation, interview, and record review, the facility failed to ensure rooms 2, 4, 6, 7, 8, 9, 11, 14, 16, 17, 18, 19, and 20 had no more than three residents and rooms [ROOM NUMBERS] had no more than six residents. This failure had the potential to have an adverse effect on the health and safety of the residents in rooms 1, 2, 4, 6, 7, 8, 9, 10, 11, 14, 16, 17, 18, 19, and 20 and impede the ability of any resident in the room to attain his or her highest practicable well-being.During an observation on 7/15/2025 at 2:03 PM in room [ROOM NUMBER], a total of six residents were in each room. During a concurrent interview Resident 32 stated he had no issues with his room and liked where he was. Resident 49 stated he had enough space for his belongings and did not have any complaints. During an interview on 7/15/2025 at 2:10 PM with the Certified Nurse's Aide (CNA) 2, CNA 2 stated CNA 2 was able to do all of CNA 2's nursing care in room [ROOM NUMBER] without any problems and that space was not a problem. During an interview on 7/15/2025 at 2:15 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the space in room [ROOM NUMBER] had enough space to do LVN 3's nursing care. During an interview on 7/15/2025 at 2:33 PM with the facility Administrator (ADM), ADM stated ADM never received any complaints from either the residents in rooms [ROOM NUMBERS] nor from the staff who cared for the residents in rooms [ROOM NUMBERS]. During a review of the facility policy and procedures (P&P) titled, Bedrooms, revised May 2017, the P&P indicated that, all residents were provided with clean, comfortable, and safe bedrooms that meet federal and state requirements and bedrooms must accommodate no more than two residents at a time.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (a progressive state of decline in mental abilities) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) and verbal abuse (abuse that involves the use of oral or written language directed to a victim, can include the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) by failing to: Ensure the facility's Security Guard (Sec 1) did not curse (using words in a negative or aggressive way to express anger, disrespect, or to cause distress) at Resident 1 and did not hit Resident 1 on the back of the head with an open hand on 6/19/2025 at approximately 9:40 PM. On 6/19/2025 at approximately 9:40 PM, Certified Nursing Assistant 1 (CNA1) witnessed Sec1 arguing with Resident 1 and saw Sec 1 hit Resident 1 on the back of Resident 1's head with an open palm. On 6/20/2025 at 3:14 PM Resident 1 went to the General Acute Care Hospital (GACH) for further evaluation. This failure resulted in Resident 1 being physically abused by Sec1, experienced pain in his head, expressed being embarrassed, and required a transfer to the GACH. Findings: During a review of Resident 1's admission Record dated 6/23/2025, the admission Record indicated Resident 1 was admitted on [DATE] with the diagnoses of encephalopathy (a disease or damage that affects the brain, leading to a change in how it functions), muscle weakness, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia, lack of coordination, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), low back pain, other abnormalities of gait and mobility (a person's way of walking or moving is different from what's considered normal), cerebral infarction (what happens when part of your brain does not get enough blood and oxygen, leading to tissue damage or death). During a review of Resident 1's History and Physical (H&P) dated 1/9/2025, the H&P indicated Resident 1 was not competent (having the necessary ability, knowledge, or skill to do something successfully) to understand his medical condition. During a review of Resident 1's Care Plan Report dated 1/9/2025, the Care Plan Report indicated if Resident 1 would become hostile or angry during care, the staff (in general) needed to stop giving care and attempt again at a later time. The Care Plan Report indicated for the staff (in general) to ask for assistance if Resident 1 would get resistive. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025, the MDS indicated Resident 1 had the ability to understand others and make himself understood. The MDS indicated Resident 1 used a wheelchair. During a review of Resident 1's Situation Background and Recommendation form (SBAR, tool used by healthcare workers when there is a change of condition among the residents) dated 6/19/2025 at 9:45 PM, the SBAR indicated Resident 1 had approached the nursing station yelling out loud because a staff (unidentified) had redirected Resident 1 not to enter the women's hall. The SBAR indicated Resident 1 became irritable and a CNA (unidentified on the SBAR) was called to help escort Resident 1 to his room. The SBAR indicated Sec 1 yelled out to stop to Resident 1 and Resident 1 was heard yelling and cursing. The SBAR indicated the staff (unidentified on the SBAR) asked Resident 1 to please go to your room. The SBAR indicated the CNA (unidentified on the SBAR) reported Sec 1 hit Resident 1 on the top of the head with an open hand. During a review of Resident 1's Progress Notes dated 6/19/2025 at 9:56 PM, the Progress Note indicated at approximately 9:40 PM Sec1 allegedly (something is claimed to have happened, but there is no concrete proof, or it has not been proven) assaulted Resident 1. The Progress Notes indicated the facility notified Resident 1's Medical Doctor (MD) and the local police department. The Progress Notes indicated Sec1 was not allowed to return to the facility. During a review of Resident 1's Police Investigation Report dated 6/19/2025, the Police Investigation Report indicated the date and time of the occurrence was 6/19/2025 at 10 PM. The Investigation Report indicated PD 1 and PD 2 were sent to Resident 1's facility on 6/20/2025 at approximately 12:15 AM. The Investigation Report indicated Resident 1 stated he (Resident 1) was assaulted by a staff member at the resident's facility. The Investigation Report indicated Resident 1 was not happy with his care level. The Investigation Report indicated Resident 1 believed the janitor or security slapped him with his left hand to the back of his head. The Investigation Report indicated the suspect cursed at Resident 1. The Investigation Report indicated Resident 1 advised the officers he (Resident 1) had a lump on the back of his head cause by the suspect, but the lump was not visible to the officers. The Investigation Report indicated the suspect was Sec 1 and indicated Sec 1 fled prior to police arrival. The Investigation Report indicated the police searched for the suspect but did not find him. During a review of Resident 1's Progress Notes dated 6/20/2025 at 7:38 AM, the Progress Notes indicated Resident 1 was being monitored for victim altercation, and able to accurately recall some details of the situation to the police officers. During a review of Resident 1's Phone Order dated 6/20/2025, at 10:26 AM, indicated to transfer Resident 1 to the GACH for evaluation. During a review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines caring for the resident) Review General note dated 6/20/2025 at 11:20 AM, the IDT Review General note indicated the guy (Sec 1) slapped him on his head. The IDT Review General note indicated Resident 1 stated his head hurt (no pain level indicated on the IDT General note) and requested something for pain. The IDT Review-General note indicated the IDT recommendation was to send Resident 1 to the Emergency Department (ER) for an evaluation and treatment as needed. During a review of Resident 1's GACH Patient Information indicated Resident 1's admit date was 6/20/2025 at 3:14 PM for Aggressive Behavior. During a review of Resident 1's Progress Notes dated 6/21/2025, at 12:16 AM, The Progress Notes indicated Resident 1 returned back to the facility at 11:56 PM (6/20/2025). The Progress Notes indicated the GACH no longer accepted aggressive residents. During a concurrent observation in Resident 1's room and interview on 6/23/2025 at 10:21 AM, Resident 1 appeared to be groggy (feeling tired, weak, and not fully awake or clear-headed) and talked in a low voice. Resident 1 stated he did not know why Sec 1 hit him. Resident 1 stated Sec1 hit him on the back of the head and could not recall the date and time. During an interview on 6/23/2025 at 11:20 AM with Sec 1, Sec 1 stated CNA 1 was assisting Resident 1 and wheeling Resident 1 to his room. Sec 1 stated he (Sec1) went over to CNA 1 and Resident 1 because Resident 1 had been acting out. Sec 1 stated he (Sec1) tried to calm Resident 1 down and put his arm up to Resident 1 to say sorry to try to calm Resident 1 down. Sec 1 stated Resident 1 balled his fist and stated Resident 1 tried to hit him (Sec 1). Sec 1 stated he (Sec 1) raised his hand to protect himself/duck out of Resident 1's way to avoid getting hit by Resident 1. During a follow up interview on 6/23/2025 at 12:50 PM with Sec 1, Sec 1 stated did not receive abuse training (you learn how to protect people from being hurt or mistreated by others) from the facility and was employed with the security company on 6/16/2025. Sec 1 stated he just signed a bunch of papers. During an interview on 6/23/2025 at 12:55 PM with CNA 1, CNA 1 stated he (CNA1) was taking Resident 1 from the female side (the side of the facility where the women reside) during the evening shift on 6/19/2025 when Resident 1 got into an argument with Sec 1. CNA 1 stated he (CNA1) took Resident 1 back to the resident's room to get him away, from Sec 1 who followed Resident 1 and CNA 1 to Resident 1's room. CNA 1 stated Resident 1 was sitting in a wheelchair facing the drawers at the head of his bed. CNA 1 stated Resident 1 had his back to the doorway when Sec 1 came through the door and hit Resident 1 on the back of his head with an open palm. CNA 1 stated the sound the hit made was loud enough for the nurse outside (unidentified) of the room to ask what happened. CNA 1 stated he (CNA1) then told Sec 1 he (Sec1) should never hit any of the residents. During an interview on 6/23/2025 at 1:27 PM with Resident 1, Resident 1 stated when Sec1 hit Resident 1 (6/19/2025), the resident felt pain at a level of 8 out of 10 (a numerical scale used to assess pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable. 0-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10 worst pain imaginable) Resident 1 also reported feeling bad and embarrassed. During an interview on 6/23/2025 at 1:44 PM with the Director of Nursing (DON) and the facility Administrator (Adm), the DON stated abuse training was required for all staff working at the facility as well as anyone working in the resident care area. The DON stated she (DON) only received verbal understanding that Sec 1 had received abuse training. The DON stated the Director of Staff Development (DSD) was responsible for verifying Sec 1's abuse training was completed. The DON stated the DSD was not at the facility because the DSD was sick. The DON stated if the DSD was not available then it would be DON's responsibility to verify Sec 1 received abuse training. The DON stated she met with Sec 1 on 6/9/2025 and Sec 1 received orientation from the DON who went over de-escalation tactics (ways to calm down a tense or potentially violent situation without using force) with Sec 1. The DON stated abuse training was part of the requirement for competent staffing (making sure your team has the right people with the right skills in the right places to get the job done well) and stated the alleged abuse by Sec 1 on Resident 1 could have been prevented. During a telephone interview on 7/3/2025 at 2:11 PM, with Registered Nurse (RN1), Resident 1's IDT Review General note dated 6/20/2025 at 11:20 AM was reviewed. RN1 stated the IDT Review General note indicated Resident 1 stated his head hurt and the Director of Nursing (DON) asked if the nurse (unidentified) gave him any medication for pain and the resident replied No. RN1 stated the IDT notes did not indicate the pain level of Resident 1's head pain. RN1 stated the IDT notes did not indicate Resident 1 received pain relief medication for head. During the concurrent telephone interview on 7/3/2025 at 2:37 PM, with RN1 Resident 1's Progress Notes for 6/20/2025 and the Medication Administration Record (MAR) for the month of June 2025 were reviewed. RN1 stated the Progress Notes and the (MAR) did not indicate Resident 1 received pain relief medication for head and did not indicate the pain level of Resident 1's head pain. During a review of the facility's P&P titled Abuse Prevention Program dated 1/16/2025, the P&P indicated Our residents have the right to be free from abuse, neglect, misappropriation of property (when someone uses money or property that doesn't belong to them for their own personal use or another unauthorized purpose, without permission from the actual owner) and exploitation (the act of using someone or something unfairly for one's own advantage). This includes but is not limited to freedom from corporal punishment (a punishment which is intended to cause physical pain to a person), involuntary seclusion (means being forced to stay in a room or confined space against your will, where you cannot leave), verbal, mental, sexual, or physical abuse and physical (limiting someone's movement) or chemical restraint (when medication is used to control a person's behavior, not because it's the right treatment for their condition, but to make them less active or easier to manage) not required to treat the resident's symptoms (what you feel or notice when you're sick or have a health problem). The P&P indicated the facility would protect our residents from abuse from anyone including, but not necessarily limited to: facility staff, other residents, consultants (a specialized expert brought in from outside to help a company or organization with a specific problem or goal), volunteers, staff from other agencies, family members, legal representatives (someone authorized to act on behalf of another person or entity in legal matters), friends, visitor, or any other individual (person). The P&P indicated the facility would require staff training/orientation (the initial period where a new hire gets introduced to the company, their team, and their specific job duties and helps them understand the company's culture, policies, and expectations, and get comfortable in their new role) programs that include such topics as abuse prevention, identification and reporting of abuse, stress management (learning to cope with stress in healthy ways), and handling verbally or physically aggressive resident behavior.

Based on interview and record review the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding risks, benefits and alternatives offered) for one of three sampled residents (Resident 1). For Resident 1, the facility failed to obtain informed consent from Resident 1 and Resident 1 ' s responsible party (RP) before administering the Haldol (medication used to treat certain mental/mood disorders) on 1/26/25. This deficient practice resulted in Resident 1 and Resident 1 ' s RP not given their right to know the risks and benefits of taking the Haldol and alternative treatment available. Findings: During a review of the Admission Record indicated the facility admitted Resident 1 on 1/3/25 with diagnoses including schizoaffective disorder (chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors) and hypothyroidism (when the thyroid gland [small, butterfly-shaped gland in front of neck] creates less than the normal amount of thyroid hormone). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 1/8/25 indicated Resident 1 was cognitively intact. Resident 1 needed set-up (helper sets up, resident completes activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene and independent with upper /lower body dressing and putting/taking off footwear. During a review of Resident 1's Behavior Note dated 1/26/25 at 2:25 p.m., indicated Resident 1 was exhibiting physical and verbal aggression towards staff. Resident 1 ' s psychiatrist was notified and gave one time order that included Haldol five milligrams (mg. - metric unit of measurement, used for medication dosage and/or amount) to be administered intramuscularly (IM, the injection of medication into a muscle). During a review of Resident 1 ' s Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/26/25 indicated the Haldol was given to Resident 1 on 1/26/25 at 2:11 p.m. During a review of Resident 1 ' s care plan initiated on 1/26/25 indicated Resident 1 had an episode of verbal and physical aggression towards staff. The care plan goal indicated Resident 1 will verbalize understanding of need to control physically aggressive behavior through the review date. The care plan intervention included to give Resident 1 as many choices as possible about care and activities. During a concurrent interview and record review on 2/14/25 at 11:27 a.m., Resident 1 ' s MAR and progress notes dated 1/26/25 were reviewed with the director of staff development (DSD). DSD stated Resident 1 had verbal and aggressive behavior towards staff on 1/26/25. Resident 1 ' s psychiatrist was notified and gave order that included to give Resident 1 Haldol five mg. IM as one time order. DSD stated the Informed Consent should be obtained and filled out even though the Haldol was a one-time order. During an interview on 2/14/25 at 12:35 p.m., LVN 1 stated informed consent should be obtained from Resident 1 ' s RP before administering the Haldol. During review of the email sent on 2/14/25 at 2:36 p.m., the medical record director (MRD) confirmed that Resident 1 had no informed consent for the Haldol. During a review of the facility's policy and procedures (P&P) titled Informed Consent reviewed on 1/16/25, the P&P indicated, it is the policy of the facility to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic drugs, physical restraints and medical devices that may lead to the inability of a patient to regain use of a normal bodily functions after prolonged use. The same Policy indicated in an emergency in which it is impractical to obtain the consent order for psychotropic drugs, may be initiated upon a physician order without informed consent for a period of 48 hours. Informed consent must then be obtained to continue the medication, physical restraint or medical device. Based on interview and record review the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding risks, benefits and alternatives offered) for one of three sampled residents (Resident 1). For Resident 1, the facility failed to obtain informed consent from Resident 1 and Resident 1's responsible party (RP) before administering the Haldol (medication used to treat certain mental/mood disorders) on 1/26/25. This deficient practice resulted in Resident 1 and Resident 1's RP not given their right to know the risks and benefits of taking the Haldol and alternative treatment available. Findings: During a review of the Admission Record indicated the facility admitted Resident 1 on 1/3/25 with diagnoses including schizoaffective disorder (chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors) and hypothyroidism (when the thyroid gland [small, butterfly-shaped gland in front of neck] creates less than the normal amount of thyroid hormone). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 1/8/25 indicated Resident 1 was cognitively intact. Resident 1 needed set-up (helper sets up, resident completes activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene and independent with upper /lower body dressing and putting/taking off footwear. During a review of the Behavior Note dated 1/26/25 at 2:25 p.m., indicated Resident 1 was exhibiting physical and verbal aggression towards staff. Resident 1's psychiatrist was notified and gave one time order that included Haldol five milligrams (mg. - metric unit of measurement, used for medication dosage and/or amount) to be administered intramuscularly (IM, the injection of medication into a muscle). During a review of Resident 1's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/26/25 indicated the Haldol was given to Resident 1 on 1/26/25 at 2:11 p.m. During a review of Resident 1's care plan initiated on 1/26/25 indicated Resident 1 had an episode of verbal and physical aggression towards staff. The care plan goal indicated Resident 1 will verbalize understanding of need to control physically aggressive behavior through the review date. The care plan intervention included to give Resident 1 as many choices as possible about care and activities. During a concurrent interview and record review on 2/14/25 at 11:27 a.m., Resident 1's MAR and progress notes dated 1/26/25 were reviewed with the director of staff development (DSD). DSD stated Resident 1 had verbal and aggressive behavior towards staff on 1/26/25. Resident 1's psychiatrist was notified and gave order that included to give Resident 1 Haldol five mg. IM as one time order. DSD stated the Informed Consent should be obtained and filled out even though the Haldol was a one-time order. During an interview on 2/14/25 at 12:35 p.m., LVN 1 stated informed consent should be obtained from Resident 1's RP before administering the Haldol. During review of the email sent on 2/14/25 at 2:36 p.m., the medical record director (MRD) confirmed that Resident 1 had no informed consent for the Haldol. During a review of the facility's policy and procedures titled Informed Consent reviewed on 1/16/25, the P&P indicated, it is the policy of the facility to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic drugs, physical restraints and medical devices that may lead to the inability of a patient to regain use of a normal bodily functions after prolonged use. The same Policy indicated in an emergency in which it is impractical to obtain the consent order for psychotropic drugs, may be initiated upon a physician order without informed consent for a period of 48 hours. Informed consent must then be obtained to continue the medication, physical restraint or medical device.

Based on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for two of three sampled residents (Resident 5 and Resident 35). The facility failed to: -Ensure Resident 5 was free from physical abuse and was not struck in the face by Resident 206 with an open hand on 6/23/2024. -Prevent Resident 206 from splashing coffee onto Resident 35 on 6/3/2024, when Resident 206 had an aggressive behavior, was angry and upset. and splashed coffee onto another resident (Resident 35). These deficient practices resulted in Resident 5 and Resident 35 being subjected to abuse and psychosocial (mental health) harm by Resident 206, while under the care of the facility. Resident 5 asked the police to take Resident 206 away. Findings: A review of Resident 206's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Parkinson disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 206's History and Physical (H&P) dated 5/9/2024, indicated the resident was not competent to understand her medical condition. A review of Resident 206's Care Plan for the Alteration in Psychosocial Well-being related to schizophrenia and bipolar disease initiated on 5/9/2024, indicated Resident 206 had a history of self-harm. The care plan goal was for the resident to show gradual positive progress towards interacting with others for the next three months. The care plan interventions indicated to allow the resident to verbalize feelings, concerns, or fears, to identify issues causing stress to the resident, address issues of concerns, identify issues important to the resident and offer social services assistance if needed, and to encourage active involvement in activities for socialization and stimulation. A review of Resident 206's Care Plan for Bipolar disorder initiated on 5/11/2024, indicated the goal for the resident was to not have injuries to herself or others during outbursts for three months. The care plan interventions indicated to monitor the resident for signs of impeding violence such as increasing activities, clenching fists, teeth and to keep the resident away from proximity of others, if above symptoms were exhibited, to provide diversional activities to keep the resident occupied and to review medications and diagnoses for possible causes of behaviors and address issues of concerns. According to a review of Resident 206's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/14/2024, the resident's cognitive skills (ability to think, remember and make decisions) for daily decision making was intact, but had trouble concentrating on things such as reading the newspaper. The MDS indicated Resident 206 had trouble falling or staying asleep, was feeling tired or having little energy, and did not display any psychosis (symptoms that happen when a person was disconnected from reality) behavior. A review of Resident 206's Nursing Progress Note dated 6/2/2024 at 9:45 AM, indicated the resident was being monitored for aggressive behavior, was redirected at times during the shift, and was re-educated on appropriate behaviors in activity room and hallways. A review of Resident 206's Social Service Note dated 6/3/2024 at 1:54 PM, indicated the resident was being monitored for aggressive behavior, as the resident got angry and upset and splashed coffee onto another resident (Resident 35). The note indicated Resident 206's conservator (a person appointed by the court to make decisions about personal matters for a person who is not able to make his/her own decision, including decisions about medical care, food, clothing, where the person will live) and psychiatric doctor (a medical practitioner specializing in the diagnosis and treatment of mental illness) were made aware. This social service note was stricken by Social Services Director (SSD) on 6/24/2024 at 3:57 PM, and was marked as incorrect documentation. A review of Resident 206's Change of Condition - SBAR Form (Situation-Background-Assessment and Recommendation - a written communication tool that helps provide important information) dated 6/23/2024 at 1:05 PM, indicated Resident 206 displayed aggressive behavior towards her roommate (Resident 5). According to a review of the Nursing Progress Note dated 6/23/2024 at 2:23 PM, Resident 206 assaulted (hit in the face with an open hand) another resident (Resident 5) at 2 PM, the Police Department arrived at the facility and arrested Resident 206 for assault. A review of Resident 5's Admission Record indicated the facility readmitted the resident on 1/10/2024, with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), and anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one`s daily activities). A review of Resident 5's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). A review of Resident 5's History and Physical (H&P) dated 5/31/2024, indicated that the resident had the capacity to understand and make decisions. A review of Resident 5's Nursing Progress Notes dated 6/23/2024 at 2 PM, indicated the resident was struck three times with an open hand by her roommate (Resident 206). According to a review of Resident 5's Nursing Progress Notes dated 6/23/2024 at 2:25 PM, on 6/23/2024 at around 2 PM, Resident 5 was walking out of her room while Resident 206 was standing by at the front of the door. Resident 5 wanted to pass through the door and asked to be excused and Resident 206 did not respond. The note further indicated that Resident 206 hit Resident 5 for no reason. A review of Resident 35's Admission Record indicated the facility readmitted the resident on 5/15/2023, with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and schizoaffective disorder ( a mental illness that can affect your thoughts, mood, and behavior). A review of Resident 35's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). A review of Resident 35's History and Physical (H&P) dated 5/9/2024, indicated the resident was not competent to understand her medical condition. During an interview on 7/10/2024 at 8:30AM, inside Resident 5's room, with Certified Nursing Assistant (CNA) 4, Resident 5 stated she never had any issues with any of her roommates. During a concurrent interview at 8:40 AM, Resident 5 asked CNA 4 Why did Resident 206 hit me? Resident 5 stated, She just did not like me. CNA 4 stated, On 6/23/2024, in the afternoon Resident 5 asked me for toothpaste and a brush. I went to the supply room at the end of the hallway. When I looked back, I saw Resident 5 was standing at her door and Resident 206 was standing in the hallway. I witnessed Resident 206 hit Resident 5 three times one on her head, one on her cheek and one on her neck. When the police came Resident 5 asked the police to take her (Resident 206) away. During an interview on 7/10/2024 at 10:45 AM, Licensed Vocational Nurse (LVN) 1 stated, Resident 206 had behavioral issues, and was extremely frustrated because she did not receive her monthly money from her conservator. LVN 1 stated Resident 206 was Resident 5's roommate and on 6/23/2024, Resident 5 and Resident 206 were talking in the hallway next to their room, in a verbal altercation. Then Resident 206 started hitting Resident 5 three times with an open hand. LVN 1 stated Resident 5 requested the police to come. Resident 5 kept saying she wanted to call the police. Resident 206 stated she was going to do it again. The police came and arrested Resident 206 for an assault. On 7/10/2024 at 11:26 AM, during an interview, the Social Services Director (SSD) stated Resident 206 was involved in another resident-to-resident altercation before 6/23/2024. The SSD stated Resident 206 threw coffee at another resident (Resident 35), but did not remember which resident. The SSD further stated, On 6/2/2023, both residents were in the activity room. Resident 206 got upset and she threw coffee at the other resident (Resident 35). I made some notes in Resident 206's chart regarding her aggressive behavior on 6/2/2024, however, I deleted the notes because a lot had happened, and I wanted to add some more information. The SSD stated licensed staff did not develop a change of condition - SBAR for this incident for Resident 206. The SSD stated, The other affected resident was not monitored for any emotional distress after the incident. During an interview on 7/10/2024 at 11:49 AM, CNA 5 stated, I heard that Resident 206 threw coffee at another resident on 6/2/2024. In the morning huddle we were told to keep a close eye on Resident 206. During an interview on 7/10/2024 at 11:57 AM, LVN 3 stated, Resident 206 was alert, ambulatory and a smoker. She had days that she was calm and days that she was mad. Resident 206 would throw coffee and food on the floor. During a telephone interview on 7/10/2024 at 12:41 PM, the Activity Assistant (AA) stated on Sunday 6/2/2024 at around 5 PM, Resident 206 threw coffee at Resident 35 inside the activity room. AA stated, I asked her why she did it and she did not answer. We had to call a charge nurse to check Resident 35. Resident 35 was assessed, and was fine. During an interview on 7/10/2024 at 1:02 PM, inside Resident 35's room, Resident 35 stated that Resident 206 threw coffee at him. Resident 35 stated he was sitting in activity room and Resident 206 threw coffee at him for no reason. He stated the coffee hit him at his chest, face and in his eyes. He stated the coffee was not hot and he did not get burned. Resident 35 stated, I did not tell Resident 206 anything because she was a girl. I just let it go. On 7/10/2024 at 2 PM, during an interview, the facility's Director of Nursing (DON) stated Resident 5 did not sustain any injuries and she verbalized that she was feeling safe in the facility. Resident 206 was removed from the facility by the police. The DON stated, I have a binder and there is documentation regarding Resident 206 throwing coffee at another resident on 6/2/2024. However, the incident was not documented as an allegation of abuse. The DON stated he was not sure what interventions were done for Resident 206 after the incident on 6/2/2024. During an interview on 7/10/2024 at 2:20PM, the facility's Administrator (ADM) stated that the incident on 6/2/2024, between Resident 206 and Resident 35 was not reported to the Department, ombudsman, or the police department. The ADM stated this was a reportable incident. The ADM stated she was in charge of reporting the allegation of physical abuse between Resident 206 and Resident 35. The ADM stated, The potential outcome of not reporting a resident-to-resident physical altercation is a delay in the investigation and delivery of necessary interventions to ensure resident safety. A review of the facility's documentation of its Leadership Staff dated from 10/2023 to 6/27/2024 indicated the facility had an Interim DON working at the time of this incident and an Interim Administrator was also working during this incident. The Interim Administrator last day was 6/3/2024, and the abuse was not reported or investigated. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevent Program, reviewed April 2024, 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: identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegation within timeframe required by federal requirements. Protect residents from further harm during investigation. Implement measures to address factors that may lead to abusive situations. A review of the facility's policy and procedure titled, Abuse Prevention Program, reviewed 4/11/2024, indicated as a part of abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse. Investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on interview and record review the facility failed to follow the physician order for one of two sample residents, Resident 1. The facility failed to carry out the physician order and transcribe the itraconazole (medication used to treat histoplasmosis (infection of the lungs caused by fungus [disease caused by mold] 200 milligrams (mg., unit of measurement) two times a day orally. On 3/19/24, the facility received an order from Resident 1 ' s general acute hospital (GACH 1) infectious disease physician (ID, medical doctor that specialized in in infectious diseases) to administer Resident 1 itraconazole 200 milligrams (mg., unit of measurement) orally three times a day for three days and followed by itraconazole 200 mg. orally two times a day. The facility administered the itraconazole 200 mg. orally three times a day for three days from 3/19/24 at 5 p.m. to 3/22/24 at 1 p.m. but failed to continue giving the itraconazole 200 mg. orally two times a day as ordered by the ID physician. Resident 1 did not receive itraconazole from 3/23/24 to 4/24/24. This deficient practice resulted in Resident 1 ' s histoplasmosis has spread from his lungs to his bones and requiring prolonged hospitalization from [DATE] to 5/14/24 to manage and treat the histoplasmosis. Findings: During a review of the Admission Record, the Admission Record indicated the facility admitted Resident 1 initially on 6/29/23 and readmitted on [DATE]. During a review of the GACH 1 History and Physical Note (H&P, a physician ' s examination of the resident) dated 2/23/24 indicated Resident 1 had dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities) and pulmonary histoplasmosis. During a review of the GACH 1 ID Telephone Note dated 3/15/24 and sent to the facility on [DATE] by facsimile (fax) indicated The ID physician gave an order dated 3/15/24 to give Resident 1 itraconazole 200 mg. orally three times a day for three days followed by itraconazole 200 mg. orally two times a day for pulmonary histoplasmosis (no end date). During a review of Resident 1 ' s Progress Note (Health Status Note) dated 3/19/24 at 3:21 p.m., indicated Resident 1 is receiving itraconazole 200 mg. capsules three times a day for three days and after three days, Resident 1 should receive 200 mg. itraconazole orally two times a day until further notice. During a review of Resident 1 ' s Primary Physician Progress Note dated 3/21/24 indicated to continue the itraconazole as prescribed by Resident 1 ' s ID physician (itraconazole 200 mg. orally three times a day for three days followed by itraconazole 200 mg. orally two times a day for pulmonary histoplasmosis). During a review of Resident 1 ' s Minimum Data Set (MDS, standardized care and health screening tool) dated 3/30/24 indicated Resident 1 had severe cognitive impairment (loss of ability to remember things and solve problems resulting in inability to live independently). Resident 1 needed moderate assistance (helper does less than half the effort) with personal hygiene, putting/taking off footwear, lower body dressing, shower, toileting hygiene and supervision (helper provides verbal cues) with upper body dressing, oral hygiene and eating. During a review of the Social Service Note dated 4/8/24 at 3:23 p.m., indicated Resident 1 had an appointment with the pulmonologist (doctor who specialized in lung [breathing organ] health and breathing problems) on 4/25/25 at 2:30 p.m. During a review of the Pulmonary Clinic Note dated 4/25/24 at 2:54 p.m., the Pulmonary Clinic Note indicated Resident 1 ' s computed tomography (CT scan, a computer linked to an x-ray machine to make a series of detailed picture of areas inside the body) dated 4/24/24 indicated progression (becomes worse, spreads) of the histoplasmosis. The Notes indicated the pulmonologist was concerned about the result of the CT scan and that Resident 1 was not taking the itraconazole. The pulmonologist sent Resident 1 to GACH 1 for ID consultation due to the progressive and possible disseminated (spread of the histoplasmosis from the lungs to other parts of the body) histoplasmosis. During a review of the GACH 1 Emergency Department Note dated 4/25/24 at 4:40 p.m., the GACH 1 Emergency Department Note indicated Resident 1 ' s CT scan of the chest .showed innumerable pulmonary nodules (abnormal growth or mass that forms in the lungs) compared to prior imaging . The ER Notes indicated Resident 1 was admitted to GACH 1 for monitored therapy for histoplasmosis. During a review of the Nephrology (medical doctor who specialized in kidney care [a pair of small organs in the body that take away waste from the blood] and treating diseases of the kidneys) Consultation Note dated 4/27/24 at 12:08 p.m., indicated Resident 1 had not been receiving the itraconazole medication because the itraconazole serum level (blood test) showed less than 0.1 milligram per liter (mg./L, reference range is between one mg./L to four mg./L.). During a review of the ID Follow-up Consult Note dated 5/9/24 at 8:17 a.m., the ID follow-up consult note indicated Resident 1 had bone marrow biopsy (procedure in which bone samples from the soft tissue in the bone are removed with a special needle or during surgery to find infection) on 5/1/24 and the result dated 5/6/24 indicated the histoplasmosis had spread to Resident 1 ' s bones. The Notes further indicated Resident 1 not receiving the itraconazole medication while at the facility .are almost certainly the reason for patient ' s (Resident 1) disease progression. Resident 1 ' s treatment included (was treated with) itraconazole 200 mg orally two times a day, Amphotericin B (medication used to treat serious, life-threatening fungal infections) 350 mg intravenous (IV, given through a flexible tube through the vein) every 24 hours and isavuconazole (drugs used to treat yeasts, fungi, and molds) 372 mg. orally daily. During a review of Resident 1 ' s GACH 1 Discharge Summary dated 5/15/24 indicated Resident 1 was at the GACH 1 for 20 days from 4/25/24 and discharged on [DATE] to another facility. During an interview on 5/9/24 at 9:59 a.m. Licensed Vocational Nurse (LVN 1) stated, Resident 1 went to his pulmonologist appointment on 4/25/24. LVN 1 stated Resident 1 was sent from the pulmonologist appointment to the GACH 1 and had not returned to the facility. During a concurrent interview and record review on 5/9/24 at 11:31 a.m., Resident 1 ' s Progress Notes dated 3/19/24 at 3:21 p.m., and physician order for itraconazole dated 3/19/24 . LVN 2 stated she was unable to find a physician order for the itraconazole 200 mg. orally two times a day on 3/19/24. During a telephone interview on 5/9/24 at 12:44 p.m., the GACH 1 pharmacist (Pharmacist 1) stated Resident 1 was supposed to receive itraconazole orally 200 mg. as maintenance dose (medication given to maintain desired level of the drug in the body) two times a day until Resident 1 is seen by the pulmonologist on 4/25/24. Pharmacist 1 stated it is important for Resident 1 to receive the itraconazole so that Resident 1 ' s pulmonary histoplasmosis will not worsen. Pharmacist 1 further stated the ability to supply the itraconazole is not a problem because GACH 1 pharmacy can always send the itraconazole to the facility. Pharmacist 1 stated when Resident 1 was seen by the pulmonologist on 4/25/24 Resident 1 ' s histoplasmosis had worsened and was sent to GACH 1 immediately for further treatment. During a concurrent interview and record review on 5/9/24 at 12:51 p.m., Resident 1 ' s Medication Administration Record (MAR) dated 3/19/24 to 4/25/24 was reviewed with Resident 1 ' s primary physician. Resident 1 ' s primary physician stated Resident 1 was not given the itraconazole 200 mg. for over a month. The last dose of itraconazole 200 mg was given on 3/19/24 at 1 p.m. and restarted 200 mg. itraconazole on 4/25/24 at 1 p.m. before Resident 1 was readmitted to GACH 1.Primary physician stated Resident 1 should have been given the itraconazole 200 mg. orally two times a day because Resident 1 ' s histoplasmosis can worsen. During a concurrent interview and record review on 5/9/24 at 1:01 p.m., the Resident 1 ' s Progress Notes dated 3/19/24 at 3:21 p.m., was reviewed with the Director of Nursing (DON). The DON stated the notes indicated itraconazole 200 mg capsule two tablets three times a day and then 200 mg. two times a day until further notice. The DON stated this means that the itraconazole should be given continuously to Resident 1 until the itraconazole was discontinued by the primary physician. The DON further stated the facility has protocol in getting telephone orders from the physician and that included to read back the order to the physician, enter the name of the ordering physician and enter the order in the physician order form. During a telephone interview on 5/15/24 at 11:53 a.m., Resident 1 ' s family member (FM) stated Resident 1 had fungal infection in his lungs. The facility stopped giving the itraconazole. Resident 1 ' s FM stated Resident 1 was admitted to GACH 1 and had to stay in GACH 1 for approximately four weeks because Resident 1 had to receive extra doses of the itraconazole and other treatment. FM also stated Resident 1 had to undergo bone biopsy and the result indicated the histoplasmosis had spread to Resident 1 ' s bones. During a review of the facility Policy titled Medication Ordering and Receiving from Pharmacy reviewed on 1/11/24 indicated medication orders are written on a medication order form (i.e., telephone order sheet, reorder form, etc.) provided by the pharmacy or written in the chart by the physician or authorized personnel and transmitted to the pharmacy. The written entry included the following: a. date ordered. b. whether the order is new or a repeat order (refill). b. medication name and strength when indicated. c. direction for use, is a new order, or direction changes to a previous order with indication as to whether a new supply is needed form the pharmacy. The Policy further indicated when re-ordering medication that requires special processing such as GACH 1 prescriptions, order as directed by the provider pharmacy. The nurse who re-orders the medication is responsible for notifying the pharmacy of changes in directions for use. During a review of the facility Policy titled Administering Medications, reviewed on 1/11/24 indicated medications are administered in a safe and timely manner, and as prescribed. During a review of the Medication and Treatment Orders reviewed on 1/11/24 indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Orders for medications must include: a. name and strength of the drug b. number of doses, start and stop date and/or specific duration of therapy. c. dosage and frequency of administration d. route of administration e. clinical condition or symptoms for which the medication is prescribed. f. interim follow-up requirements

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 5), who had no capacity to understand, had history of elopement (when the resident leaves the premises or a safe area without the facility's knowledge or supervision), and was at risk for wandering and elopement, received the care and supervision needed to prevent elopement by failing to: -Develop a person-centered, comprehensive care plan to include frequency of monitoring Resident 5's location through visual checks, per the At Risk of Elopement care plan. -Review Resident 5's elopement assessment form for accuracy, per the previous IJ removal plan approved on 2/29/2024. -Revise / Update Resident 5's At Risk for Elopement care plan to include monitoring every 15 minutes, per the previous IJ removal plan approved on 2/29/2024. -Ensure adequate staffing for the 11 PM - 7 AM shift on 3/16/2024. As a result of these deficient practices, on 3/16/2024 around 5:15 AM, Resident 5 was found to have eloped from the facility and remains missing. Resident 5 has an increased risk of serious harm or death due to not receiving the physician ordered care, which includes administration of Haloperidol 5 mg (an antipsychotic medication used to treat schizophrenia, hallucinations and delusions) twice a day, Risperidone 3 mg (antipsychotic medication) every 12 hours and Physical Therapy Program for unsteadiness on feet. On 3/20/2024 at 4:15 PM, 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 to a resident) was called in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) due to the facility's failure to develop a person-centered comprehensive elopement care plan and to implement the care planned interventions to monitor Resident 5's location through visual checks to prevent his elopement from the facility on 3/16/2024. This placed Resident 5 at an increased risk of serious harm or death due to not receiving medications and care. On 3/22/2024, the facility submitted an acceptable IJ Removal Plan (IJRP - interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP implementation through observation, interview, and record review, the IJ was removed on 3/22/2024 at 7:49 PM, in the presence of the facility's ADM and the Director of Nursing (DON). The facility's IJRP included the following immediate actions: -Resident 5 was identified to have eloped on 3/16/2024 around 5:15 am. Throughout the day and for the next two days, the facility received hourly calls from LAPD, inquiring if resident was found or had returned. Facility staff made several calls to different hospitals inquiring whether the resident was admitted . The undersigned together with a CNA went to several shelters, skid row, medical clinics, restaurants in the area throughout the weekend. As of 3/16/2024, the resident has not been located. - On 3/20 and 3/21/2024, the Director of Nursing and the Administrator reviewed the elopement assessments. As of 3/21/2024, out of 51 residents reviewed for elopement assessment, there were 16 residents identified that remained to be at risk for elopement. - The care plan of the 16 residents identified to be at risk for elopement were reviewed and the plan of care was updated on 3/20/2024 to indicate every 15 minutes visual monitoring of residents. - A dedicated staff for door monitoring was initiated on 3/19/2024 and as of 3/21/2024. There is a staff assigned for the 7-3, 3-11 and 11-7 shift. The door monitor designated staff will be sitting in the area across the front door to monitor and redirect residents who are approaching and walking towards the front doors. Another staff will be assigned when the door monitor staff takes a break for meals or bathroom breaks. -There are three exit doors of the facility, and the three exit doors were serviced for routine maintenance check on 3/19/2024, for another service maintenance check performed on the front doors and were found to be functioning normal. -The Maintenance Supervisor will be performing a daily check of all the three exit doors to ensure that they are functioning starting 3/21/2024. - In-service education was initiated by the Infection Prevention (IP) Nurse on 3/21/2024, at 10:30 am, regarding the Policy & Procedure for Elopement including the identified residents at risk for elopement, the action plan for visual check of residents whereabouts every 15 minutes. The in-service included the new action plan for the updated list dated 3/20/2024 of the identified resident elopement risk that needed every 15-minute visual check of whereabouts, the door monitor staff for additional safety support. Inservice education included documentation of the CNA of the 15-minute visual monitoring for whereabouts of the resident identified to be at risk for elopement. -Additional in-service education will be provided to staff on 3/21/2024 at 3:30 PM until 100% of staff are in-service regarding the plan for monitoring of at risk for elopement resident, the 15-minute visual check plan, the front door monitoring staff and the updated list that is in the binder with resident's pictures. -The updated list will be placed at the Elopement Risk Binder and will also contain the pictures of the residents identified to be at risk for elopement for easier identification. -The resident identified to be at risk for elopement will be monitored every 15 minutes and will be documented for the whereabouts in the form titled Visual Check Every 15 minutes which was in place since 2/27/2024 and will continue to use the same form as of 3/21/2024. - The charge nurses will monitor every shift that the identified resident to be at risk for elopement is monitored every shift for their whereabouts by the CNA starting 3/21/2024. -The Elopement at Risk Resident List will be reviewed by the IDT weekly every Friday starting 3/22/2024 x 6 months and the updated list will be placed at the binder. - Any findings from the monitoring of the above plans will be addressed to the QA Committee meeting x 6 months beginning 4/19/2024. The ultimate responsibility is the Administrator. Findings: A review of the Admission Record indicated the facility admitted Resident 5 on 12/12/2023 with diagnoses including encephalopathy (the group of conditions that causes brain dysfunction [can appear as confusion, memory loss and personality change]), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of the History and Physical (H&P), dated 12/13/2023, indicated Resident 5 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/18/2023, indicated Resident 5 had severely impaired cognition (decisions poor; cues/supervision required) and needed supervision or touching assistance for eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 5 did not have any wandering behavior. A review of the Elopement Risk Assessment, dated 12/20/2023, indicated Resident 5 did not readily accept nursing home placement and was at risk for elopement. A review of the At Risk for Wandering / Elopement Care Plan initiated on 1/12/2024, indicated this care plan was related to Resident 5's schizophrenia and schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may occur at the same time or at different times). The care plan goals for Resident 5 were to provide a hazard-free environment and keep him from wandering out of the facility. The interventions indicated to monitor the resident's location through visual checks, redirect him as needed and to speak with Resident 5's family or friends to record all information regarding the resident's history of wandering and areas where he might attempt to go. According to a review of the Progress Note, Intradisciplinary Team Review (IDT) meeting, dated 2/27/2024, Resident 5 was at risk for elopement, with no new attempts while in the facility. The progress note indicated Resident 5 needed simple, clear directions and constant redirection from the staff. A review of the Change of Condition / Situation, Background, Assessment and Recommendation (SBAR) dated 3/16/2024, indicated Resident 5 eloped from the facility on 3/16/2024 around 5:15 AM through the front door, while Licensed Vocation Nurse (LVN) 1 administered medications to another resident. On 3/19/2024 at 11:41 AM, during a phone interview, LVN 1 stated that around 5 AM, Resident 5 was in the hallway and asked about some Ensure (a nutritional supplement). LVN 1 stated he promised Resident 5 that he would come back to him in a few minutes. LVN 1 stated he was administering medication in another resident's room when he heard the front door alarm. LVN 1 stated he quickly went to the front door to find out who was trying to get in or out of the facility, because he did not know that residents could easily open the front door. LVN 1 stated he immediately sent two CNAs outside to look for the resident while he drove around the neighborhood. LVN 1 stated they could not find Resident 5 and reported the incident to the police. LVN 1 stated that on 3/16/2024 during the 11 PM - 7 AM shift, there was only 1 LVN and 3 CNAs for all 52 residents in the facility. LVN 1 stated there was no designated person to monitor the 16 residents with elopement risk and nobody to monitor the front door at 5 AM. LVN 1 stated the CNAs were monitoring the residents for elopement, while also providing the morning diaper changes to the residents. During a phone interview, on 3/19/2024 at 11:51 AM Certified Nurse Assistant 1 (CNA 1) stated that she was taking care of Resident 5 on 3/16/2024. CNA 1 stated Resident 5 required monitoring every 15 minutes due to his risk of elopement. CNA 1 stated that around 5 AM on 3/16/2023, she went with CNA 2 to another resident's room to provide a diaper change. CNA 1 stated when she heard the alarm go off, she went to look for Resident 5 in his room but did not find him there. On 3/19/2024 at 1:46 PM, during a phone interview, CNA 2 stated that on 3/16/2024 around 5 AM she was helping CNA 1 with a diaper change. CNA 2 stated she was taking the dirty linens out from room, when the front door alarm went off. CNA 2 stated she quickly ran to the front and saw there was nobody watching the front door at that time. During a concurrent interview and record review with the Director of Nursing (DON), on 3/19/2024 at 4:35 PM, the DON stated she did not document that she reviewed the elopement risk assessment dated [DATE] for Resident 5 or update the resident's At Risk for elopement care plan to include frequency of monitoring, and per the Immediate Jeopardy Removal Plan (IJRP) approved 2/29/2024. The DON reviewed a document called Visual Check every 15 minutes, dated 3/16/2024, implemented as part of the IJRP, approved 2/29/2024 and stated, Usually the facility had an extra CNA, who was designated to monitor the residents with elopement risk. The DON stated the CNAs were rotating every 30 minutes to provide monitoring for the 16 residents with elopement risk, while other CNAs were providing care to residents with Activities of Daily living (ADLs), but on 3/16/2024 there was no staff designated to monitor the residents with elopement risk. The DON stated that according to the Visual Check every 15 minutes, form dated 3/16/2024, There was to be a designated person to monitor the 16 residents with elopement risk. But there was not. Under the section titled, Name of Person Performing Monitoring, it did not indicate who was monitoring the residents or at what time. On 3/19/2024 at 5 PM, during interview, the Administrator stated that on 3/16/2024 the facility was short staffed with one LVN and three CNAs for 52 residents which resulted in Resident 5 being able to elope from the facility through the front door. A review of the facility's policy and procedure titled, Wandering and Elopement, revised March 2019, indicated if the resident was identified as at risk for elopement or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety and strive to prevent harm. A review of the facility's policy and procedure (P&P) titled, Routine Resident Checks, revised 7/2013, indicated, staff shall make routine resident checks to help maintain resident safety and well-being. A review of the facility's P&P titled, Safety and Supervision of Residents, revised in 7/2017, indicated residents' safety risks are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. The P&P indicated the facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The P&P indicated resident supervision may need to be increased when there was a change in the resident's condition.

Based on interview and record review, the facility failed to provide a safe environment and supervision for one sampled (Resident 4), who was at risk for elopement (leaving the facility without notice or permission, presenting an imminent threat to resident's health and safety), at risk for wandering (a person with loss of memory, thinking, or reasoning roams around and becomes lost or confused about their location), and had diagnoses of schizophrenia (a mental illness that cause disturbed or unusual interest in life, and strong or inappropriate emotions; usually involves delusions [false beliefs], hallucinations [seeing or hearing things that don't exist]), and psychosis (a person loses contact with reality), to address Resident 1's history of elopement. The facility failed to: 1) Include Resident 4's two successful elopements from previous facility as part of their Interdisciplinary Team (IDT - a group of different healthcare professionals working together towards a common goal for a resident) review on 2/12/2024. 2) Address in the Interdisciplinary Team (IDT) meeting on 2/12/2024 about a call made to 911 (designated as a universal emergency number) when Resident 4 became very violent hitting the front glass door forcefully with her body weight and hands in an attempt to elope on 2/11/2024. 3) Provide adequate supervision to prevent elopement on Resident 4 who was identified as an at-risk for elopement resident. 4) Perform strict hourly checks on Resident 4 and all residents' locations and their conditions. 5) Conduct a Situation-Background-Assessment-Recommendation (SBAR - a technique that provides a framework for communication between members of the health care team and used as a tool to foster patient safety) to alert facility staff of Resident 4's attempt at elopement on 2/11/2024. These deficient practices placed Resident 4 at an increased risk of decline in physical, mental, and psychosocial needs due to interrupted medical care and medications, suffer injury, pain, serious harm, serious impairment or death when Resident 4 eloped from the facility on 2/22/2024 between 6:30 PM and 7 PM. Resident 4 has not been found nor returned to the facility as of 2/29/2024. On 2/26/2024 at 7:14 PM, an Immediate Jeopardy (IJ - a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM), Director of Nursing (DON), Medical Records Director, Director of Staff Development, and Payroll clerk regarding the facility's failure to provide a safe environment for Resident 4 who eloped on 2/22/2024. On 2/29/2024 at 4:06 PM, while onsite at the facility, the IJ was removed in the presence of the ADM, and the DON, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan of action (POA) was as follows: -On 2/23/24 at 7 AM, the DON conducted an in-service education on the elopement incident, policy and procedure (P&P) on Wandering and Elopements for 25 of the 75 clinical and non-clinical staff. The completion date was 3/4/2024. -On 2/23/2024, the bathroom window in Room A was permanently closed with screws to prevent the window from opening more than an inch. -On 2/27/2024, the facility had the wooden fence, located on the west side of the facility building, inspected by a [NAME] Company (WC). The wooden fence was replaced with an expanded metal frame with an expected date of completion on 3/5/2024. -On 2/27/2024, the IDT identified 18 residents to be at risk for elopement and determined to cohort all at risk for elopement residents to Rooms 1, 2, 10, and 11 to enhance their monitoring and supervision by designated staff. One of the 18 residents who were at risk for elopement was Resident 4. -On 2/27/2024, the IDT conducted a review and revised the care plans of 18 at risk for elopement residents. -On 2/27/2024 at 1:30 PM and 3:30 PM, 2/28/2024 at 4 PM, and 2/29/2024 at 7 AM, the Infection Control and Prevention Nurse Consultant (IPNC) conducted an in-service education on At Risk for Elopement/Wandering Residents, P&P on Wandering and Elopements, and plan for a designated staff to monitor residents at risk for elopements for a total of 48 of the 75 clinical and non-clinical staff. The completion date was 3/4/2024. -On 2/27/2024, the facility created an At Risk for Elopement Log to be used as a tool for staff to identify which residents were at risk for elopement. Any findings will be reported to the Quality Assurance (QA - measures compliance against certain necessary standards focusing on individuals) Committee x3 months and reviewed on their next QA Committee meeting on 3/14/2024. The task was under the supervision of Medical Records Director (MRD). -On 2/27/2024, the facility created a Change of Condition Elopement Tracker to facilitate monitor compliance of facility process when a resident elopes This will be reviewed by the IDT. Any findings will be reported to the QA Committee x3 months and reviewed on their next QA Committee meeting on 3/14/2024. The task was under the supervision of DON. -On 2/27/2024, six of the 18 residents at risk for elopement room changes were implemented under the supervision of ADM and DON. -On 2/28/2024, six of the 18 at risk for elopement residents' room changes were implemented under the supervision of ADM and DON. -On 2/28/2024, five of the 18 at risk for elopement residents stayed in the same room. -On 2/28/2024, the facility created a Supervision Elopement Binder to ensure facility was following their plan of action. IDT reviews the binder daily for compliance. Any findings will be reported to the QA Committee x3 months and reviewed on their next QA Committee meeting on 3/14/2024. The task was under the supervision of ADM. -On 2/28/2024, a designated staff was responsible for providing every 15-minute monitoring/supervision of all at risk for elopement residents every shift. -On 2/28/2024, Social Services Designee (SSD) along with Licensed Vocational Nurse (LVN) 3 contacted family members/resident representatives of 18 at risk for elopement residents regarding residents' room change. Resident 3 was notified by LVN 3 and agreed with the room change. -On 2/29/2024, the Accounts Payable and Payroll clerk (APP) was assigned to send text notification to the remaining staff who were required to complete in-service education. A YouTube video (https://youtu.be/r3hzjFBMUz0?si=X8XrCz0PkdhdaCxa) was made available to staff to view followed by a post test. Results of the posttest was sent to APP. -On 2/29/2024, the Maintenance Supervisor (MS) installed a wooden board covering the broken wooden fence for safety purposes. Findings: a.A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including fracture of medial malleolus (bone on the inside of the left ankle), schizophrenia and psychosis. A review of Resident 4's Resident Transfer Record from Skilled Nursing Facility 2, dated 2/9/2024, indicated the was transferred to SNF 1 because Resident 4 required a locked facility. SNF 1 indicated it was a partially locked facility. Resident 1 eloped from SNF 2 twice during her 24-hour stay. A review of Resident 4's Elopement Risk assessment dated [DATE], indicated the resident had a history of elopement / wandering / and getting lost. Resident 4's risk determination was considered at risk for elopement. A review of Resident 4's Wandering Risk assessment dated [DATE] and 2/22/2024, indicated the resident's behavior / mood was combative / severely agitated and experiencing feelings of anger and fear of abandonment. The assessment indicated Resident 4 was taking antipsychotic medications (medications work by altering brain chemistry to help reduce psychotic symptoms such as hallucinations, delusions and disordered thinking [disturbance in how thoughts are organized and expressed]) and a history of wandering (occurs when a person with loss of memory, thinking, or reasoning roams around and becomes lost or confused about their location). A review of Resident 4's history and physical (H&P), dated 2/10/2024, indicated, Resident 4 was not competent to understand her medical condition. A review of Resident 4's Interdisciplinary Team (IDT, a team of facility administrative personnel which include the facility's medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents) meeting notes dated 2/12/2024 at 10:04 AM, indicated Resident 4's two recent elopements from another facility were not addressed by the facility's IDT team during the meeting on 2/12/2024. The IDT meeting notes indicated a call was made to 911 (designated as a universal emergency number) on 2/11/2024 when Resident 4 became very violent hitting the front glass door forcefully with her body weight and hands while attempting to elope. The IDT meeting notes did not indicate any recommendations, needed updates to plans of care, or physician's orders were made to address the elopement attempt on 2/11/2024. A review of Resident 4's Documentation Survey Report v2, a documentation of visual checks performed every two hours by CNAs, indicated Resident 1 was visually checked from 2/12/2024 until 2/23/2024. Most visual checks were not documented every two hours. Resident 1 eloped on 2/22/2024 between 6:30 PM and 7 PM. According to a review of Resident 4's Social Service Assessment, dated 2/14/2024 at 5:22 pm, indicated the resident had a psychosocial adjustment problem and was still adjusting to the facility. The assessment did not indicate an assessment was completed by the social worker regarding the resident's elopement history or reasons why Resident 4 would want to elope from the facility. A review of Resident 4's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/15/2024, indicated the resident had intact cognition (mental ability to make decisions of daily living), had hallucinations but no delusions, and had wandering behavior occurred one to three days. The MDS indicated Resident 4 did not have a significant risk of getting to a potentially dangerous place such as outside of the facility. A review of Resident 4's Weekly Nursing Progress Notes dated 2/21/2024, indicated the resident had no change in condition, was compliant with medication and care, and was adjusting well to the facility. A review of Resident 4's undated care plan had a focus on Alteration in Psychosocial Well-Being related to aggressive behavior. The care plan this was manifested by Resident 4 hitting the door and trying to get out. The goal indicated gradual positive progress towards interacting with others at least once a week for three months, but the care plan did not have any timeframes. A review of Resident 4's undated care plan with a focus At risk for Wandering/Elopement from facility related to schizophrenia, psychosis, schizoaffective disorder (a long term mental health condition showing symptoms of mental illness such as hallucinations or delusions [false beliefs]), and mood disorder (inconsistent general emotional state), indicated a goal of resident will be accommodated in a hazard free environment and not wander out of facility daily for three months. The care plan indicated interventions needed to prevent elopement included monitor resident's location through visual checks and redirect as needed, speak with family or friends who are familiar with resident to determine any history of wandering out & areas where resident might attempt to go & record all information, and speak with resident to determine possible location of old address where resident might potentially end up going. The care plan did not indicate who was responsible for carrying out the interventions, where the information was to be documented, nor in what time frame the interventions needed to be carried out. During an interview on 2/24/2024 at 1:07 PM, CNA 2 was asked if her supervisor told her that Resident 4 was at risk for elopement. CNA 2 stated LVN 3 told her, We have to be sure with [Resident 4] because she is always close to the door. During an interview on 2/24/2024 at 1:39 PM, CNA 3 stated, I don't know if she (Resident 4) is looking for anything in particular, she (Resident 4) walks around near the exit doors. I think she's (Resident 4) checking out the door to see if it will be left open. According to a review of Resident 10's Admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and major depressive disorder (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 10's H&P dated 11/2/2023, indicated, Resident 10 did not have the capacity to understand and make decisions. A review of Resident 10's Wandering Risk assessment dated [DATE], did not indicate Resident 10's behavior/mood. The assessment indicated Resident 10 had diagnoses of early dementia and Alzheimer's disease (a common type of dementia that affects memory, thinking and behavior). A review of Resident 10's At Risk for Wandering/Elopement care plan initiated on 11/21/2023, indicated the resident had a history of trying to open the door related to dementia. The care plan's goal indicated Resident 10 would not wander out of facility daily x3 months with a revision date of 12/4/2023 and a target date of 5/7/2024. A review of Resident 10's Elopement Risk assessment dated [DATE], indicated the resident had a history of elopement / wandering / getting lost. Resident 10's risk determination was considered at risk for elopement. According to a review of Resident 10's MDS dated [DATE], indicated the resident had a severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). A review of Resident 10's Documentation Survey Report v2, a documentation of visual checks performed every two hours by CNAs, indicated the resident was visually checked from 2/12/2024 until 2/27/2024. Most visual checks were not documented every two hours. A review of Resident 18's Admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, dementia, mood disorder, and anxiety disorder. A review of Resident 18's Elopement Risk assessment dated [DATE], indicated the resident had a history of elopement / wandering /getting lost. Resident 18's risk determination was considered at risk for elopement. A review of Resident 18's Wandering Risk assessment dated [DATE], indicated the resident's behavior / mood exhibited was expressed fear and / or anxiety. The assessment indicated Resident 18 was taking antipsychotic medications and did the assessment did not indicate Resident 18 to have a history of wandering. A review of Resident 18's H&P dated 2/8/2024, indicated the resident was currently competent, but had a history of intermittent confusion which may impair understanding. A review of Resident 18's Documentation Survey Report v2, a documentation of visual checks performed every two hours by CNAs, indicated Resident 18 was visually checked from 2/12/2024 until 2/27/2024. Most visual checks were not documented every two hours. A review of Resident 18's MDS dated [DATE], indicated Resident 18 had severely impaired cognition. Facility video footage observation was obtained indicating staff not providing the frequent visual checks. During an interview with Resident 19 on 2/24/2024 at 1:20 PM, Resident 19 was asked how she call for assistance from the staff. Resident 19 stated, Most of them [staff] are very busy. I can't find them a lot of times. During the day it's okay but in the evening and at night, they are not always around. During an interview with CNA 3 on 2/24/2024 at 1:39 PM, CNA 3 stated, We checked in on them every one hour sometimes more than that. During an interview with LVN 2 on 2/24/2024 at 1:54 PM, LVN 2 was asked what interventions were in place to ensure residents' safety. LVN 2 stated they monitor residents every 2 hours, everybody in the facility. Anybody can monitor a resident. We make sure we monitor the doorways. We can hear the alarm if the door is attempted to be open, we redirect the resident to go away from the door. LVN 2 was asked if their interventions were enough to prevent any resident from eloping. LVN 2 stated, If a resident wants to leave they will leave anyhow, they find a way out. During an interview with LVN 3 on 2/24/2024 at 2:29 PM, LVN 3 stated, I know [Resident 1] eloped from one of our facilities in Pasadena [SNF 2]. She was transferred to us because we are a locked facility. That makes her an elopement risk. LVN 3 was asked how residents were monitored to ensure their safety. LVN 3 stated, We monitor our residents. We do visual checks every one hour, to make sure they are in their rooms or we have to know where they are so we can account for their whereabouts. LVN 3 was asked if the current interventions were enough to prevent a resident from eloping. LVN 3 stated, As you can see if a resident is really determined, they will try to find a way to get out of the facility. During an interview with the DON on 2/24/2024 at 3:04 PM, the DON was asked what interventions were in placed prior to Resident 1's elopement on 2/22/2024. The DON stated, Monitoring by everyone every one hour, not just the assigned nurse but everyone to redirect the resident. I don't think what else we could do besides that. We cannot do a 1:1 due to staff issue. The DON was asked how if she knew the interventions were working or not. The DON stated, I don't know how to answer that. They [staff] are here watching them [residents] 24 hours every two hours obviously it still happened. During an interview with the ADM on 2/26/2024 at 12:15 PM, the ADM stated they have a monitoring system where CNAs and licensed nurses monitor the whereabouts of each of our residents. Every one hour by CNAs on all three shifts. Every two hours by licensed nurses on all three shifts. They [staff] go from room to room, they do body count, visual count, they check resident's room, activity room, lobby, smoking patio. The ADM was asked what interventions were in place prior to Resident 1's elopement on 2/22/2024. The ADM stated, Door alarms, monitoring by CNAs and LVNs, engage residents in activities, smoke breaks, chairs in hallways and lobby where residents sit down and talk with one another. The ADM was asked if she knew Resident 1's history of elopement including eloping twice from SNF 2. The ADM stated, Yes, I am aware of [Resident 1's] history of elopement, but I did not know about eloping twice while in SNF 2. A review of Resident 18's care plan with an initiation date of 02/27/2024, indicated a focus on, at risk for wandering/elopement from facility related to dementia .with other behavioral disturbance, schizoaffective disorder. The care plan's goal indicated resident will .not wander out of facility daily x3 months with a revision date of 02/28/2024 and a target date of 05/26/2024. A review of the facility's policy and procedure (P&P) titled, Routine Resident Checks, revised 7/2013, indicated, staff shall make routine resident checks to help maintain resident safety and well-being. A review of the facility's P&P titled, Safety and Supervision of Residents, revised in 7/2017, indicated residents' safety risks are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. The P&P indicated the facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The P&P indicated resident supervision may need to be increased when there was a change in the resident's condition. A review of the facility's P&P titled, Wandering and Elopements, revised 3/2019, indicated, when a resident was identified as at risk for wandering [and] elopement, he resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's P&P titled, Behavioral Assessment, Intervention and Monitoring, revised 3/2019, indicated the IDT will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a care plan accordingly. The P&P indicated the director of nursing, or designee, will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care. Additional staff and/or training will be provided if it determined that the needs of the residents cannot be met with the current level of staff or staff training. 41852 b. Based on interviews and record reviews, the facility failed to provide adequate supervision and implement care plan interventions for two of three sampled residents (Resident 1 and 27), who had diagnosis of schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood) and prior resident to resident altercations in order to prevent resident harm. The facility failed to: - Implement and revise a comprehensive person-centered care plan to include individualized, resident centered supervision of Resident 1 and Resident 27 to prevent harm. As a result, on 1/31/2024 at 4:50 AM, Resident 1 was pushed to the ground by Resident 27, causing Resident 1 to feel upset and fearful. Resident 1 was transferred to the General Acute Care Hospital (GACH) Emergency Department (ED) where Resident 1 was unable to stand or ambulate (walk) due to pain. Findings: a.A review of Resident 1's admission record indicated the facility admitted the resident on 10/27/2023 with unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), and anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension). A review of the Schizophrenia / Bipolar Disorder care plan dated 10/27/2023 indicated the goal included Resident 1 would have no injuries to self or other during outburst and no side effects to medication daily for three months. The intervention included to monitor for signs of impending violence and keep resident away from proximity of others if symptoms are exhibited. The care plan did not specify the frequency of the monitoring for signs of impending violence. A review of the Physician's History and Physical (H&P) dated 10/28/2023, indicated Resident 1 did not have 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 11/2/2023, indicated the resident was cognitively moderately impaired (decisions poor; cues/supervision required), had verbal behavioral symptoms (threatening others, screaming at others, cursing at others) directed towards others occurred one to three days. The MDS further indicated resident required partial/moderate assistance for toileting hygiene and personal hygiene. According to a review of Resident 1's Change of Condition (COC - technique provides a framework for communication between members of the health care team and used as a tool to foster patient safety) form, dated 1/28/2024 at 5:49 PM, Resident 1 was hit in the face by Resident 2 with an open hand. A review of the Patient-to-Patient Altercations care plan, initiated on 1/28/2024 manifested by increased agitation towards others, indicated Resident 1 would not engage in any altercations for three weeks. The care plan intervention indicated the resident would be attended to promptly in order to avoid incidents. A review of Resident 1's COC, dated 1/31/2024 (three days later), indicated at 4:50 AM, resident was involved in another resident-to-resident altercation, as Resident 1 was pushed to the ground by Resident 27. A review of Resident 1's General Acute Care Hospital (GACH) emergency department record, dated 1/31/2024, indicated there was no obvious deformity or skin discoloration, but Resident 1 was unable to stand or ambulate (walk) due to pain. According to a review of Resident 1's Patient-to-Patient Altercations care plan and the Schizophrenia / Bipolar Disorder care plan, neither care plan was revised or updated after Resident 1 was pushed to the ground by Resident 27 and transferred to the GACH on 1/31/2024. During an interview on 2/13/2024 at 10:50 AM, Resident 1 stated she was pushed to the floor, but did not remember how and when Resident 27 pushed her. Resident 1 stated she did not like to be hit or pushed and was mad and afraid. During a concurrent interview and record review on 2/14/2024 at 6:40 AM, with Licensed Vocational Nurse 1 (LVN 1), Resident 1's care plans, Schizophrenia / Bipolar Disorder and Patient to Patient Altercation care plan was reviewed. LVN 1 stated the care plans did not indicate how often to monitor for signs of impending violence. LVN 1 also stated the care plans were not revised after Resident 1 had an altercation on 1/31/2024. LVN 1 stated the care plans for Resident 1 should be revised to include interventions to prevent additional altercations after the incident on 1/31/2024. She stated the facility staff already conducts visual checks every two hours for all the residents as part of facility protocol but maybe more frequent supervision might be possible for resident safety for Resident 1. During an interview on 2/14/2024 at 10:28 AM, the Director of Nursing (DON) stated Resident 1 had a prior incident on 1/28/2024 when Resident 2 slapped her on the face. The DON stated Resident 1 could have benefited from either more frequent visual checks like every 30 minutes or even a one-to-one sitter for resident safety. The DON stated the more frequent visual check should have been incorporated into Resident 1's diagnosis of schizophrenia / bipolar disorder with episodes of aggression-risk for side effects care plan. She stated the facility did not provide a one-to-one sitter or more frequent visual check every 30 minutes for Resident 1. b.A review of Resident 27's admission record indicated the facility admitted the resident on 10/27/2023 with diagnoses including paranoid schizophrenia (a severe mental disorder that can result in hallucinations, delusions, and extremely disordered thinking and behavior), anxiety disorder, and hypertension (HTN - elevated blood pressure). A review of Resident 27's MDS dated [DATE], indicated the resident was cognitively moderately impaired (decisions poor; cues/supervision required), had verbal behavioral symptoms (threatening others, screaming at others, cursing at others) directed toward others and other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, screaming) which occurred one to three days. The MDS further indicated resident required supervision or touching assistance for transfer and walking. According to a review of Resident 27's COC, dated 11/25/2023 at 7:45 AM, Resident 27 physically assaulted Resident 5. A review of Resident 27's Alteration in Psychosocial well-being care plan dated 11/25/2023 indicated the resident was involved in an altercation with another resident. The care plan intervention indicated to identify issues causing stress to Resident 27 and address the issues of concern. A review of the Paranoid Schizophrenia care plan dated 11/25/2023 indicated Resident 27 was at risk of Zyprexa (antipsychotic medication treats mental disorders) side effects. The care plan intervention indicated to monitor for signs of impending violence and to keep Resident 27 away from proximity of others if symptoms observed. The care plan did not specify the frequency of the monitoring for signs of impending violence. A review of Resident 27's COC, dated 1/31/2024, indicated at 4:50 AM, Resident 27 was the aggressor in a resident-to-resident altercation and pushed Resident 1 to the ground. During an interview on 2/14/2024 at 10:29 AM, the Director of Nursing (DON), stated the visual check log for 1/2024 indicated staff conducted two-hour visual checks for Resident 1 and Resident 27 on 1/31/2024, and that it was not part of Resident 1 or Resident 27 care plans. The DON stated the care plans should include new or revised interventions to try to prevent another altercation. A review of the facility's policy and procedure titled, Safety and Supervision of Residents, reviewed 7/2017, indicated our 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 devices. A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, revised 4/2009, indicated when goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, reviewed 12/2016, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary team must review and update the care plan when there has been significant change in the resident's condition, and when the desired outcome is not met.

Based on interview and record review, the facility failed to protect the resident's right and ensure residents were free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 1/28/2024, Resident 2 hit Resident 1's face with an open hand. Resident 2, who was known to be aggressive, combative, would refuse her medications, with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning) and refused her medications, did not receive monitoring, per the resident care plan. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 on 1/28/2024 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1's moderately impaired cognition (ability of think and make decisions), an individual subjected to physical abuse can have lifetime physical pain and or psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: a.A review of Resident 2's Admission Record indicated the facility admitted the resident on 1/23/2024, with diagnoses including schizophrenia, major depressive disorder (a mood disorder with feelings of sadness, loss, anger, or frustration), and anxiety disorder. A review of the Physician's History and Physical (H&P) dated 1/24/2024, indicated Resident 2 was not competent (having capacity) to understand her medical condition. A review of the Physician's Orders dated 1/24/2024, indicated Resident 2 was to receive Quetiapine Fumarate (medication that treats several kinds of mental health conditions including schizophrenia) 100 milligrams (mg) two times a day for schizophrenia, Lorazepam 1 mg two times a day for anxiety and Clozapine (medication used to treat schizophrenia) 100 mg two tablets at bedtime. A review of Resident 2's Care Plan for schizophrenia initiated on 1/25/2024, indicated the goal was for the resident to not have injuries to self or others during outbursts. The care plan interventions indicated to monitor the resident for signs of impeding (about to happen) violence such as increasing activities, clenching fists (to press fingers tightly against the inside part of the hand, when angry), teeth and to keep the resident away from the proximity (closeness) of others if above symptoms were exhibited. A review of Resident 2's Medication Administration Records (MAR) indicated Resident 2 refused to take Clozapine on 1/25, 1/28, and 1/29/2024 at 9 PM. The MAR indicated that Resident 2 refused to take Lorazepam on 1/25, 1/26, and 1/28/2024 at 9 AM. The MAR further indicated Resident 2 refused to take Quetiapine 100 mg on 1/25/2024 at 5 PM, and on 1/26/2024 at 9 AM. A review of Resident 2's Change of Condition (COC) - Situation-Background-Assessment and Recommendation form (SBAR - a written communication tool that helps provide important information) dated 1/28/2024 at 4:33 PM, (five days after admission) indicated Resident 2 had an altercation with Resident 1 and hit Resident 1 on the face with an open hand. The SBAR form indicated Resident 2 had behavioral issues and was not compliant with commands (orders) and her medications. A review of the Physician's Orders dated 1/30/2024 (after the altercation) indicated Resident 2 was to receive monitoring of the behaviors of schizophrenia manifested by aggressive behavior and anxiety. Further review of the Physician's Orders (after the altercation) indicated Resident 2 to receive monitoring of behaviors of schizophrenia manifested by outburst (sudden violent expression of strong feeling) towards others every shift. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 1/31/2024, indicated Resident 2 had severely impaired cognition and required supervision with eating, toileting, oral, and personal hygiene. b. A review of Resident 1's Admission Record indicated the facility admitted the resident on 10/27/2023, with diagnoses including dementia (loss of memory, thinking and reasoning), schizoaffective disorder (a mental health condition with symptoms of schizophrenia and mood disorder) and anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). A review of the Physician's History and Physical (H&P) dated 10/28/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's MDS dated [DATE], indicated Resident 1 had severely impaired cognition (never/rarely made decisions) and required moderate assistance with toileting, personal hygiene and upper and lower body dressing. A review of Resident 1's COC - SBAR dated 1/28/2024 at 5:49 PM, indicated Resident 1 was hit on her face by another resident (Resident 2) with an open hand. The SBAR indicated the only witness to this altercation was another resident (Resident 3). The SBAR further indicated, Resident 1 was assessed, no further changes noted other than minimal pain. During an interview on 2/9/2024 at 9:10 AM, with Resident 1 inside the activity room, Resident 1 stated she did not recall being slapped on her face outside in the patio. A review of Resident 1's Care Plans on 2/9/2024 at 12 PM, indicated no care plan was initiated after Resident 1 was hit by Resident 2 on her face. c. A review of Resident 3's Admission Record indicated the facility admitted the resident on 12/13/2023, with diagnoses including schizophrenia, major depressive disorder, and anxiety disorder. A review of the Physician's History and Physical (H&P) dated 12/14/2023, indicated Resident 3 was competent to understand her medical condition. A review of the MDS dated [DATE], indicated Resident 3 had intact cognition (decisions consistent/reasonable) and required supervision with upper and lower body dressing, and toileting, oral, and personal hygiene. During an interview on 2/9/2024 at 9:23 AM, with Resident 3 inside his room, Resident 3 stated he witnessed the physical altercation between Resident 1 and Resident 2. Resident 3 stated, On 1/28/2024, in the afternoon, I was outside in the patio. Resident 2 was laying on a bench covered with blankets. Resident 1 walked towards Resident 2 and tried to adjust her blankets. Out of nowhere, Resident 2 slapped Resident 1 on her face. Resident 1 did not fall or did not have any injuries. Resident 3 stated Resident 2 was transferred to hospital by the police because she had another incident with one of the staff in the facility. During an interview on 2/9/2024 at 10:02 AM, the Activity Assistant (AA) stated, On 1/28/2024, Sunday, I was working in the facility from 10 AM-6:30 PM. I was inside the activity room when Resident 3 came to me and stated, The lady got hit. I asked Resident 3 who hit who and stated, The black lady hit the older lady. The AA stated, Resident 1 came inside the activity room and told me that she offered to help Resident 2 to carry her blankets and Resident 2 slapped her on the face. The AA stated, I am not a nurse, but I checked Resident 1's face. There was no bleeding, redness, or injuries. The AA stated, I informed the Licensed Vocational Nurse (LVN 1) about the alleged abuse incident. During a telephone interview on 2/9/2024 at 10:11 AM, LVN 1 stated, Resident 2 was strange, she would put toothpaste all over her mouth. She would do some weird stuff; she would say non-logical stuff. She had psych issues. LVN 1 stated, The AA reported to me about the altercation between Resident 1 and Resident 2 and I went to the activity room and both residents were there. I made sure they were not together. Resident 1 and Resident 2 were not able to give me clear reports of what happened. Resident 3 told me that Resident 2 slapped Resident 1's face. LVN 1 stated, I assessed Resident 1's face, and there was no bruising, redness, or any injuries. LVN 1 stated, When I interviewed Resident 1, she did not say much about the incident, she was not able to tell me what had happened, she just mumbled. During an interview on 2/12/2024 at 11:40 AM, LVN 3 stated, Resident 2 was aggressive towards other residents; she was pushing other residents. Resident 2 was going inside other residents' room. LVN 3 stated there were two binders including monitoring logs for all residents for every two hours. One binder was for Certified Nursing Assistants (CNA) to document and the other one was for LVNs to complete. During a concurrent record review and interview with LVN 3, Active Residents Every Two-Hours Visual Check logs were reviewed. LVN 3 stated, This log has the residents' room numbers and not their names. We do not have time to complete this log every two hours for each resident. LVN 3 stated these binders were the only place staff documents residents` visual checks. LVN 3 stated the visual check log for 1/28/2024, for all residents was missing from the binder. LVN 3 stated the potential outcome of not monitoring the resident frequently was injuries or accidents. During a concurrent interview and record review, on 2/12/2024 at 12:10 PM, with the facility's Director of Nursing (DON), Resident 2's MAR for January, the care plans and the nursing progress notes were reviewed. The DON stated, Resident 2 was out of control, she was aggressive, combative, and would refuse her medications. The DON stated if a resident refused to take her medication on three different occasions, licensed staff were required to call the physicians and make them aware. The DON stated Resident 2 did refuse her medications, including her psychotropic medications on three different occasions. However, the required notification to the physician was not made. The DON stated the potential outcome of not taking psychotropic medication could be aggressive behavior and the potential outcome of not notifying the physician was the inability to take the appropriate steps as a result of the resident's refusal. The DON stated Resident 2's schizophrenia care plan was initiated on 1/25/2024 and was not revised after resident's physical altercation on 1/28/2024. The DON stated one of the interventions was to monitor for signs of impeding violence such as increasing activities, clenched fists, and teeth and to keep the resident away from others if symptoms were exhibited. The DON stated this intervention was not being implemented and documented anywhere in the resident`s medical record. The DON stated the only place that residents' visual monitoring was documented was the binder which included visual check logs. The DON confirmed the resident's visual check monitoring log was missing for 1/28/2024. The DON stated, This is not an effective way of monitoring residents. The DON stated the potential outcome of not monitoring residents with psychological problems was accidents, injuries, and harm to other residents. During a concurrent interview and record review on 2/12/2024 at 12:30 PM, with the DON, Resident 1's care plans were reviewed. The DON stated staff did not initiate a person-centered care plan for Resident 1 after Resident 2 hit her face with an open hand on 1/28/2024. The DON stated licensed staff were required to initiate a person-centered care plan for each resident after a change of condition. The DON stated the potential outcome was inability to establish interventions to monitor the resident and deliver appropriate care. A review of the facility's policy and procedure titled, Abuse Prevention Program, revised December 2016, indicated our residents have the right to be free from abuse, neglect and misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including but not necessarily limited to facility, staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, revised April 2017, indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives were defined as the desired outcome for a specific resident problem. When goals and objectives were not achieved, the resident's clinical record would be documented as to why the results were not achieved and what new goals and objectives have been established. Goals and objectives were reviewed and or revised where there has been a significant change in condition in the resident's condition.

Based on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1), who was identified as severe cognitively impaired (confusion or memory loss that is happening more often or is getting worse during the past 12 months), wanderer (a person who had a random or repetitive locomotion), and high risk for elopement (leaving the facility unsupervised and without staff knowledge) by failing to 1. Ensure to evaluate and analyze hazard(s) and risk(s) of elopement when Resident 1 was observed hanging around and sitting by the front door of the facility. 2. Ensure to monitoring for effectiveness and modifying interventions of the At Risk of Elopement plan of care. 3. Implement the Routine Resident Checks policy to keep documentation related to these routine checks, including the time, identify of the person making checks, and any outcomes of each check. These deficient practices resulted in Resident 1 eloped on 7/7/2023 and was found by the paramedics (an allied health professional whose primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system) on the ground, unconscious, in a pool of blood, and taken to the general acute hospital (GACH) on 7/12/2023. Resident 1 was admitted in the Intensive Care Unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation). Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing convulsions), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 6/23/2023, indicated Resident 1's had severe cognitively impaired (confusion or memory loss that is happening more often or is getting worse during the past 12 months) and required supervision from staff for dressing, eating, toilet use and personal hygiene. During a review of Resident 1's Elopement Risk assessment dated [DATE], the Elopement Risk Assessment indicated Resident 1 was at risk for elopement. An updated Resident 1's Elopement Risk Assessment after 1/6/21 was requested to the facility but was not provided. During a review of Resident 1's At Risk for Wandering/Elopement from the Facility Care Plan with a date initiated on 3/26/2021 and revision date on 10/8/2022 indicated Resident 1 was at risk for wandering/elopement from facility indicated intervention includes Orient resident to key areas in the facility such as dining room, bathroom, business office and kitchen and assist to key areas as needed. Monitor resident's location through visual checks and redirect as needed. During a review of Resident 1's Progress Notes dated 7/7/2023, the Progress Notes indicated Resident 1 was last seen around 7/7/2023 around 5:45 AM and was not in their bed around 6 AM during medication pass. Staff stated that he (Resident 1) visits other residents' room. Progress Notes indicated staff had searched the facility and discovered Resident 1 was not inside the facility. Director of Nursing (DON), Administrator (FA) and police department was notified. During a review of Resident 1's Progress Notes dated 7/12/2023, the Progress Notes indicated Resident 1 was admitted in GACH on 7/12/2023. During an interview on 7/13/2023 at 9:37 AM with the Administrator (FA), FA stated, the last time staff saw Resident 1 was on 7/7/2023 was around 5:30 AM-5:45 AM. Around 6 AM, during medication pass, staff could not locate Resident 1. FA stated Resident 1 usually paces around the facility all day and night. FA stated the facility has a gate next to the outside patio where staff enters and leaves the facility. FA stated Resident 1 was assumed to be outside patio, near the gate and had waited for incoming morning shift staff to open the gate, to come in the facility. FA predicted Resident 1 could have exited the facility without staff knowing. FA stated the resident eloped the facility on 7/7/2023. FA stated the facility received a phone call from the hospital (GACH) that Resident 1 was admitted to the hospital on 7/12/2023 for an injury. FA stated the gate can be opened by a remote control which allowed staff to go in and out of the facility. FA stated the parking was also located at the outdoor patio for residents in the facility. During an interview on 7/13/2023 at 10:10 AM with Registered Nurse Supervisor (RNS), RNS stated Resident 1 was confused and walks around the facility. RNS stated Resident 1 was currently not in the facility because he had eloped and has not returned since. RNS stated Resident 1 was still in GACH. During a concurrent interview and record review on 7/13/2023 at 10:39 AM with Social Services Director (SSD), Resident 1's care plan dated 3/26/2021 and Quarterly Risk Data Collection Tool dated 1/16/2021 and 12/27/2020 were reviewed. SSD stated there were no changes in the interventions of Resident 1's At Risk for Wandering/Elopement from the Facility Care Plan since 3/21/2021. SSD stated Resident 1 was at risk for elopement because he always walks around the facility. SSD stated Resident 1's cognitive baseline was confused. SSD further stated Resident 1 had eloped the facility on 7/7/2023 in the morning. SSD stated on 7/7/2023, staff, including herself, had walked around the facility area and could not locate Resident 1. SSD stated she reported Resident 1 missing to the administrative team. SSD stated local enforcement was notified and visited the facility on 7/7/2023. SSD stated GACH had called the facility on 7/12/2023 stating Resident 1 was found and was in the hospital. During an interview on 7/13/2023 at 11:05 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 walks around the hallways and mostly hangs around with his walker by the front door of the facility. LVN 1 stated Resident 1 was always so close to the front door. During an interview on 7/13/2023 at 11:18 AM with LVN 2, LVN 2 stated Resident 1 sits by the front door of the facility all the time. LVN 2 stated Resident 1 was admitted to GACH on 7/12/2023 and had bruises to his face from either a fall or an altercation outside the facility. During an interview on 7/13/2023 at 1:27 PM with FA, FA stated Resident 1's care plan revised date on 10/8/2022, regarding elopement should have been reviewed at least quarterly and it was not a comprehensive person-centered care plan. FA stated the facility did not conduct an Interdisciplinary Team (IDT- a group of health care professionals from difference disciplines to help residents receive care needed) meeting regarding updating elopement risks and interventions for Resident 1. FA stated the facility did not document Resident 1's visual routine checks as indicated in the policy. During an interview on 7/13/2023 at 1:45 PM with Resident 1's Representative (RP 1), RP 1 stated on 7/7/2023 the facility notified her regarding Resident 1's elopement and was admitted to GACH. RP 1 stated that they had notified staff previously that Resident 1 needs to be in a locked facility to prevent Resident 1 from eloping. RP 1 stated he was absolutely an elopement risk and should not be around open doors. During an interview on 7/13/2023 at 2:42 PM with Intensive Care Unit Social Services Staff (ICUSS) from GACH, ICUSS stated Resident 1 was admitted to the hospital on 7/12/2023. ICUSS stated Resident 1 was brought in by ambulance to the Emergency Department because Resident 1 was found on the ground unconscious, in a pool of blood with injuries to the head. ICUSS stated Resident 1 was then placed in the ICU. During an interview on 7/13/2023 at 2:55 PM with Minimum Data Set Nurse (MDSN), MDSN stated Resident 1 paces back and forth in the facility. MDSN further stated Resident 1 will usually stay outside his room and hang out in the nursing station by the door. MDS stated Resident 1 was an elopement risk because of his disease processes (dementia and epilepsy) and forgetful. MDSN further stated elopement risk residents, including Resident 1, should be monitored every shift or hourly to monitor resident whereabouts. MDS stated they are a member of the IDT committee. MDS stated elopement risk factors are episodes of forgetfulness MDS stated Resident 1 skin was all intact and had no issues prior to his 7/7/2023 elopement. During an interview on 7/13/2023 at 3:09 PM with Resident 1's primary Medical Doctor (MD), MD stated Resident 1 had eloped the facility around 5 AM. MD stated Resident 1 needs to place in a locked facility, that's all that's needed. MD stated if residents are at risk of elopement, accidents, or at high-risk of harm, they go in a locked facility. MD stated he does not any more details about Resident'1 care, including the elopement. A review of the facility's policy and procedures (P & P) titled, Emergency Procedure- Missing Resident dated 8/2018, indicated Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. A review of the facility's P & P titled, Wandering and Elopements, dated 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's P & P titled, Safety and Supervision of Residents, dated 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. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident accident data; and a facility-wide commitment to safety at all levels of the organization. When accident hazards are identified, the QAPI/ safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. The interdisciplinary care team shall analyze information obtain from assessments and observations to identify any specific accident hazards or risks for individual residents. A review of the facility's P & P titled, Routine Resident Checks dated 7/2013, indicated to ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8 (eight) hour shift. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met. The nursing supervisor/charge nurse shall keep documentation related to these routine checks, including the time, identify of the person making checks, and any outcomes of each check.

Based on interview, and record review, the facility failed to ensure one sampled resident (Resident 1), who was at risk of elopement (leaving the facility unsupervised, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decisions) and diagnosed with [CONDITION(S)] (a condition that affects the way the brain processes information, and causes one to lose touch with reality) was provided a safe environment with supervision as indicated in the resident's care plans and the facility's policy on Wandering (someone leaves a safe area or a responsible caregiver) and Elopement. As a result, on 3/10/2022, Resident 1 eloped from the facility, suffered a fall and was transferred to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with a right femoral neck fracture (broken hip) and a finger abrasion (a superficial rub or wearing off of the skin). Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 8/13/2018 with diagnoses including [CONDITION(S)] disorder (a combination of symptoms of [CONDITION(S)] [a serious mental disorder in which people interpret reality abnormally] and mood disorder, such as depression [mental health problem that involves a low mood and a loss of interest in activities] or [CONDITION(S)] disorder [a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks]), [CONDITION(S)] (a condition that affects the way the brain processes information, and causes one to lose touch with reality), [CONDITION(S)] (A condition in which bones become weak and brittle), and unsteadiness on feet (unable to stand or walk easily). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 3/5/2022, indicated the resident had severely impaired cognition (never/rarely made decisions), was experiencing delusions (false belief or opinion, especially one held in resistance to strong evidence against it), and required supervision and set-up help for walking, transferring, and toilet use. A review of Resident 1's Elopement Risk assessment dated [DATE], indicated the resident was at risk for elopement. A review of Resident 1's Fall Risk assessment dated [DATE], indicated due to the medical history of hypertension (a condition in which the force of the blood against the artery walls is too high), [CONDITION(S)], occasional incontinence of both bladder and bowel (unintentional leakage and the inability to control urine or stool), and the inability to always recall that she was in the nursing home, or her room location, Resident 1 was a risk for falls. A review of Resident 1's Elopement Risk Care Plan, dated 3/5/2022, indicated a goal for the resident to not wander out of the facility. The interventions included monitoring the resident's location through visual checks and redirecting as needed. A review of Resident 1's Risk for Falls Care Plan, dated 3/5/2022, indicated a goal to minimize the resident's falls and injuries from falls. The interventions included monitoring the resident's location through visual checks. A review of the Physician's Orders for Resident 1, dated 3/10/2022, indicated to monitor the resident's whereabouts every two hours for elopement. A review of Resident 1's Medication Administration Record (MAR) for the month of 3/2022, indicated the resident's location and whereabouts were monitored starting on 3/10/2022. The MAR did not include documentation the resident's location and whereabouts were monitored prior to 3/10/2022. A review of Resident 1's Social Service Note, dated 3/10/2022 and timed at 8:02 a.m., indicated staff could not locate Resident 1 in the facility. Resident 1 was last seen around 6 a.m. The Social Service note indicated the Social Services Director (SSD) took Resident 1's picture and drove around outside the facility asking vendors and people around the area if they recognized the resident. The note further indicated a vendor recognized Resident 1, stated the resident was wearing black clothes, and was picked up by an ambulance. SSD received a text from the Admission Coordinator the Resident 1 was safe and was at GACH 1. A review of Resident 1's SBAR (Situation-Background-Assessment-Recommendation, - technique provides a framework for communication between members of the health care team about a patient's condition) Communication form dated 3/10/2022, indicated Resident 1 was wandering in and out of her room while Licensed Vocational Nurse 1 (LVN 1) was passing medications. LVN 1 heard the exit alarm, went to the front of the facility, and no one was around. LVN 1 looked for Resident 1 from room to room, and informed the resident's responsible party of the resident's elopement on 3/10/2022 at 8:45 a.m. Resident 1's physician was notified on 3/10/2022 at 9 a.m. A review of GACH 1 Emergency Department (ED) Documentation, dated 3/10/2022 and timed at 6:40 a.m., indicated Resident 1 came to the ED complaining of left middle finger pain after a trip and fall that occurred that day. Resident 1 had a small abrasion to the left middle finger with no active bleeding and dried blood. A review of GACH 1 Social Services form, dated 3/10/2022 and timed at 1:47 p.m., indicated Resident 1 eloped from the facility prior to the ED visit. A review of GACH 1 Discharge Summary dated 3/10/2022 and timed at 9:22 p.m., indicated Resident 1 presented to the hospital after a fall and finger laceration. Resident 1 reported she fell with an associated episode of dizziness. Resident 1 reported falling on the street. Resident 1's finger abrasion was irrigated (applying a continuous flow of water to a wound to cleanse it), and derma bonded (a medical skin adhesive used to glue the sides of a wound closed). A review of Resident 1's Health Status Note dated 3/10/2022 at 10:05 p.m., indicated the resident returned to the facility at 9:40 p.m., via gurney from GACH 1. A review of Resident 1's SBAR Communication form dated 3/15/2022, indicated Resident 1 complained of pain at a level of 9 of 10 (9/10, pain rating scale from zero to 10, zero indicating no pain and 10 the most excruciating pain possible) to the right leg (hip and thigh), Tylenol (medication to relieve pain) was given but was ineffective. Resident 1's primary care physician was notified and recommended a STAT (immediately) x-rays of the right hip/pelvis and right femur (thighbone). A review of Resident 1's Radiology Results Report, dated 3/15/2022 and timed at 10:58 p.m., indicated the resident had a right femoral neck fracture (broken right hip). Resident 1 was transferred to GACH 2 for further evaluation. A review of GACH 2 Medical Record indicated Resident 1 was admitted to GACH 2 on 3/16/2022 for an intertrochanteric fracture of the right femur (a type of hip fracture). During an interview on 3/24/2022 at 6:36 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was very confused and frequently tried to escape. CNA 1 stated on the day of the resident's elopement (3/10/2022) Resident 1 left between 4:30 a.m. to 5:30 a.m. I heard the exit alarm going off but didn't know what it was. I screamed to the LVN, and he said alright. CNA 1 stated he was informed Resident 1 had gone outside. CNA 1 stated at the time, maintenance workers were coming into the facility and probably did not pull the front door closed all the way. During an interview on 3/24/2022 at 7:36 a.m., LVN 1 stated Resident 1 walked up and down the facility asking if she could leave because she wanted to see her family. LVN 1 stated he was attending to another resident when he heard the exit alarm going off and Resident 1 eloped. LVN 1 stated he was the only LVN working that shift, and he could not attend to the exit alarm quick enough. LVN 1 stated when he discovered Resident 1 was missing, he drove his car around the streets surrounding the facility, called hospitals, notified the resident's physician, family, and the police. On 3/24/2022 at 9:15 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 was a wanderer and during the time of the elopement on 3/10/2022, employees were coming in and out of the facility and staff were working with other residents. The DON stated staff did not respond to the alarm in a timely manner and assumed staff triggered the alarm. The DON stated on 3/15/2022 on the 3 p.m. to 11p.m. shift Resident 1 started complaining of pain in her right hip and thigh and was currently at GACH 2 for a broken right hip. The DON stated there was no indication Resident 1 had fallen or had any altercation with other residents or staff upon her return to the facility after the elopement. A review of GACH 2 Physician Discharge Summary Noted dated 3/26/2022 indicated Resident 1 underwent an ORIF (open reduction and internal fixation surgery to stabilize and heal a broken bone) of the intertrochanteric fracture of the right hip. Resident 1 was discharged back to the facility on [DATE]. A review of the facility's policy and procedure 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. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training as necessary; ensuring that the interventions are implemented; and documenting interventions. A review of the facility's policy and procedure titled, Wandering and Elopements, revised 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. When the resident returns to the facility, the director of nursing services or charge nurse shall examine the resident for injuries.

Based on observations, interviews, and record reviews, the facility failed to ensure one of two sampled residents (Resident 53) maintained parameters of acceptable nutrition and hydration and had adequate food and fluid intake. The facility failed to: -Assist Resident 53 with set up of meal trays, opening carton/containers, season food, and cut up food as indicated in Resident 53's plan of care. -Encourage Resident 53 to consume all food/fluids served and offer substitute food when the resident refused food or consumes less than 75 percent (%) of his meal as indicated in Resident 53's plan of care. -Notify the physician that Resident 53 was refusing food and consumed less than 75 % of meals. -Implement facility's policies and procedures to prevent significant weight loss for Resident 53. These deficient practices resulted in Resident 53 significant weight loss of (7.6 %) in three months. Findings: A review of Resident 53's Admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] `s real and what`s not real), [CONDITION(S)] (a condition in which the [CONDITION(S)] does not produce enough [CONDITION(S)] hormone) and hypertension (high blood pressure). A review of the Care Plan, dated 8/6/2014, indicated Resident 53 had occasional hand tremors with involuntary movements of mouth, tongue, and lips. The interventions indicated staff should set up meal trays by opening cartons/containers, season food as needed, cut up foods and butter bread as needed, assess any problem related to inability to feed self-related to hand tremors and to provide reassurance as needed to Resident 53. Was this care plan updated? Revised? A review of Resident 53's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 53's Care Plan, dated 8/6/2021, indicated resident had unplanned/unexpected weight loss related to poor appetite and alert dietitian if not consuming on a routine basis. The care plan indicated if weight decline persists, contact physician and dietitian immediately. According to a review of the Dietary Consultant notes dated from 8/6/2021 to 8/27/2021, Resident 53 had the following weight measures: -On 8/6/2021, 143 pounds (lbs.) with a Body Mass Index (BMI) of 22.4. -On 8/13/2021, 142 lbs. with a BMI of 22.2 -On 8/20/2021, 141 lbs. with a BMI of 22.1 -On 8/27/2021, 139 lbs. with a BMI of 21.8 A review of Resident 53's Food Intake Records, dated 8/7, 8/12, 8/18, 8/20, 8/24, 8/25, 8/27 and 8/30/2021 indicated the resident consumed 0 -25 % of his meals. A review of Resident 53's Speech Therapy Discharge Summary dated 9/11/2021, indicated Resident 53 required supervision for oral intake as a part of precautions to ensure Resident 53 did not choke on his food or fluids. A review of Resident 53's Dietary Consultant notes dated 9/6/2021 to 9/24/2021, indicated the following weight measures: -On 9/6/2021, 138 lbs. with a BMI of 21.5 -On 9/17/2021, 136 lbs. with a BMI of 21.3 -On 9/24/2021, 134 lbs. with a BMI of 21.0 A review of 53's Food Intake Records dated 9/1, 9/2, 9/4 -9/7, 9/15, 9/19, 9/22 - 9/24 and 9/27/2021, indicated the resident consumed less than 25 % to 50 % of his meals. According to a review of the Dietary Consultant notes dated 10/4 to 10/29/2021, Resident 53 had the following weight measures: -On 10/4/2021, 133 lbs. with a BMI of 20.8 -On 10/8/2021, 133 lbs. with a BMI of 20.8 -On 10/15/2021, 130 lbs. with a BMI of 20.4 -On 10/22/2021, 131 lbs. with a BMI of 20.5 -On 10/29/2021, 132 lbs. with a BMI of 20.7 A review of the Intake Records dated 10/4, 10/5, 10/11, 10/13, 10/19, 10/22, 10/24, 10/25, 10/30 and 10/31/2021, indicated Resident 53 consumed zero (0) to 25 % of his meals. A review of the Care Plan, dated 10/8/2021, indicated Resident 53 needed a regular diet, regular textured, risk for weight fluctuations, dehydration, and to monitor tolerance of diet and alter texture as needed. The care plan nursing interventions indicated to encourage resident to consume all foods/fluids served and offer substitutes if the resident refused or consumed less than 75 % of his meals. A review of the Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/14/2021, indicated Resident 53 had severe cognitive impairment and required set up help with meals from staffs. A review of Resident 53's Telephone Order, given by Resident 53's Occupational Therapist (OT), dated 10/22/2021, indicated resident may utilize sippy cup and built-up utensils with all meals. During an observation on 11/2/2021 at 12:20 p.m., Resident 53 was sitting at the edge of his bed in an upright position with meal tray that had regular sized utensils with cups and ice cream, which was covered with plastic wrap. During the observation, there were no specialized utensils or cups on the tray. Resident 53's hands were observed shaking and was unable to hold the regular size utensils and was unable to slice the steak on his plate into eatable slices. During a concurrent interview, Resident 53 stated he was unable to hold the regular size utensils during meals due to the tremors on his hands and expressed his frustration. There was no staff member available to assist Resident 53 with cutting his steak or opening his food and drink containers. During an interview on 11/2/2021 around 12:23 p.m., Certified Nurse Assistant (CNA) 1 stated Resident 53 could not hold regular utensils and needed to be assisted in setting up his meal tray, cut up and open up his foods because of his inability to hold or grab utensil due to hand tremor. CNA 1 stated and confirmed Resident 54 received regular utensils and cups on his meal trays, and not the specialized utensils or cups. During a lunch observation on 11/3/2021, at 12:46 p. m., Resident 53 had a regular lunch tray served with regular utensil and cups. Resident 53's hands were observed and were not able to hold the regular eating utensils to cut the cheese enchilada on his plate and could not eat it. During a concurrent interview, Resident 53 stated he could not hold the regular eating utensils to cut up his cheese enchilada and stated he was frustrated. There were no staff in the room to assist the resident with the setup of his meals or assisted of slicing or cutting his cheese enchilada. During an interview on 11/3/2021 at 12:55 p.m., CNA 2 stated Resident 53's lunch tray did not have specialized eating utensils or a cups on it and that Resident 53's cheese enchilada was not cut up for him. On 11/3/2021 at 1:05 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated and verified Resident 53's cheese enchilada were not chopped for easy consumption. LVN 1 stated that not chopping his foods could result to further weight loss. According to LVN 1, Resident 53 had significant weight loss and stated the uncut food might be the reason Resident 53 was unable to eat his food and may be a contributing factor in Resident 53's weight loss. LVN 1 stated she would call the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 11/4/2021 at 10:20 a.m., the Registered Dietician (RD) stated, I was not aware of Resident 53's inability to cut the food and did not receive any phone calls from nursing staff regarding Resident 53's poor appetite or refusal to eat. The RD stated Resident 53 could benefit from having a chopped-food diet and would change his diet to chopped food as soon as possible. During an interview on 11/4/2021 at 12:20 p.m., the Director of Nursing (DON) stated he was not aware Resident 53 was not able to use regular utensils to cut his food or to open drink containers without assistance. The DON stated that uncut food might be the reason Resident 53 was unable to consume his food and may be a contributing factor to Resident 53's weight loss. The DON further stated the facility contacted Resident 53's physician on 11/3/2021 and received a new order for a chopped-food diet. During an interview on 11/9/2021 at 3 p.m., the DON verified Resident 53's order for utilizing sippy cup and built-up utensils with all meals, since 10/22/2021. The DON stated he could not find documentation of the facility providing a sippy cup and built-up utensils to Resident 53 but would ask for the Dietary Manager if she had that documentation. During a concurrent interview at 3:05 PM, the DON stated and acknowledged Resident 53's Food Intake Record for the months of August, September and October of 2021, indicated Resident 53 ate less than 25% of his meals or refused them all together, for a total of 64 meals, and ate between 25% and 50% of his meals, for a total of 38 times. On 11/9/2021 at 3:15 p.m., during an interview, the Administrator (ADM) agreed with the DON that for residents in the skilled nursing facilities, weight loss could be dangerous and led to serious illness, hospitalization , and death. The ADM stated the facility did not have a written protocol to identify residents who need assistance with opening drink and food contains, cutting their food, and feeding themselves, and did not have a protocol for what to do when a resident refused three or more meals in a row, or consumed less than 50% of their meals three or more meals in a row. The ADM stated the facility did not have a written protocol detailing how staff can document the specific assistances they provided to residents with meals. The ADM stated it was well known and an accepted standard of practice that the facility should and must follow the care plans they create for residents, and stated that not following the care plans can result in the residents not meeting their care plan goals, which can lead to their not obtaining their highest quality of life possible and serious illness, hospitalization , and death. During an interview on 11/9/2021 at 3:20 PM, the Dietary Manager (DM) stated she was not aware that Resident 53 required and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Lesson Plan for Monitoring, Assistance, Adaptive Equipment and Communication and Documentation, dated 11/10/2021, indicated the consequence of poor oral intake was decline in ADLs (activities of daily living), weight loss, dehydration, psychosocial effect such as activity participation, serious illness, hospitalization and death. According to a review of Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings, published by the Academy of Nutrition and Dietetics, dated 4/2018, indicated health care practitioners must assess risks vs benefits of therapeutic diets, especially for frail older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life. A review of facility's policy titled, Accommodation of Needs, dated 1/2020, indicated the facility's environment and staff behaviors were directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. A review of facility's policy titled, Therapeutic Diet, dated 10/2017, indicated therapeutic diets are prescribed by the attending physician to support the residents' treatment and plan of care and in accordance with his or her goals and preferences. The dietitian, nursing staff and attending physician will regularly review the need for and resident acceptance of, prescribed therapeutic diet. The dietitian and nursing staff will document significant information relating to the residents' response to his/her therapeutic diet in the resident`s medical record. A review of facility's policy and procedures titled, Weight Assessment and Intervention, revised September 2008, indicated interventions for undesirable weight loss shall be based on careful consideration of the following: resident choice and preferences, nutrition and hydration needs of the residents, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities and the need for diet modifications, medications that may interfere with appetite, chewing, swallowing or digestion, the use of supplementation and/or feeding tubes and end of life decisions and advanced directive. A review of facility's policy and procedures titled, Nutritional Assessment revised October 2017, indicated the dietitian in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by change of condition that places resident at risk for impaired nutrition. As a part of comprehensive assessment, the nutritional assessment with be a systemic multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3), who was at risk for skin breakdown, admitted with pain in unspecified knee, and a small wound on the left knee, received care and services in accordance with professional standards of practice and the comprehensive person centered care plan. Resident 1 did not receive wound treatment on the left knee for 10 days (from 4/28/2021 to 5/8/2021). This deficient practice resulted in Resident 3's required admission to General Acute Care Hospital 1 (GACH 1) on 5/9/2021 for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 3's admission record indicated an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Data tool dated 4/28/2021, indicated Resident 3 was admitted with bruises on lateral right thigh, interior left knee, second toe, left arm and a small scar on top of left foot. A review of Resident 3's Progress Note Admission Summary, dated late entry 4/28/2021 7:50 PM indicated skin assessment done. Resident 3's Progress Note Admission Summary indicated Resident 3 had a small wound on left knee. According to a review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/4/2021, Resident 3 had short-term and long-term memory problems, and was severely impaired for cognitive skills (main skills the brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS indicated under the section for skin condition, no open cuts or skin tears were indicated. A review of the Skin Care Plan, dated 5/6/2021 (eight days after admission), indicated Resident 3 was at risk for skin breakdown related to bedfast status (bedridden or unable to leave one's bed), bowel and bladder incontinence (lack of voluntary control over urination or defecation), and impaired bed mobility. The Skin Care Plan goal indicated Resident 3's skin would remain intact for three months and the interventions indicated to keep skin clean and dry, check skin daily during care and report any red, irritated or excoriated areas promptly. The care plan did not include a specific location of Resident 3's skin. A review of Resident 3's Progress Note Discharge Summary, dated 5/9/2021 indicated body check done. The Progress Note Discharge Summary indicated Resident 3's wound on the left knee measured 1 centimeter (cm) by 1 cm. A review of Resident 3's Progress Note Health Status Note, dated 5/9/2021 at 12:18 PM indicated Resident 3 was discharged home at 11:15 AM. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of the Emergency Department (ED) Admission Record, Resident 3 arrived to the GACH on 5/9/2021 at 3:30 PM (four hours and 15 minutes after discharge from the skilled facility) and was admitted , same day, for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The ED Admission Record indicated Resident 3's family member (FM) reported they were visiting Resident 3 at the skilled facility and noticed the wounds over bilateral knees and top of toes were becoming red and warm. The FM decided to bring Resident 3 to the GACH. The ED Admission Record indicated Resident 3 was noted with multiple abrasions throughout the extremities, with [CONDITION(S)] surrounding bilateral knee abrasions. The Admission Record indicated Resident 3 was administered [MEDICATION(S)] (antibiotic) for the infection during the three-day hospital stay. A review of the GACH wound assessment, dated 5/10/2021, indicated Resident 3 had right knee abrasion/trauma, measured 2 cm in length by 2 cm in width by 0.2 cm in depth. The left knee trauma measured 3 cm by 3 cm by 0.2 cm. During an interview on 6/23/2021 at 1:40 PM, Registered Nurse (RN) 1 stated she completed the skin assessment for Resident 3 on the day of discharge 5/9/2021. During an interview on 6/23/2021 at 2:42 PM, the DON stated and confirmed Resident 3 had a left knee wound, per review of Progress Note dated 4/28/2021. The DON stated and acknowledged there was no intervention initiated for Resident 3's wound on left knee and that intervention was needed to prevent infection and to promote healing. A review of facility's policy titled, Admission Assessment and Follow-Up: Role of the Nurse, revised 9/2012, indicated the purpose was to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. The policy indicated to conduct supplemental assessment including skin assessment and to contact the Admitting Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of facility's policy titled, Pressure Ulcers/ Skin Breakdown - Clinical Protocol, revised 4/2018, indicated under assessment and recognition the staff and practitioner will examine the skin with newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The policy indicated the physician will order pertinent wound treatments, including wound cleansing approaches, dressings, and application of topical agents (used locally, where the medicine is applied on the area being treated).

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), was free from abuse and prevent abuse (willful infliction of injury) by another resident (Resident 1). During a resident to resident altercation Resident 1, who had behavior with hallucinations, had physical, verbal and other behavioral symptoms directed towards others, walked into Resident 2's room and grabbed the finger of Resident 2 resulting in pain. As a result, Resident 2 was transferred to the General Acute Care Hospital (GACH) for surgery of a comminuted fracture (break of bone in more than two fragments) involving the midshaft of the proximal phalanx (baby finger) of the left hand. Resident 2 was afraid of Resident 1. Findings: A review of the Admission Record indicated Resident 1 (aggressor) was admitted to the facility on [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 9/9/2020, indicated Resident 1 as having unclear speech, rarely /never able to understand and rarely /never able to be understood. The MDS indicated Resident 1 had short- and long-term memory problems, requiring supervision with activities of daily living (ADL), transfers, eating and extensive assistance with toilet use and personal hygiene. The MDS further indicated Resident 1 had trouble concentrating and was short-tempered. The MDS indicated Resident 1 had behavior with hallucinations, had physical, verbal and other behavioral symptoms directed towards others and was a wanderer. A review of the care plan dated 10/8/2020, indicated Resident 1 had episodes of wandering in other resident's room. The care plan goal indicated resident to have minimal wandering behavior. The care plan interventions indicated to assess resident for presence of wandering behavior, noting time place and people whom she ambulates with. A review Resident 2's Admission Record indicated Resident 2 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of Resident 2's MDS dated [DATE], Resident 2 had clear speech, able to understand and able to be understood. The MDS indicated Resident 2 required supervision in activities of daily living (ADL), and extensive assistance with personal hygiene. A review of the Situation, Background, Assessment, Appearance and Review (SBAR) form, dated 1/13/2021 at 10:30 AM indicated Resident 2 verbalized Resident 1 wandered into her room and invaded her personal space. Resident 2 stated Resident 1 (aggressor) grabbed Resident 2's left hand and squeezed it really hard, resulting in pain. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Psychiatric Assessment and Behavior Team Conference note dated 1/14/2021, indicated Resident 1 (aggressor) was confused, wandered around, and went into another resident's room (Resident 2) and broke her finger. The Psychiatric Assessment note indicated Resident 1 had psychomotor agitation, lack of impulse control, was delusional and had impaired orientation, memory and judgement. The Psychiatric Assessment further indicated Resident 1's behavior toward another resident was due to baseline confusion and inability to rationally assess the consequences of her actions. According to a review of the Operative Report from the GACH dated 1/15/2021, Resident 2 had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Interdisciplinary Team (IDT) notes, dated 1/15/2021, indicated on 1/13/2021 at 7:30 a.m., Resident 1 went into Resident 2's room and pulled her left hand, caused pain, and fractured Resident 2's left fifth finger (pinky finger). The IDT note recommended monitoring Resident 1 for striking out, monitoring her whereabouts every 15 minutes and redirect as needed. The staff would be in serviced on how to approach the aggressive, wandering resident and how to redirect. A review of Resident 1's Monitoring Sheet, dated 1/20/2021 at 4:15 a.m., (five days later), indicated inconsistent monitoring. There was no documentation for the night shift on 1/21/2021, 1/23/2021, and 1/24/2021. There was no documentation for any shift on 1/16/2021 - 1/20/21, 1/22/2021, and 1/25/2021 - 1/27/2021. A review of the Progress Note dated 1/23/21 indicated Resident 2 returned to the facility from the GACH with fracture of 5th finger of left hand and status post [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with Resident 2, on 2/4/2021 at 11 AM, Resident 2 stated Resident 1 entered her room looking at her belongings and Resident 2 told her to stop and leave the room. Resident 2 stated she tapped Resident 1 on the arm and Resident 1 began screaming then grabbed Resident 2's left finger and bent it backwards causing it to brake. On 2/4/2021 at 12 PM, Resident 1 with a translator was uninterviewable, was observed smiling and laughing. On 2/4/2021 at 12:10 PM, Resident 2 was heard screaming loudly in the hallway, Get away from me! Get away from me! Get away from me! Resident 2 was observed walking past Resident 1 and two other residents as the nurse ran to get Resident 2. Resident 2 was observed frightened with a red face, hands shaking and stated, I just don't like her coming near me. During an interview with the director of Nurses (DON), on 2/16/2021 at 2:10 PM, when asked about the inconsistent documentation on Resident 1's Monitoring Sheet, the DON stated the staff was visually monitoring Resident 1. When the facility's policy for 72-hour observation was requested, the DON stated there was no policy and procedure for 72-hour observation. During an interview with the DON on 6/15/21 at 3:50 p.m., when asked why is it important to assess the behaviors of Resident (aggressor) and to implement the care plan, he stated, it was important to assess the behavior because the resident was a danger to self and others, to mitigate any risk of harm and to control the behavior through observations and medications. The DON stated it was important to implement the care plan interventions to safeguard and protect the residents and stop further incidences from occurring. The facility's Policy and Procedure titled, Abuse Prevention Program, dated December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The Administration will protect the residents from abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers, or any other individual.

Based on observation, interview, and record review, the facility failed to develop and implement resident-centered interventions and perform a physical therapy (PT) evaluation after Resident 1's fall incident, for one of two sampled residents. This deficient practice resulted in a subsequent fall with a [MEDICAL CONDITION] requiring surgery, pain, and a decline in functional status. Cross reference F656 and F676. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility, on 10/2/15, and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the minimum data set (MDS- an assessment and care planning tool, dated 10/1/17, indicated Resident 1 had a brief interview for mental status score of six, indicating severely impaired cognition. The MDS indicated Resident 1 required supervision when walking. A review of the resident fall risk evaluation, dated 10/1/17, indicated Resident 1 was at risk for falls. A review of the care plan titled, At Risk for Falls, related to Impaired Cognition, hypertension, high blood pressure, history of Muscle Weakness, Lack of Coordination, Difficulty Walking, dated 10/4/15, indicated a goal was to minimize falls/injuries daily for three months. Interventions? A review of the Progress Note, dated 11/13/17, indicated Resident 1 had an actual incident of unwitnessed fall. Resident 1 was found sitting on the floor after coming from the restroom. During an interview and record review, on 4/17/18, at 8:25 a.m., the Fall Risk care plan, initiated 10/4/15, and actual incident of fall care plan, dated 11/13/17, was reviewed with the director of nursing (DON). The DON stated the interventions implemented after the fall occurred on 11/13/17 were neurologic checks and the report of residual injuries. The DON admitted these interventions would not contribute to the reduction of falls. The DON stated it was the expectation of the facility to implement new interventions to prevent falls in coordination with the interdisciplinary team (IDT). The DON had no explanation for not developing interventions that would prevent falls. A review of the IDT Review note, dated 11/15/17, indicated Resident 1 had unsteady gait. A review of the Fall Risk Assessment, dated 2/8/18, indicated Resident 1 was at risk for falls. A review of the Change in Condition Evaluation, dated 3/31/18, indicated Resident 1 was found on the floor, unwitnessed, and was assessed. The change in condition evaluation indicated Resident 1 complained of pain to left and right hip when touched. Resident 1 was unable to walk back to his room. A review of the Health Status Note, dated 4/1/18, indicated Resident 1 was transferred out to the general acute care hospital (GACH) for evaluation of left hip secondary to fall. Site immobilized and treated with ice pack as tolerated. The Health Status Noted indicated as needed (PRN) pain medication was administered. A review of the Medication Administration Record, [REDACTED]. A review of the Radiology Results Report, dated 4/1/18, indicated Resident 1 had a fractured left femoral trochanter (an anatomical portion of the femur near its joint with the hip bone, the trochanters serve as important muscle attachment sites). A review of the GACH History and Physical, dated 4/1/18, indicated Resident 1 had a comminuted intratrochanteric (hip) fracture, Resident 1 would be admitted , and placed on as needed medications for pain control. The GACH History and Physical indicated Resident 1 would undergo surgical intervention the next day. A review of the GACH Operative/Procedure Reports, dated 4/2/18, indicated Resident 1 had a preoperative [DIAGNOSES REDACTED]. Resident 1's postoperative [DIAGNOSES REDACTED]. Surgery was indicated because of the injury of the left hip with significant pain, difficult to function. Surgical intervention, fracture reduction, and fixation were medically necessary. A review of the GACH Occupational Therapy Documentation, dated 4/3/18, indicated Resident 1 was seen for occupational therapy evaluation (OT), which was limited by severe pain by transitional movements. A review of the GACH Physical Therapy Documentation, dated 4/4/18, indicated Resident 1 was extremely guarded with all mobility throughout session. Resident 1 continued to require moderate/maximum assistance for bed mobility and sit to stand transfers with front wheel walker. Resident 1 required extra time to execute all mobility secondary to left lower extremity pain. On 4/17/18, at 7:50 a.m., Resident 1 was interviewed in his room. Resident 1 stated he could not recall the fall incident at which he fractured his hip. Resident 1 was observed to be in his bed. Resident 1 lifted the blanket up, pointed at his left hip, and stated he has left hip pain especially while turning. During a concurrent interview with a restorative nurse assistant (RNA 1), she stated prior to the fall, Resident 1 would ambulate independently. RNA 1 stated Resident 1 was mostly in bed after the fall. RNA 1 did not know if Resident 1 required supervision with walking prior to the fall on 3/31/18. On 4/17/18, at 8:30 a.m., the assistant director of rehabilitation (ADR) services was interviewed and stated Resident 1 did not have a physical therapy (PT) evaluation since 9/25/16. Resident 1 would likely have an organic decline in functional status. Residents begin to lose function because of their diagnoses, co-morbidities, and age. There was no set frequency for PT screenings, but it was the facility's practice to perform one after a fall and as needed. The ADR confirmed there was no PT screening after the first fall, which occurred on 11/13/17. The ADR stated the nurses would initiate a PT screening by making a referral, however, there was no evidence this occurred. The ADR could not verbalize the specific criteria, which would prompt a PT screening, other than as needed. The ADR confirmed there are no interventions in the fall risk or actual falls care plans which indicate to perform a PT screening after a fall. The IDT determines whether a PT screen is required during the care plan process. The ADR confirmed there is no documented evidence the IDT determined a PT screening was not relevant. The ADR acknowledged there was no assessment to determine whether Resident 1's functional status would have benefited from PT. On 4/17/18, at 9:01 a.m., the DON was interviewed. The DON stated the process for initiating a PT screening included: Performing a clinical review where PT can make recommendations to prevent a decline in function and falls. For Resident 1, PT should have updated an additional functional and fall assessment. The DON stated he was not the DON when Resident 1 had his initial PT evaluation (9/25/16). The DON stated an expectation would be to perform a PT evaluation after a fall. A review of the policy titled, Managing Falls and Falls Risk, dated (MONTH) 2007, indicated based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remains relevant. A review of the policy titled, Functional Impairment - Clinical Protocol, revised (MONTH) 2012, indicated upon admission to the facility, at any time a significant change of condition occurs, and periodically during a resident's stay, the physician and staff would assess the resident's physical condition and functional status. As appropriate, the physician and other staff would identify and evaluate the individual's co-morbidities, conditions causing functional decline, symptoms, risks, impairments, and disabilities, and investigate their cause, for example: recent fall and/or fracture. The physician and staff would evaluate the resident for complications secondary to functional decline and/or immobility, such as: falls.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent recurrent gastrostomy tube dislodgement (GT, a small stomach tube for medications, food, and fluids administration), and to prevent development of a pressure injury of the skin from the gastrostomy tube disc (a plastic device used to keep a GT in place) for one of 13 sampled residents (Resident 5) by failing to: 1. Promptly investigate circumstances surrounding Resident 5 ' s recurrent GT dislodgement and take corrective action. 2. Identify the cause of Resident 5's GT dislodgement and develop a care plan to prevent future gastrostomy tube dislodgement as indicated in the facility's policy for Accidents and Incidents. 3. Update Resident 5's care plan with interventions that were targeted and meaningful when the desired outcome related to GT dislodgement was not met. 4. Identify Resident 5's as a resident who was at-risk for a pressure injury due to the use of an abdominal binder, resulting in pressure of the GT disc against the resident's skin, and implement promptly interventions to prevent a pressure injury, as indicated in the facility's policy for Accidents and Incidents. These deficient practices resulted in Resident 5's transfer to the general acute care hospital (GACH) six times for GT replacement, and subsequently developing an open area at the GT insertion site (abdominal area) from the pressure of the GT disc against the resident's skin. Findings: 1.a A review of Resident 5's Admission Record (face sheet) indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. that causes long-[MEDICATION NAME] inflammation and ulcers (sores) in the digestive tract), and had a GT. A review of Resident 5's quarterly Minimum Data Set (MDS, a resident assessment and care screening tool), dated 6/24/16, indicated that the resident had short and long-term memory problem with cognition (ability to think and reason) that was severely impaired. The MDS indicated Resident 5 did not exhibit physical and verbal behavioral symptoms directed towards others such as grabbing, scratching, screaming at others, and rummaging. The MDS indicated Resident 5 did not exhibit behavior of rejecting care and wandering and required extensive assistance to totally dependent on the staff with all activities of daily living. a. A review of Resident 5's nurses Progress Notes on 1/17/16, at 8:20 a.m., a certified nurse assistant (CNA) reported that the resident's gastrostomy tube was dislodged. The note indicated the physician was made aware and the resident was transferred to GACH for gastrostomy tube replacement. On 1/17/16, at 2:27 p.m., Resident 5 was transferred to the GACH and was readmitted to the facility. The progress note indicated that the gastrostomy tube was patent (unobstructed) and intact and without leakage to the site. Resident 5's care plan, initiated on 1/18/16, indicated the resident attempted to pull out the gastrostomy tube related to [MEDICAL CONDITION] (a general term that means brain disease, damage, or malfunction) with poor safety awareness and resident was at risk for injuries. The goal indicated to minimize pulling out of gastrostomy tube/injuries daily for three months. The interventions included: i. To apply abdominal binder at all times ii. Discuss risks and complications with family that may result from continuous gastrostomy tube removal and replacement iii. Involve resident with diversional activities to keep occupied iv. Provide music to engage resident with auditory stimulation v. Provide pillow/towel as needed to minimize site of gastrostomy tube vi. Provide activities that require resident to use hands vii. Reevaluate continued need for abdominal binder quarterly and as needed to ensure least restrictive form of restraint without compromising safety viii. Transfer the resident to GACH when gastrostomy tube is pulled out for re-insertion as ordered by the attending physician and ix. Use two nursing staff members when providing care to reduce risk of injury when abdominal binder was removed. b. A review Resident 5's document titled Change of Condition (also known as SBAR: Situation, Background, Assessment, and Recommendation, provides a framework for communication between members of the health care team), dated 2/12/16, indicated the resident had a dislodged gastrostomy tube. The section of the resident's assessment that indicated Things that make the problem/symptoms worse; things that make the problem/symptoms better, and other contributing factors that have occurred with the problem/symptoms, indicated that the facility staff was unable to determine any problem/symptoms associated with the cause of the gastrostomy dislodgement. The note indicated a physician's orders [REDACTED]. A review of Resident 5's nurses' Progress Note, dated 2/12/16, at 11:27 p.m., indicated the resident was transferred back to the facility and the resident was calm and cooperative. Another plan of care dated 3/4/16, indicated the resident tends to pull out gastrostomy tube and needs an abdominal binder to minimize pulling out of the gastrostomy tube. The care plan indicated the that the resident will minimize pulling out of gastrostomy tube daily for three months and will minimize injuries from pulling out of gastrostomy tube within the next three months. The care plan indicated the following facility interventions: i. Apply abdominal binder at all times; ii. Monitor any behavioral problems related to use of abdominal binder; iii. Provide restrictive clothing to minimize sight of gastrostomy tube; iv. Reevaluate need for continued use of abdominal binder quarterly and as needed; v. Take the resident to the activity room and involve in diversional activities to keep occupied; and vi. Provide visual checks every 2 hours to visually inspect that abdominal binder remained in place and applied appropriately. c. A review of Resident 5's Change of Condition (SBAR), dated 7/16/16, at 10:06 a.m., indicated that the resident had gastrostomy tube dislodgement. The notes indicated a physician order [REDACTED]. A review of Resident 5's nurses' Progress Notes, dated 7/16/16 at 10:23 a.m., indicated that a nurse reported the resident's gastrostomy tube was dislodged and the abdominal binder was in place. d. A review of Resident 5's Nursing Admission/ Readmission Data, dated 7/29/16, indicated the resident was readmitted to the facility from a GACH. The Nursing Admission/ Readmission Data indicated Resident 5 had weakness/paralysis, and the gastrostomy tube site had skin redness and drainage. e. A review of Resident 5's Change of Condition (SBAR), dated 7/30/16, at 3:57 p.m., indicated the resident's gastrostomy tube was out (dislodged). The section of the resident's assessment that Things that make the problem/symptoms worse; things that make the problem/symptoms better, and other contributing factors that have occurred with this problem/symptoms, indicated unable to determine. (i.e. unable to determine the cause of the gastrostomy dislodgement.) The SBAR indicated a new physician order [REDACTED]. A review of Resident 5's nurses' Progress Notes, dated 7/31/16, at 3:55 p.m., indicated the resident returned from the GACH. The documentation indicated the gastrostomy tube site was clean, dry and intact. f. A review of Resident 5's Change of Condition (SBAR), dated 8/24/16, at 4:32 p.m., indicated the resident's gastrostomy tube was dislodged. The review of the SBAR for the resident's gastrostomy dislodgement which indicated Things that make the problem/symptoms worse; things that make the problem/symptoms better, and other contributing factors that have occurred with the problem/symptoms, revealed that the facility staff was unable to determine the cause of the gastrostomy dislodgement. The SBAR indicated a new physician order [REDACTED]. A review of Resident 5's nurses' Progress Notes dated 8/24/16, at 10:19 p.m., indicated the resident returned from GACH, and the gastrostomy tube was intact and patent. The progress note indicated an abdominal binder was in place to prevent dislodgement and will continue to monitor. g. A review of Resident 5's Change of Condition (SBAR), dated 8/25/16, at 4:18 p.m., indicated the resident was noted to have a dislodged gastrostomy tube. The note indicated there was leakage noted around the gastrostomy site and as well on the resident's shirt. The SBAR indicated Resident 5 had an abdominal binder in place. The SBAR indicated a new physician order [REDACTED]. On 9/13/16, at 6:50 a.m., during initial tour observation accompanied by licensed vocational nurse (LVN 4), Resident 5 was observed in his bed with gastrostomy tube feeding. The resident was observed calm and did not exhibit behaviors of attempting to pull out the gastrostomy tube. During a concurrent interview with LVN 4, she stated that Resident 5 did not have a behavior of attempting to pull out his gastrostomy tube. On 9/13/16, at 10:45 a.m., during an observation, certified nurse assistants (CNA) 4 and 5 were providing care to Resident 5. CNA 4 and CNA 5 were observed cleaning Resident 5, and the resident was calm and cooperative. The resident did not exhibit behaviors of attempting to pull out the gastrostomy tube. On 9/13/16, at 11 a.m., during an interview and review of Resident 5's clinical record, LVN 2 stated Resident 5 had an abdominal binder in place to prevent gastrostomy tube dislodgement; however she was not aware of the cause of frequent gastrostomy tube dislodgments. LVN 2 stated Resident 5 was not known to exhibit behavioral symptoms of attempting to pull out the gastrostomy tube. On 9/15/16, at 3:50 p.m., during an interview, the director of nurses (DON) stated the facility did not do an investigation or incident report on gastrostomy tube dislodgement. DON stated an IDT meeting could have been done for each incident of Resident 5's gastrostomy tube dislodgment to discuss and identify the appropriate interventions and to prevent further gastrostomy tube dislodgement. The DON stated that Resident 5 was compliant and did not exhibit behavior of pulling out gastrostomy tube. The DON stated the resident's care plan did not reflect the actual status of the resident that addressed the resident's minimization of pulling out the gastrostomy tube. According to the 12/2011, facility's policy and procedures, titled Accidents and Incidents: Investigating and Reporting, all accidents or incidents involving residents shall be investigated and reported to the Administrator. The policy indicated the facility shall promptly initiate and document investigation of the accident or incident. The policy indicated the Report of Incident/Accident form should include: i. Circumstances surrounding the accident or incident. ii. The name of witnesses and their accounts of the accident or incident. iii. The injured person's account of the accident or incident and iv. Any corrective action taken; and follow up information. The review of the facility's policy and procedures dated 10/2010 and titled Care Plans: Comprehensive, indicated that the facility's Care Planning/Interdisciplinary Team were responsible for developing and maintaining a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The policy indicated the comprehensive care plan was based on a thorough assessment and was designed to: Incorporate identified problem areas to aid in preventing or reducing declines in the resident's functional status and/or functional levels; and reflecting currently recognized standards of practice for problem areas and conditions. The policy indicated care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes, and addressed the underlying source of the problem area. The policy indicated the facility was responsible for identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. The policy indicated assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change, and the Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans: When there has been a significant change in the resident's condition; when the desired outcome was not met; when the resident have been readmitted to the facility from a hospital stay; and at least quarterly. 2a. A review of Resident 5's Change of Condition (SBAR), dated 8/29/16, at 10:40 a.m., indicated the resident was noted to have a device related pressure injury from the disc of the gastrostomy tube. The note indicated the resident had an open (skin breakdown) at the gastrostomy tube site, located at the left side of the abdomen, downward area (3 p.m., to 6 p.m., location) with the deepest injury at the 6 p.m., location. The review of the SBAR for the Things that make the problem/symptoms worse; things that make the problem/symptoms better, and other contributing factors that have occurred with the problem/symptoms, was left blank. During the evaluator's observation and interview while LVN 2 was providing treatment to Resident 5's gastrostomy tube site on 9/13/16, at 11 a.m., LVN 2 stated that the surrounding skin of the gastrostomy tube site was red, and the abdominal binder caused pressure to the gastrostomy tube disc onto the resident's abdominal skin that caused a skin breakdown. During a record review of Resident 5's care plans and concurrent interview on 9/16/16, at 9:15 a.m., LVN 2 stated that there was nothing in the care plan that addressed and anticipated the complication of the abdominal binder that contributed to pressure exerted to the gastrostomy tube disc that led to skin break down. The review of the facility's policy and procedures dated 7/2016 and titled Pressure Injury Risk Assessment, indicated pressure injuries were often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. wound discharge). The policy indicated that nurses would conduct skin assessments at least weekly to identify changes and the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure injuries. The policy indicated that once risk factors have been identified, proceed to the Care Area Assessment, care planning and interventions individualized for the resident and their particular risk factors.

Based on observation, interview, and record review, the facility failed to provide necessary care and nursing intervention as stated in the facility's policy and procedure after Resident 1 fell on the floor, hitting his head against a wall and leaving a dent on the wall. Licensed vocational nurse 1 (LVN 1), the charge nurse at the time of the resident's fall, sat the resident up on a chair after the fall without immobilizing his head/neck, placed a cold compress on his forehead and right eyelid and administered oxygen via mask when the resident became less responsive. The paramedics arrived to the facility and found the resident sitting on a chair without a blood pressure, pulse or respiration. The director of nursing, the therapist, and the coroner's examiner stated the appropriate intervention during a head impact is to immobilize the head/neck and not to move the resident. This deficient practice resulted in the death of the resident. Findings: On [DATE], at 1:45 p.m., an unannounced visit was conducted to investigate a complaint related to Resident 1's fall resulting in his death. A review of the Resident 1's closed clinical record revealed the resident was a [AGE] years old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated [DATE], indicated the resident was cognitively impaired for daily decision-making, was unable to make himself understood or understand others, exhibited daily wandering behavior that was easily altered and was independent in walking and locomotion on and off the unit. The LVN Personnel Weekly Progress Notes, documented by LVN 1, indicated on [DATE], at 2:20 a.m., the resident was seen by certified nursing assistant 1 (CNA 1) running down the hallway. CNA 1 ran after the resident, who went inside and across the dining room to the exit of another hallway. Before CNA 1 could reach the resident, he fell and hit his head on the wall opposite to the exit door of the dining room. The resident was lying on the floor, on his right side and a dent from the impact of the head was noted on the wall. LVN 1's nursing progress note further indicated the resident, while lying on the floor, was able to open his eyes and look at LVN 1, CNA 1, and at CNA 2, when his name was called. The vital signs were taken indicating the blood pressure was 107 millimeters of mercury (mmHg) over 68 mmHg (,[DATE]), the pulse rate was 67 beats per minute and the respiration rate was 18 breaths per minute. Chest movement was noted and the resident was assisted to sit up on a chair because he tried to get up. While the resident was in the chair, a cold compress was placed on his forehead and right eyelid. There was no evidence in the clinical record that LVN 1 and CNAs 1 and 2 tried to immobilize the head and neck of the resident prior to moving him from the floor. LVN 1 documented at 2:30 a.m., the resident became less responsive, a weak pulse was still noted, 911 emergency services was called and the resident was given oxygen via mask. Upon arrival of the paramedics (a medical emergency response team), the resident was transferred to a gurney and CPR (cardiac [MEDICAL CONDITION] resuscitation) was performed. According to the Emergency Medical Service Report, the paramedics arrived at the facility at 2:35 a.m., and found the resident sitting in a chair. At 2:36 a.m., the resident's vital signs (blood pressure, pulse, respiratory rate, and oxygen saturation) were zero. CPR and cardiac monitoring were provided and emergency fluid and medications were given. At 2:50 a.m., the resident's vital signs were re-checked and the values remained zero, and at 2:59 a.m., the resident was pronounced dead. On [DATE], at 1:20 p.m., during an interview, a licensed registered occupational therapist (OTR/L) stated whenever a head impact/injury is involved, first aid should include protecting and immobilizing the head and neck first, not moving the resident until after the paramedics arrived and performing an appropriate assessment. The OTR/L stated the best position after a head impact is a neutral position, not hyperflexed or hyperextended. On [DATE], at 2:40 p.m., during an observation with the director of staff development (DSD) and restorative nurse aide 1 (RNA 1), the dent the resident left on the wall, which was approximately 20 inches from the floor, was noted to be covered with a patch that was approximately seven inches in length and seven inches in width. On [DATE], at 3 p.m., during an interview, the current director of nursing (the director of nursing at the time of the resident's fall no longer worked in the facility) stated the facility did not have policies and procedures addressing immobilization of the head after an impact because that was a basic nursing approach. The director of nursing stated paramedics should have been called immediately after the fall and the resident should not have been moved until paramedics arrived. On [DATE], at 9:51 a.m., during a telephone interview, CNA 2 stated it was the decision of the charge nurse, LVN 1, to sit the resident up on a chair after the fall. CNA 2 stated the resident was trying to get up. According the Autopsy Report by the Department of Coroner, dated [DATE], an autopsy was performed on [DATE], and the cause of death was a neck fracture. The report also documented the resident's head snapped backward when he fell and hit his forehead on the wall and thereby breaking his neck. This caused an injury to his spinal cord, which was fatal, because it interfered with his ability to breathe. The fall also caused a subdural hematoma around the decedent's (deceased 's) brain, which, although not fatal, gives evidence of the severe degree of force involved in the impact. The examiner wrote his opinion that, "When a person suffers a suspected neck fracture, the best treatment is not to move them, because this can exacerbate the fracture by causing movement of the broken bones against the spinal cord. One thing you certainly don't want to do is to sit the person up; that is highly likely to exacerbate the fracture." The facility's policy and procedure titled "Fall Prevention and Incident Management," revised [DATE], revealed when a resident incident occurs, the employee making the discovery immediately notifies the licensed nurse to conduct appropriate assessment and provide interventions and/or emergency care as needed. According to The Incident/Accident Treatment, Investigation, and Reporting Flow Chart, Incident Management, when an incident occurs, assess the resident, provide appropriate intervention and/or emergency care, if necessary.