Every finding on record at Mar Vista Country Villa Healthcare & Wellness

Based on interview and record review the facility failed to obtain weight upon admission according to professional standards of practice for one of three sampled residents,(Resident 2).This deficient practice caused the Registered Dietician (RD) to use the most recent general acute care hospital (GACH) weight. This led to an inaccurate baseline weight causing Resident 2 to trigger a weight variance for weight loss and placed Resident 2 at risk for unnecessary weight gain.On 2/27/2026 The California Department of Public Health (CDPH) received a complaint alleging the facility neglects residents nutritional needs. A review of Resident 2's face sheet indicated the facility re-admitted Resident 2 on 1/27/2026 with diagnoses including sepsis (infection in the blood), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hip and knee, cognitive communication deficit, hypokalemia (low potassium), hypothyroidism (low thyroid), hyperlipidemia (fat in the blood), thrombocytopenia, vitamin D deficiency, gastroesophageal reflux disease (GERD-heartburn), hypertension (high blood pressure) and disorder of phosphorus metabolism. A review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 2/3/2026 indicated Resident 2's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 2 required supervision or touch assistance with eating (helper provides verbal cues and or touching to complete activity). Resident 2 required moderate assistance (helper does less than half the effort) with toileting and transferring in between surfaces. A review of Resident 2's physician order dated 1/27/2026 indicated RD consultation to evaluate and treat as needed. A review of Resident 2's dietary profile dated 2/3/2026 indicated no weights recorded. A review of Resident 2's physician order dated 2/13/2026 indicated weekly weights x 4 weeks. A review of Resident 2's Interdisciplinary Team (IDT) note dated 2/20/2026 indicated reason for review: MDS triggered significant weight change: 30-day comparison weight (1/24/2026): 110lbsWeight loss noted: approximately 19-19.2 lbs.Percentage weight change range: 17.3% to 17. 5%The weight change is considered clinically significant and places the resident at risk for malnutrition, functional decline, dehydration, and increased morbidity. During a concurrent interview and record review on 3/12/2026 at 1:52 p.m. with the RD. Resident 2's Care Plan revised by RD on 2/11/2026 titled, Resident 2 has nutritional problem or potential nutritional problem, at risk for malnutrition and related complications was reviewed. The Care Plan indicatedMonthly weight change:90.5lbs (pounds, unit of measurement) (2/9/2026)89.4 lbs. (2/4/2026)110 lbs. (1/24/2026)Down 20.6 lbs./18.7% x 1 month.The RD stated, Resident 2 did not have a weight documented at time of admission, so I used the last weight from the hospital. Ideally the restorative nursing assistant (RNA) would get the weight at admission, and I would use that weight as a baseline. I just noticed it triggered weight loss, I should probably change that.

Based on observation, interview, and record review, the facility failed to ensure a resident's written notice of proposed transfer and discharge provided to the resident's responsible party and a copy sent to the office of the state long-term care ombudsman (a representative who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) at least thirty days prior to proposed discharge date for one of three sampled residents, Resident 1. This deficient practice had resulted in Resident 1 and Resident 1's responsible party feeling harassed and forced to sign a notice of proposed transfer and discharge document on 1/29/2026 for a proposed discharge date on 1/31/2026. Findings: A review of Resident 1's admission Record indicated, the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses including type 2 diabetes mellitus (a disease that result in too much sugar in the blood), end stage kidney disease (ESRD-- The stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life).A review of Resident 1's history and physical (H&P) dated 11/25/2025 indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 1's minimum data set (MDS- a resident assessment tool) dated 12/5/2025 the MDS indicated, Resident 1 had no cognitive (ability to acquire and understand knowledge) impairment, the MDS also indicated Resident 1 is independent to eating, oral hygiene, toileting hygiene, personal hygiene, upper body dressing. Requires setup or clean-up assistance for shower/bath self, putting on or taking off footwear. A review of Resident 1's Notice of Proposed Transfer and Discharge with notification date 1/2/2026, the record indicated, reason for discharge, The discharge is appropriate because your health has improved sufficiently so that you no longer require services provide by this facility. Resident/Representative signature and date were not completed. Facility representative signature is completed on 1/29/2026. A review of Resident 1's Physician's Order Summary dated 1/31/2026 at 6:13 PM indicated, discharge Resident 1 on 1/31/2026 with HH (home health) and DME (durable medical equipment), bed, and mattress. During an interview on 1/30/2026 at 10:44 AM with Resident 1, Resident 1 does not recall the notice of proposed discharge documents were provided to her or her responsible party within the last four weeks, felt rushed and harassed by the facility staff to sign a document and on the same day to discharge. During an interview on 1/30/2026 at 11:20 AM with the ombudsman, the ombudsman stated, the facility did not fax the notice of proposed discharge record until 1/30/2026, ombudsman had reminded the social services about the 30-day notice and keeping records. During an interview on 1/30/2026 at 12:45 PM with licensed vocational nurse (LVN) 2, LVN2 stated, part of his responsibility is planning and coordinating during resident discharges. LVN 2 stated I usually get a notification at least a week before a resident is discharged , it helps for a smooth and safe process. LVN 2 was provided Resident 1's discharge plan and notification on 1/29/2026 at 1:30 PM. LVN 2 stated, when I asked why the last-minute notice, I was told the discharge is moved up and details were not provided. During an interview on 1/30/2026 at 1:05 PM with the social services director (SS), the SS stated once a notice of proposed discharge document is signed by a resident or responsible party, it will be faxed to the Ombudsman within 72 hours. In cases when a resident refuses to sign, reason why the resident did not sign will be noted and faxed to the Ombudsman. Resident 1 was informed the discharge plan on 1/2/2026 but declined to sign the document, the document was not faxed to the ombudsman. During an interview on 1/30/2026 with the facility administrator (ADM), the ADM stated, notice of proposed discharge didn't need to be faxed to the Ombudsman because it was not a facility initiated or involuntary discharge. A review of the facility's policy and procedure (P&P) titled Notice of Transfer/Discharge revised on 2/7/2025 indicated, Prior to discharge, the facility will provide the resident/resident representative with Notice of Proposed Transfer and Discharge document. A copy of the notice of Proposed Transfer and Discharge will be placed in the Resident's medical Record and a copy faxed to the ombudsman.A review of the P&P titled Notice of Transfer/Discharge revised on 7/19/2025 indicated, When a transfer or discharge is initiated by the facility, the facility will provide the resident,responsible party, and the Ombudsman with a Notice of Transfer and Discharge 30 days prior tothe transfer or discharge unless the following exceptions apply:A. The safety of individuals in the facility is endangered due to the clinical or behavioral statusof the resident;B. The resident's health has improved to allow a more immediate transfer or discharge;C. The resident's urgent medical needs that cannot be met in the facility and requiresimmediate transfer; andD. The health of individuals in the facility would otherwise be endangered;In these cases, the notice will be given as soon as practicable.

Based on interview and record review, the facility failed to ensure:1) Resident 34 received accommodation for a scheduled shower days twice a week to maintain Resident 34's personal hygiene care.2) Medical equipment, such as a shower chair, is in good working condition for residents' use. This deficient practice of failing to accommodate one of three residents (Resident 34's) personal hygiene care with twice a week showers and the shower chair not in good working condition caused Resident 34 psychological distress, discomfort, and not feeling clean. Findings: During a review of Resident 34's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 34 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: hemiplegia and hemiparesis (hemiplegia is a paralysis that affects one side of the body and hemiparesis is a weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) and a history of falling. During a review of Resident 34's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) on activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) self-care performance deficit dated 7/18/2022 with a revision date of 1/04/2025. The CP goal indicated Resident 34 will maintain and improve current level of function. The CP intervention included to encourage/provide showers as scheduled. During a review of Resident 34's history and physical (H&P - a physician's complete patient examination) dated 7/13/2025 indicated, Resident 34 had the capacity to understand and make medical decisions. During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool) dated 9/25/2025, indicated, Resident 34 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS also indicated, Resident 34 used a mobility device (helps a person walk or move from place to place when one has a disability or injury) wheelchair to get around. The MDS also indicated, Resident 34 needed maximal assistance with toileting hygiene (maintaining cleanliness before and after using the toilet) due to urinary and bowel incontinence (lack of voluntary control over urination or bowel movement). During a review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) titled Equipment Not in Working Order dated 11/11/2025 indicated, employees were given an education on what to do when medical equipment is not in good working condition. During an interview on 12/16/2025 at 11:34 AM, Resident 34 stated, I cannot get my shower because the shower chair that I use is broke so they gave me bed bath. Resident 34 also stated I enjoy my showers. According to Resident 34, Resident 34 did not have her shower on Friday, 12/12/2025 and Tuesday, 12/16/2025, which were her scheduled shower days. Resident 34 stated, i am not feeling clean even when bed baths were done instead of showers. During an interview on 12/17/2025 at 2:53 PM, Director of Staff Development (DSD - a licensed nurse who is responsible for planning and implementing the facility's orientation and educational programs for all employees) stated Resident 34's shower days are on Tuesdays and Fridays. DSD stated that the facility only has one large shower chair that Resident 34 specifically use was broken and that the facility had placed an order for a new shower chair. DSD stated Resident 34 must have felt unhappy, upset and not clean because Resident 34 did not have her showers. During an interview on 12/17/2025 at 2:58 PM, Maintenance Supervisor (MS) stated three large shower chairs were ordered but has not been delivered yet. MS stated MS did not know why the facility only has one large shower chair. MS stated the expected deliver date would be about 8-10 weeks. During a record review on 12/18/2025 at 8:12 AM, MS provided copies of receipts indicating two large shower chairs were ordered on 10/02/2025 and another large shower chair was ordered on 12/17/2025. MS stated as of 12/18/2025, no shower chair delivery has been received. During a review of the facility's policy and procedures (P&P - a document that explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Resident Rights - Accommodation of Needs with a review date of 7/17/2025 indicated, the facility provides an environment and services that meets residents' individual needs. During a review of the facility's P&P titled Maintenance Service with a review date of 7/17/2025, indicated, the maintenance department is responsible for maintaining equipment in a safe and operable manner at all times. During a review of the facility's P&P titled Showering and Bathing with a reviewed date of 7/17/2025 indicated, residents are given a shower bath to provide with cleanliness, comfort and to prevent body odors.

Based on interview and record review, the facility failed to ensure that the residents' right to formulate an advanced directive were recorded for one of six sampled residents (Resident 23). This deficient practice violated the residents' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 23. Finding: A review of Residents 23's admission Record indicated the facility admitted Resident 23 on 9/5/2025 with diagnoses that included dysphagia (difficulty swallowing), hypertension (HTN - elevated blood pressure), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). A review of Resident 23's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2025, indicated Resident 23 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills. The MDS indicated Resident 23 required set up or clean up assistance from staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an interview and record review on 12/18/2024, at 2:34 P.M., with the Interim Social Services Director (ISSD) Resident 23's medical chart was reviewed. ISSD stated that advanced directive acknowledgement form is completed upon admission, within 72 hours of admission and then reviewed quarterly thereafter. ISSD stated that Resident 23 did not have documented evidence of an advanced directive acknowledgement form being given or provided. The ISSD stated advanced directives are so the resident can make their medical decisions wishes known on paper in the even that they are unable to wishes known. The ISSD stated not having advanced directive acknowledgement in the residents charts violated Resident 23's right to have one. During an interview on 12/18/2025, at 2:27 P.M., the Interim Director of Nursing (IDON) stated that an advanced directive stipulates the residents' wishes in the event that they are not able to make them known. The IDON stated that the advanced directive acknowledgement form should be completed immediately when a resident admitted in the facility so in the event that something happens to the resident, the facility will know what to do for the resident. IDON stated that if this is not done, the residents' medical wishes may not be known and carried out which can lead to resident frustration and infringement on their rights. A review of the facility Policy and Procedures (P&P) titled Advance Directives indicated, Purpose: To ensure that the Facility respects advance directives.Upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record.AdmissionA. Upon admission, the Admissions Staff or designee will provide written information to the resident concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 9), Minimum Data Set (MDS- a resident assessment tool) within 14 days after completion. This failure resulted in Resident 9's MDS information being inaccurate, which could have caused a delay in health coverage for Resident 9. Findings: During an interview with MDS Nurse (MDS Nurse) on 12/18/2025 at 11:23 PM, MDS Nurse stated Resident 9 was discharged to the hospital on 7/24/2025 and bed hold was implemented. However, Resident 9 never returned to the facility. During a concurrent interview and record review with MDS nurse on 12/18/2025 at 11:23 AM MDS Nurse stated the following MDS assessment had not been transmitted within 14 days to the Centers for Medicare and Medicaid (CMS) (provides health coverage to more than 100 million people through Medicare and Medicaid). MDS Record for Resident 9 indicated 7/31/2025 Discharge/Return Assessment was completed however it was not transmitted. A review of the facility's Center for Medicare and Medicaid Services' Resident Assessment Instrument Version 3.0 Manual, Chapter 5, provided by the facility indicated that, MDS must be transmitted no later than 14 days after the Assessment Reference Date (ARD).

Based on interview and record review, the facility failed to notify the physician when they were unable to collect Resident 4's STAT (Immediately) Brain Natriuretic Peptide (BNP - a protein the heart makes, acting like a stress signal; when the heart works too hard to tell your blood vessels to widen and kidneys to flush out salt/water, helping lower blood pressure and reduce the heart's workload, so high levels often mean heart failure or strain), Bilateral Lower Extremity (BLE -involving or affecting both sides) Duplex (special type of ultrasound that gives a two-in-one view of the blood vessels, showing pictures of the vessels themselves [like a regular ultrasound] and a graph/sound of how fast and in what direction your blood is flowing, helping find blockages or narrowed arteries), and D [NAME] (a protein fragment produced when your body breaks down a blood clot, indicating that both clotting and clot breakdown are occurring) per physician's orders for one of four sampled residents, (Resident 4). This deficient had the potential to result in the delay of the appropriate and necessary physician care instructions to prevent critical life threatening complications such as heart failure, pulmonary embolism (a sudden, serious blockage in a lung artery, usually caused by a blood clot that forms elsewhere [often in the leg], travels through the bloodstream, and gets stuck, cutting off blood flow to part of the lung), hospitalization, and or death. Findings: A review of Resident 4's admission Record indicated the facility admitted Resident 4 on 7/30/2024 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain), and hypertension (HTN - elevated blood pressure). A review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 11/12/2025, indicated Resident 4 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 4 required extensive staff assistance with activities of daily living (ADL -tasks of everyday life). A review of Resident 4's change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 10/30/2025, indicated a Licensed Vocational Nurse (LVN) documented that Resident 4 had swelling on the right lower extremity. and that on 10/30/2025 at 7 P.M., the physician clinician was notified with recommendations for BLE duplex, stat BNP and D dimer . A review of the physician order dated 10/30/2025 at 11:04 A.M., the physicians order indicated that STAT BLE Duplex, BNP and D dimer STAT. During a concurrent interview and record review, on 12/18/2025, at 12:19 P.M., with Licensed Vocational Nurse (LVN) 4, Resident 4's electronic chart was reviewed. LVN 4 stated facility process when there is an order for a STAT order, which means to be done as soon as possible within 4 hours to 6 hours, requires a faster approach as time is of the essence. LVN 4 stated that a physician ordered STAT, BNP, and D Dimer on 10/30/2025 at 9:55 P.M. for Resident 4. LVN 4 stated that Resident 4's BNP and D [NAME] laboratory (lab) results indicated that the BNP and D Dimer were collected on 10/31/2025 at 8:33 A.M. LVN 4 stated that if the facility does not obtain STAT labs within 4 hours to 6 hours, the physician needs to be notified so that the physician can make the decision as to whether the facility needs to wait until the lab technician gets to the facility or to transfer the resident out to a hospital. LVN 4 stated the physician notification is then documented in the resident's progress notes. LVN 4 stated that there is no documented evidence that a physician was notified that Resident 4's BNP, and D Dimer were not collected STAT as ordered. LVN 4 stated not collecting the labs STAT may lead to a delay in care leading to worsening circulatory issues that may lead to a pulmonary embolism or a stroke (a medical emergency when blood flow to part of your brain is cut off [ischemic] or a blood). During an interview, on 12/18/2025, at 2:22 P.M., the Interim Director of Nursing (IDON) stated that the facility expectations is that STAT labs are done immediately upon receiving the order because the resident is in a critical situation. IDON stated if the tests are not done within the time frame, then the doctor needs to be notified so that the doctor can give an option/s. IDON stated that if the labs in this case (Resident 4) that are for checking if the resident has a blood clot are not done on time, the resident may have an undetected blood clot that can travel to the heart and cause a heart attack, lungs, cause a pulmonary embolism or the head and cause an ischemic stroke. A review of the facility policy and procedures (P&P), titled, Laboratory Services reviewed 7/17/2025, indicated, Procedure: To ensure the provision of laboratory services as required for residents at the Facility.Policy: The Facility will provide laboratory services in an accurate and timely manner to meet the needs of residents per Attending Physician orders.Nursing Staff will monitor to make sure that lab results are received promptly.i. Any lab test ordered STAT will be followed up on the same shift. A review of the facility utilized resource titled Reference Manual [NAME] Edition 2025 indicated, STAT Testing Service: STAT Testing is defined as Critical Life-Threatening Requests which require unexpected urgency in obtaining diagnostic information. This means the phlebotomist is dispatched to perform the venipuncture and/or pick-up the specimen(s) as soon as the order is placed. The assigned phlebotomist will arrive as soon as possible; the specimen is taken to the laboratory and run Immediately. To consistently provide timely.

Based on observation, interview and record review the facility failed to accurately complete the smoking assessment for one of two sampled residents (Resident 11). This deficient practice placed Resident 11 at a risk for injury such as burns.A review of Resident 11's admission record indicated the facility re-admitted the resident, on 3/31/2025with diagnoses that chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities) and nicotine dependence. A review of the Quarterly Minimum Data Set (MDS- a resident assessment tool), dated 9/30/2025, indicated Resident 11's cognition was intact. A review of Resident 11's Smoking and Safety assessment, dated 11/1/2025, indicated the resident did not smoke. A further review of the smoking and safety assessment indicated the following sections titled, Care Planning and Clinical Suggestions were not filled out. A review of Resident 11's history and physical, dated 11/4/2025, indicated the resident was having memory loss and the resident had the capacity to make medical decisions. The H&P also indicated the reside was smoking two to three cigarettes a day and was not interested in quitting at that time. A review of Resident 11's smoker care plan, initiated 3/31/2025, indicated Resident 11 bought her own cigarettes. The review of the care plan indicated the goal was for the resident to not sustain an injury from unsafe smoking practices. The interventions included to instruct the resident about smoking risks, smoking hazards and on the facility's policy on smoking including, locations, times and safety concerns. During a concurrent interview and observation on 12/17/2025 at 11:09 AM, Resident 11 was observed smoking on the smoking patio. The Activities Director (AD) stated Resident 11 was currently smoking. AD stated there is smoking apron available but most residents refuse. During a concurrent interview and record review on 12/17/2025 at 11:14 AM, Resident 11's most recent smoking assessment, dated 11/1/2025, was reviewed with the Interim Director of Nursing (IDON). IDON stated she completed Resident 11's 11/1/2025 smoking assessment. IDON stated that the smoking assessment for Resident 1 was wrong as Resident 11 does smoke and that the IDON had observed the resident smoking. The IDON further stated the smoking assessment must be completed correctly for the safety of the resident. The IDON also stated the smoking assessment is completed to prevent injuries to the resident including burns. A review of the facility policy and procedures titled, Smoking Residents, dated 8/18/2023, indicated, smoking by residence is allowed outside the facility in designated comma marked smoking areas with the following safety measures readily available:a. Ashtrays made of Non combustible material and safe design;b. Metal containers with self closing covers into which ashtrays can be emptied,c. Portable fire extinguisher; Andd. Fire retardant smoking blanket).

Based on observations, interviews, and record reviews the facility failed to provide the appropriate care and supervision to maintain the safety and highest practical physical, mental, and psycho-social wellbeing for one of two sampled residents (Resident 11) diagnosed with dementia (impairment of brain functions such as memory loss forgetfulness, limited social skills, loss of judgment, and impaired thinking). By failing to:Develop and implement an individualized care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for Resident 11's dementia diagnosis. This deficient practice had the potential to lead to inadequate and/or delayed delivery of Dementia care for Resident 11.Findings: A review of Resident 11's admission record indicated the facility re-admitted the resident, on 3/31/2025 with diagnoses that included dementia, anxiety and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 11's Quarterly Minimum Data Set (MDS- a standardized resident assessment tool), dated 9/30/2025, indicated Resident 11's cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions) was intact. The MDS indicated the resident was diagnosed with dementia and was receiving antipsychotic (a type of drug used to treat symptoms of psychosis, which is a condition where a person has difficulty distinguishing between what is real and what is not) medication. A review of Resident 11's history and physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 11/4/2025, indicated the resident was having memory loss and the resident had the capacity to make medical decisions. The H&P also indicated the resident's diagnosis included unspecified dementia with behavioral disturbance. A review of Resident 11's Order Summary Report, dated 12/17/2025 indicated the had active orders for:- Risperidone (a prescription medication known as an atypical antipsychotic used to treat specific mental health conditions) 1 milligram (mg) by mouth two times a day for Schizophrenia (a serious, long-term brain disorder that makes it difficult for a person to distinguish between what is real and what is imaginary) which was manifested as angry outbursts.- Ativan (an anti-anxiety medication) 0.5 mg by mouth every day as needed for Anxiety manifested by restlessness- Depakote (a medication that is used to stabilize one's mood) 250 mg by mouth two times a day for bipolar disorder (a mental health condition that causes extreme, intense shifts in mood, energy, and activity levels) manifested by shifts in mood A review of Resident 11's complete active care plans on 12/17/2025 at 7:57 AM, indicated there was no active care plan for the resident's dementia diagnosis. A review of Resident 11's Psychosocial Notes dated 12/1/2025, indicated the resident Endorsed persistent anxiety and stated that she would like to speak with the psychiatrist regarding adjustments to her antipsychotic medication and anti-anxiety medication. During a concurrent interview and record review on 10/17/2024 at 10:10 AM, Resident 11's complete active care plans were reviewed with the Interim Director of Nursing (IDON). The IDON stated Resident 11 had diagnoses of anxiety disorder and dementia. The IDON confirmed by stating Resident 11 did not have any care plan in place with measurable goals and interventions that addressed the resident's diagnosis of dementia or cognitive skills. The IDON stated a possible outcome of not having a care plan that addressed Resident 11's dementia could lead to the resident receiving ineffective care. During an interview on 12/18/2025 at 12:50 PM, Resident 11 stated she took Ativan to calm herself down. A review of the facility's policy and procedure (P&P) titled Dementia Care, reviewed 7/17/2025, indicated It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, psychosocial, and behavioral needs of residents living with dementia. The P&P also indicated The resident's plan of care will reflect a baseline of common behaviors (target behaviors) exhibited by the resident, interventions and specific goals.

Based on interview and record review the facility failed to ensure one of five sampled residents (Resident 11) was free of unnecessary medication (a prescription that may be doing more harm than good or isn't needed for the resident's current condition) by failing to ensure Resident 11 was monitored for side effects and effectiveness of ativan (an anti-anxiety medication). This deficient practice could result in increased risk of a broad range of adverse consequences such as medication interactions.Findings: A review of Resident 11's admission record indicated the facility re-admitted the resident on 3/31/2025, with diagnoses that included dementia (impairment of brain functions such as memory loss forgetfulness, limited social skills, loss of judgment, and impaired thinking), anxiety, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 11's Quarterly Minimum Data Set (MDS- a standardized resident assessment tool), dated 9/30/2025, indicated Resident 11's cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions) was intact. The MDS indicated the resident was diagnosed with dementia and was receiving antipsychotic (a type of drug used to treat symptoms of psychosis, which is a condition where a person has difficulty distinguishing between what is real and what is not) medication. A review of Resident 11's Order Summary Report, dated 12/17/2025, indicated on 12/1/2025 Resident 11's physician ordered: ativan 0.5 milligrams (mg- unit of measurement) by mouth every day as needed for anxiety manifested by restlessness. A review of Resident 11's psychotropic medications (medications that alter brain function, affecting mood, perception behavior and cognition) care plan, revised on 3/31/2025, indicated staff were to administer psychotropic medications as ordered and were to monitor for side effects and effectiveness every shift. A review of Resident 11's Medication Administration Record (MAR) for December 2025, indicated there was no documentation of monitoring for side effects or the effectiveness of ativan. During a concurrent interview and record review on 12/17/2025 at 11:32 AM, Resident 11's physician orders, care plan, and MAR were reviewed with the Interim Director of Nursing (IDON). The IDON confirmed by stating Resident 11 had an order for ativan and the facility was not monitoring for side effects of ativan nor for the behaviors that the ativan was to treat. The IDON stated monitoring of side effects and behaviors of ativan enabled the facility to care for the residents and to assess the effectiveness of the medication. During an interview on 12/18/2025 at 12:50 PM, Resident 11 stated she took ativan to calm herself down. A review of the facility's policy and procedure (P&P) titled, Behavior/Psychoactive Medication Management, dated 11/14/2025, indicated the facility would observe and monitor the resident for side effects, and adverse consequences, including sedation. The P&P also indicated all complications and side effects should be reported to the Healthcare practitioner.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 10) was free from significant medication errors (an error in medication preparation or administration that can cause the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice by failing to: 1. Ensure Licensed Vocational Nurse 5 (LVN 5) administered Omega 3 (essential fats the body cannot make crucial for brain, heart, cell health and vital for reducing inflammation, triglycerides and supporting development) oral capsule 1000 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give capsule via gastrointestinal tube (G-tube -feeding tube surgically inserted into the stomach) one time a day for supplement as per physician's orders dated 11/4/2025. This deficient practice had the potential to result in Resident 10 being under or overdosed, experience severe side effects, or a complete loss of drug effectiveness which could result in serious injury, harm, or death. Findings: A review of Resident 10's admission Record indicated the facility admitted Resident 10 on 10/18/2022, and readmitted Resident 10 on 8/1/2025 with diagnoses including dysphagia (difficulty swallowing), hyperlipidemia (too much fats, or lipids in the blood, essentially meaning high cholesterol or high fats), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough). A review of Resident 10's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 10/30/2025, the MDS indicated Resident 10 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 10 required extensive staff assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). A review of Resident 10's physician's orders dated 11/4/2025, indicated an active order for Omega 3 oral capsule 1000 mg, give capsule via G-Tube one time a day for supplement. A review of Resident 10's Medication Administration Record (MAR) for 11/2025, the MAR indicated Resident 10 was given Omega 3 Capsule 1000mg (Omega 3 Fatty acids) give 1 capsule via G-tube one time a day for supplement daily from 11/4/2025 to 11/30/2025. A review of Resident 10's Medication Administration Record (MAR) for 12/2025, the MAR indicated Resident 10 was given Omega 3 Capsule 1000mg (Omega 3 Fatty acids) give 1 capsule via G-tube one time a day for supplement daily from 12/1/2025 to 12/16/2025. During a concurrent medication administration observation and interview on 12/17/2025, at 8:20 A.M., LVN 5 was observed dispensing one Omega 3 capsule. LVN 5 took a subcutaneous needle (a small, short needle used to inject medication into the fatty tissue layer just beneath the skin) and attached the needle to a syringe. LVN 5 then poked a hole into the Omega 3 capsule and emptied the liquid contents in the capsule into a medicine cup. LVN 5 then added 15 millimeters (ml -unit of measure for liquid) of water into the medicine cup containing the Omega 3 liquid and carried the mixture content in the cup to Resident 10's G-tube to administer it. LVN 5 did not administer the mixture after Surveyor intervened. LVN 5 stated that the Omega 3 oil was in a capsule so the medication inside would be slowly released and the oil inside the capsule should not have been punctured out because the medication would lose effectiveness and would not work as planned and would be ineffective. LVN 5 stated Omega 3 was used for heart function and if not given properly, it could affect the residents' blood flow leading to high blood pressure which could then lead to a heart attack. LVN 5 stated she would be calling Resident 5's physician to ask for an order for liquid Omega 3 for the resident. During an interview on 12/18/2025, at 2:14 P.M., with the Interim Director of Nursing (IDON), the IDON stated that all G-tube medications needed to be in liquid form and not a capsule. The IDON stated Omega 3 was in capsule form to prevent the medication from been given fast. The IDON stated opening the capsule and emptying its content could cause the medication to be ineffective. The IDON stated that Omega 3 was used for heart function and if not given properly could affect the residents' blood flow by causing elevated blood pressure which could lead to a heart attack. A review of the facility's policy and procedures (P&P), titled, Medication Administration reviewed 7/17/2025, indicated All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner. e. If the resident has difficulty swallowing pills, the Licensed Nurse will notify the physician to discuss the possibility of a different form of the medication i.e. crushed, liquid or suspension. If the medication is to be crushed, a physician order is required. A review of the medication insert titled, Omega 3 Acid Ethyl [NAME] -Oral dated 5/2025, indicated Important. How to Use this information.How to use: .Swallow the capsules whole. Do not crush, chew, or dissolve the capsules.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation in the kitchen during tray line (assembly line system for preparing and assembling residents' meal trays) food preparation, by failing to ensure one of three staff (Cook 1) wore gloves during tray line food preparation. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness in 63 of 63 medically compromised residents who received food from the kitchen.Findings: During observation on the initial tour in the facility kitchen and observation of breakfast tray line on 12/15/2025 at 7:18 AM, [NAME] 1 was observed placing a waffle on a tray meant for residents without gloves. [NAME] 1 became aware of the incident and removed the waffle and put gloves on to replace the waffle on another tray meant for residents for breakfast. During an interview on 12/15/2025 at 7:22 AM [NAME] 1 stated he made a mistake and should have been wearing gloves while preparing the trays after cooking breakfast for residents. During an interview on 12/15/2025 at 7:28 AM, dietary assistant 1 (DA 1) stated she always wore gloves when preparing food for residents to eat. DA 1 stated it was policy to wear gloves when in direct contact with food meant for residents. During an interview on 12/15/2025 at 11:07 AM, DA 2 stated before preparing food for the residents, kitchen staff had to wash their hands and put on gloves if coming into direct contact with food. During an interview on 12/17/2025 at 9:48 AM, the dietary supervisor (DS) stated any time the cook or any staff member directly handled food they had to wash their hands and then put on gloves before handling food for residents. The DS stated it was standard practice to always wear gloves while handling food to prevent contamination, which may could residents to get sick from eating contaminated food. A review of the facility's Policy and Procedure (P&P) titled Dietary Department - Infection Control, dated Revised 2/29/2024, indicated Proper Hand Washing: i. Before initially donning gloves for working with food.

Based on interview and record review the facility failed to provide annual in-service training on dementia care to one of five certified nursing assistants (CNA 1) sampled for sufficient and competent nurse staffing. This deficient practice had the potential for residents not to receive the appropriate care and services needed, which could affect the quality of care received, and potentially lead to resident harm.Findngs: During a concurrent interview and record review on 12/18/2025 at 1:26 PM, employee records for five CNAs (CNA 1, CNA 2, CNA 3, CNA 4 and CNA 5) were reviewed with the Director of Staff Development (DSD). The DSD stated it was necessary for staff to have yearly training on dementia care in order for the staff to care for residents. The DSD stated CNAs had to have yearly dementia training and stated CNA 1 completed the most the last dementia training on 3/12/2024 (1 year and 9 months prior to date of interview). During an interview on 12/18/2025 2:47 PM, the Interim Director of Nursing (IDON) stated around half of the residents in the facility had a diagnosis of dementia. The IDON further stated CNAs required annual dementia in-service training in order to know how to care and speak with the residents. A review of the facility's policy and procedure (P&P) titled Dementia Care,reviewed 7/17/2025, indicated all staff will complete a minimum of five (S) hours of dementia specific in-service training per year, as part of the Facility's ongoing staff education program. a. Attendance at the in-service will be documented and maintained in each employee's personnel file. b. The 2 hours of dementia specific training that is completed as part of orientation is not included in the requirement of five (5) hours of annual dementia -specific training.

Based on interview and record review the facility failed to provide sufficient staffing to maintain supervision for one of four sampled residents (Resident 1) who was identified as a wanderer and a high risk of fall.This deficient practice caused Resident 1 to wander outside onto the patio and sustain an unwitnessed fall leaving a laceration (cut) over Resident 1's left eye that required transport to the general acute care hospital (GACH) where Resident received sutures (a row of stitches holding the edges of a wound together).A review of Resident 1's admission record indicated the facility originally admitted this [AGE] year old female on 4/18/2022 and most recently on 4/28/2025 including the following diagnoses, atrial fibrillation (irregular heart beat), supraventricular tachycardia (extremely fast heart beat), hypertensive heart disease (a group of heart problems caused by long term high blood pressure), hyperlipidemia (high fat in the blood), iron deficiency anemia (a condition where the body does not have enough healthy red blood cells), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of right and left shoulder, major depressive disorder (persistent low mood), cardiomegaly (enlarged heart), gastro-esophageal disorder (heartburn), diaphragmatic hernia with obstruction, dysphagia (difficulty swallowing) and dorsalgia (back pain). A review of Resident 1's Minimum Data Set (MDS- a resident assessment) dated 10/16/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was not intact. Resident 1 required set up or clean up assistance (helper sets up or cleans up; resident completes activity, helper assists only prior to or following the activity) with toileting and walking. Resident 1 required supervision or touch assistance (helper provides verbal cues and or touching/steadying and or contact guard assistance as resident completes activity) with bathing.A review of Resident 1's physician order dated 9/7/2025 indicated visual hourly checks, check the resident every hour to ensure the resident is safe and free from falls, document the visual check was completed on the medication administration record (MAR- legal document where licensed staff document administration of medications).A review of Resident 1's elopement (leaving facility without notifying staff) risk assessment dated [DATE] indicated resident was at risk of elopement.A review of Resident 1's physician order dated 10/1/2025 indicated apply wander bracelet (wearable device that is part of a larger alarm system to prevent wandering among individuals with cognitive impairment) to right ankle as ordered to alert staff secondary to high risk of elopement. A review of Resident 1's MAR dated 10/21/2025 indicated a y for yes next to hourly visual checks.A review of Resident 1's SBAR communication form dated 10/22/25 indicated Upon returning to check on Resident 1, The CNA noted Resident 1 was no longer in bed. The resident was subsequently found outside on the patio, lying on the ground, with skin flap noted above the eyebrow. Resident 1 complained of head pain rated 7/10. Resident 1's blood pressure was 209mmHg/109mmHg (Normal range 120mmHg-140mmHg/60mmHg-90mmHg) and heart rate was 80 (bpm- beats per minute) (normal range between 60bpm-100bpm).A review of Resident 1's nursing progress note dated 10/22/2025 indicated on 10/21/2025 at 11:00pm Resident 1 was observed sitting in a chair outside of the room. On 10/22/2025 at 12:00am Resident 1 was again helped go back to bed. At 1:00am Resident 1 was noted wandering in the hallway and assisted back to bed. At 3:00 am Resident was observed wandering again and refused to go back to bed so Resident 1 was placed in a chair. At 3:40 am Resident 1 was noted wandering in the hallway and assisted back to bed.Resident 1's GACH records dated 10/22/2025 indicated cat scan (CT scan-imaging scan) of brain results indicated no evidence of acute trauma. An x ray to the left knee indicated no evidence of acute trauma. Diagnosis forehead laceration, abrasion to left knee and closed head injury. Resident 1 was also given hydralazine (medication to treat high blood pressure), lisinopril (medication to treat high blood pressure) and metoprolol (medication to treat high blood pressure) for elevated blood pressure. Lastly, Resident 1 received sutures to eyebrow to be removed in 5-7 days.A review of a statement from CNA 2 dated 10/24/2025 indicated at approximately 3:30am Resident 1 was observed pacing the hallway and was assisted back to the room and placed in bed. After providing care to another resident staff returned to check on Resident 1 and Resident 1 was not in bed. Resident 1 was found outside on the patio. The CN was immediately notified and responded to assist. 911 was called and Resident 1 was transferred to the GACH for further evaluation.A review of a statement from the CN dated 10/24/2025 indicated at approximately 4:00 am CNA 2 notified CN that Resident 1 was found outside on the patio. The CNA stated earlier resident 1 was assisted back to bed and after attending to another resident and returning to Resident 1's room, Resident 1 was not in bed. The CN and CNA assisted resident up from the ground and returned to the room.A review of Resident 1's Fall Risk assessment dated [DATE] indicated Resident 1 was identified as high risk for fall.A review of Resident 1's care plan titled, Resident 1 at risk for fall r/t confusion unaware of safety needs initiated 9/15/2025 indicated resident enjoys walking at back patio, bed in low position, yellow dot next to door name, yellow bracelet identifier. Resident keeps on removing the yellow [NAME] review of Resident 2's admission record indicated the facility admitted this [AGE] year-old female on 10/21/2025 with diagnoses including displaced fracture of left femur (broken thigh bone), metabolic encephalopathy (condition where the brain's function is impaired due to an imbalance in metabolism), presence of left artificial hip joint, unspecified falls, muscle weakness, cognitive communication deficit (challenge in communication caused by impairments in thinking process), dysphagia, difficulty walking, dementia (a progressive state of decline in mental abilities), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), pressure ulcer stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible), anemia, neuralgia and neuritis (nerve inflammation and pain)A review of Resident 2's History and physical (H&P the physician assessment and plan) dated 10/24/2025 indicated Resident 2 did not have capacity to understand or make decisions.A review of Resident 2's Fall Risk assessment dated [DATE] indicated Resident 2 was at high risk for fall.A review of Resident 2's care plan titled, Resident has these behaviors: prefers to sit up when in bed, episodes of trying to get out of bed verbal report from hospital tries to get out of bed, resident at risk for further left hip dislocation. 1:1 sitter was provided on day of admission for all shifts to redirect and ensure resident will not get out of bed and to prevent a fall.On 11/4/2025 The California Department of Public Health (CDPH) received a complaint alleging Resident 1 was missing and then found 30 minutes later outside of the facility on the patio very early in the morning after having an unwitnessed fall and subsequently transferred to GACH where Resident 1 received stitches over the eye and a swollen knee.During an interview on 11/5/2025 at 3:14 p.m. with the certified nursing assistant (CNA) 2. CNA 2 stated we all watch Resident 1 because Resident 1 tries to walk to the double doors and tries to get out, so we bring Resident 1 back to the room. Resident 1 did not sleep at night and would walk up and down the hallway. Sometimes we would be Resident 1 in a chair at the nursing station to watch Resident 1. Resident 1 would go out to the patio sometimes but if we saw Resident 1 going out there at night, we would not let Resident 1 go out there alone because Resident 1 had a fall before and Resident 1 was weak. CNA 2 stated, around 3:00 am or almost 4:00 a.m. I couldn't find Resident 1, so we looked around and then we found Resident 1 just outside of the side door near the director of nursing (DON) office sitting on the walkway. The Last time I saw Resident 1 before that was around three something, I cannot remember the times exactly. I don't know what happened Resident 1 disappeared suddenly. CNA 2 stated there were no alarms on the door Resident 1 went out from however there were lights on the patio. CNA 2 stated, I have seen Resident 2 try and go out of that door before and every time we re-direct Resident 1 and either put Resident 1 in the room or sit Resident 1at the station so Resident 1 could be watched. CNA 2 stated, We did not allow Resident 1 to go out that door, especially at night because there would be no one out there to watch Resident 1. CNA 2 stated before Resident 1 was found outside we put Resident 1 in the bed and Resident 1 did not stay, then we put Resident 1 in a chair and Resident 1 did not stay. CNA 2 stated CNA 1 was assigned to Resident 1 however CNA 1 was a sitter for Resident 2 that was trying to get out of bed. CNA 2 stated, I was not assigned to Resident 1 had I my own assignment.During a concurrent interview and record review on 11/5/2025 at 4:02 p.m. with CNA1. The Nursing assignment sheet dated 10/21/2025 11:00pm to 7:00am shift was reviewed. The assignment sheet indicated CNA 1's name handwritten next to another unnamed CNA's printed name. CNA 1 was assigned to R1 and 14 other residents. CNA 1 stated on 10/21/2025 CNA 1 worked a double shift starting at 3:00pm until 11:00pm then staying at work from 11:00pm to 7:00am. CNA 1 stated, I saw Resident 1 during the 3pm-11pm shift sitting in a wheelchair in the hallway eating snacks with a bedside table in front. They put Resident 1 there to keep an eye on Resident 1, but Resident 1 does not stay in place very long because Resident 1 liked to get up and walk around. CNA 1 stated at the beginning of the 11:00pm shift CNA 1 went to check the assignment and saw that Resident 1 was a part of the assignment. CNA 1 stated at that time CNA 1 saw Resident 1 walking towards the double doors which activated Resident 1's wander bracelet. CNA 1 reported Resident 1 stated, I'm looking for the baby then CNA 1 walked Resident 1 back to Resident 1's room and put Resident 1 in the bed. After which CNA 1 was instructed to be a sitter for Resident 2 in a different room that was not a part of CNA 1's assignment for four hours from 12:00pm to 4:00am. CNA 1 stated Resident 1 had gotten out of bed again and CNA 2 said to CNA 1, don't worry I'll take care of your assignment and sat Resident 1 in a chair outside of Resident 1's room. CNA 1 stated this happened between 11:00pm and 12:00am. Afterward, CNA 1 went to Resident 2's room to be a sitter. CNA 1 stated Resident 2 was a fall risk and was trying to get out of bed, so CNA 1 did not leave the room for the entire four hours. CNA 1 stated, I felt bad when they told me Resident 1 fell because we made a deal and they were supposed to be watching Resident 1; if CNA 2 was busy then the charge nurse (CN) should have been there. During the day when Resident 1 walks around there are more people there so when we see Resident 1 walking towards the doors we can stop or walk with Resident 1. During the 11pm-7am shift there is only the CN and the CNA's not as many people to look out for Resident 1. Lastly, CNA 1 stated, I do think the fall could have been avoided, I could have walked with Resident 1 or offered Resident 1 something to keep Resident 1 calm and to help Resident 1 stay inside.During an interview on 11/6/2025 at 12:33pm with the director of staff development (DSD). The DSD stated, I do the schedules and the assignments and if any last-minute changes are needed then the charge nurse can adjust. I divide the rooms by the number of CNA's and try to accommodate resident's requests. The DSD stated resident acuity (the severity of a patient's illness or injury which determines the level of attention needed) is considered when making the assignments and all the CNA's know if they get busy with one resident to assist with their other residents. The DSD stated residents who require redirection its easier during the day because we have additional staff for sitters and activities and rehab staff verses night shift there are less people because rehab goes home and activity staff goes home so the CAN's tend to help each other out so they will have a resident sit next to them because the resident is bored and give them an activity to do. During a concurrent interview and record review on 11/6/2025 at 12:40pm with the DSD. The Nursing assignment sheet dated 10/21/2025 11:00pm to 7:00am shift was reviewed. The Nursing assignment sheet indicated 1 sitter assignment and 5 CNA's. The DSD stated the sitter worked from 3:00pm to 11:00pm as the restorative care nurse assistant (RNA), then returned to work that night at 11:00pm to be the sitter assigned to two rooms that did not include Resident 1 nor Resident 2. The DSD stated those were the only two rooms identified as needing a sitter that night. The DSD stated Resident 1 was not identified as needing a sitter. The DSD stated there was 1 CNA who was a no call no show at the last minute, so CNA 1 was asked to stay over from the 3:00pm to 11:00pm shift. The DSD stated CNA 1 had 13 residents and CNA 2 had 14 residents which included Resident 2.During an interview on 11/10/2025 with the CN. The CN stated resident 1 was up the entire night and they kept redirecting Resident 1 back to bed after Resident 1 would get up again they would re direct Resident 1 back to bed. The CN stated CNA 2 was mostly assisting with redirecting Resident 1 back to bed. The CN stated CNA 1 was assigned to Resident 1 but CNA 1 was a sitter for Resident 2 because Resident 2 was also a high fall risk. The CN was not sure who assigned CNA 1 to be a sitter for Resident 2, and the CN did not know how long CNA 1 a sitter for Resident 2 was. The CN stated the CNA's help each other even though they each have between 12-16 residents assigned to them. The CN stated CNA 2 was watching CNA 1 and CNA 2's assignment while CNA 1 was sitting for Resident 2. The CN did rounds between 2:30am and 4:00am and did not notice any other CNA's on the floor stating, they were all in rooms busy. Lastly, The CN stated Resident 1 did not have a sitter, we just kept checking on Resident 1 every 30 minutes.During an interview on 11/6/2025 at 3:30 pm with the assistant director of nursing (ADON). The ADON stated Resident 1 was a fall risk but did not need a 1:1 sitter. I don't think we had any staffing issues that night, no one called us about staffing. The ADON stated, Resident 1 had dementia so I'm not surprised Resident 1 went out onto to the patio at 4:00am; maybe Resident 1 was thinking it was daytime because its so well lit. In Resident 1's mind there is a baby that Resident 1 was looking for. During the day when Resident 1 would go out to the patio staff would go with Resident 1 because Resident 1 might see something on the floor and try to pick it up and fall. Resident 1 had never gone out of that door onto the patio at night before. We have additional staff looking at high risk fall when we have new admissions to observe them and we put them on 1:1 monitoring. Resident 1's fall precautions included low bed, yellow sticker on the name plate at the door and a room closer to the nursing station and hourly rounding. Resident 1 did not have a 1:1 sitter.A review of the facility's policy and procedures (P&P) titled, Nursing Department-Staffing, Scheduling & Postings revised 7/2018, the P&P IndicatedPurpose: To ensure an adequate number of nursing personnel are available to meet resident needs. Nurse SchedulingPolicyI. The Facility will employ Nursing Staff that will be on duty in at least the number and with the qualifications required to provide the necessary nursing services for residents admitted for care.II. In staffing an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs, and such information will be posted as required.A. The Director of Nursing Services (DONS} and the Administrator will establish nursing hours and make adjustments to meet resident needs.B. The shift times are established and posted in the scheduling office and in the areas convenient for nursing staff to view.C. Shift times may be adjusted according to the needs of the Facility with advance notice.D. The DON and Administrator will establish nursing hours and make adjustments that meet resident needs. Nursing staff may be added to the schedule as required by Facility occupancy and workload. Part-time staff may be canceled with appropriate notice if the workload decreases.

Based on interview and record reviews for two of three sampled residents, Resident's 1 and 2. The facility failed to prevent a third incident of resident-on-resident altercation.This deficient practice caused Resident 1 to go to Resident 2's new room and provoke a fight which led to Resident 1 hitting Resident 2 on the nose and Resident 2 hitting Resident 1 on the back of the head.Cross Reference: F609.Findings:A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year old male on 12/2/2024 and most recently on 7/3/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Anxiety disorder (feelings of persistent fear and worry), hypothyroidism (thyroid gland does not produce enough thyroid hormone), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), other abnormalities of gait (walking) and mobility, hyperlipidemia (HLD-high fat in the blood), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), coronary artery ( - a slow progressive separation of the layers of the heart vessels) dissection and atrial fibrillation (heart dysrhythmia).A review of Resident 1's Minimum Data Set (MDS- a resident assessment) dated 7/10/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 1 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper only assists before or after activity) with toileting and showering. Resident was independent (Resident completes activity by themselves with no assistance from helper), with transfers (moving between surfaces) from bed to chair.A review of Resident 1's care plan titled, The resident exhibits behaviors including fabricating and confabulating stories, provoking other residents into arguments and fights, hitting the medication cart, making false accusations and demonstrating inappropriate behaviors towards staff initiated 1/13/2025, revised 6/25/2025. One goal was the resident will effectively express concerns and needs without resorting to verbal or physical aggression. Interventions included monitoring and document instances of inappropriate behaviors, including triggers, frequency and responses. Maintain a behavior log to identify patterns and inform care strategies.A review of Resident 1's care plan titled, Resident exhibits verbal aggression including use of profanity and racial remarks, during interpersonal conflicts with roommate initiated 8/12/2025. Includes goal that physical altercations will be prevented through early interventions and staff monitoring. Interventions include maintaining separate living arrangements, when possible, to reduce direct triggers and prevent escalation. Implement and maintain safety precautions during high-risk interactions (i.e. increased staff presence)A review of Resident 1's care plan initiated 8/11/2025 titled, Resident exhibits verbal aggression characterized by the use of inappropriate offensive, and racially charged language towards staff, causing distress and disruption in care environment such as the N word and black B word and similar expressions. The care plan does not include any goals. The intervention listed is to ensure staff have clear protocol for managing verbal aggression to maintain safety and a respectful care environment.A review of Resident 2's admission Record indicated the facility admitted this [AGE] year-old male on 7/16/2025 with diagnoses including Osteomyelitis (inflammation of bone or bone marrow, usually due to infection), HLD, difficulty walking, Essential hypertension (HTN-high blood pressure) and DM.A review of Resident 2's MDS dated [DATE] indicated Resident 2's cognition (mental ability to make decisions for daily living) was intact. Resident 2 required moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting, showering and transfers (moving between surfaces) from bed to chair.During a review of Resident 1's SBAR communication form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/31/2025 indicated while unnamed licensed Vocational Nurse (LVN) was in room administering intravenous (IV) medication to Resident 2, Resident 1's table was moved from the walkway. After which Resident 1 became angry and verbally aggressive toward the unnamed LVN. Resident 2 then asked Resident 1 to be nice, and Resident 1 began cursing at both the unnamed LVN and Resident 2. Resident 1 then walked up to Resident 2 and lifted the cane towards Resident 2 as if Resident 1 was going to hit Resident 2 with the cane. Room changes offered, however both residents refused. The medical doctor (MD) 1 was informed however the unnamed LVN was awaiting a response.During a review of Resident 1's SBAR dated 8/10/2025 indicated at 9:05 a.m. Resident 1 was yelling, cursing and accusing Resident 2 of stealing a shirt. Resident 2 then became upset and yelled back at Resident 1, both exchanging verbal, racial remarks. Safety precaution measures were implemented, and residents were relocated to prevent further escalation. MD 1 was informed and recommended to monitor and redirect as needed.During an interview on 8/27/2025 at 1:35 p.m. with the medical doctor (MD). The MD stated Resident 1 should have been discharged a long time ago. Resident 1 had no skilled need to be here. Resident 1 left the facility often driving a vehicle. Resident 1 was very aggressive and attacked multiple residents.During an interview on 8/27/2025 at 2:13 p.m. with LVN. The LVN stated, Resident 2 never stole Resident 1's shirt. Resident 1 had all belongings locked in a closet and Resident 1 was the only one with a key to that closet.A record review of Resident 2's Nursing progress note dated 8/10/2025 timed 4:00 p.m. indicated the unnamed LVN encouraged Resident 2 to switch rooms for safety, Resident 2 initially refused then agreed to move to another room.During an interview on 8/27/2025 at 2:00 p.m. with the Director of Medical Records (DMR). The DMR stated there was no SBAR dated 8/11/2025 found in either Resident 1 nor Resident 2's chart.During a concurrent interview and record review on 8/27/2025 at 3:55pm with the Licensed Vocational Nurse (LVN), Resident 1's Nursing progress dated 8/11/2025 timed at 2:16 p.m. was reviewed. The progress note was struck out indicating a reason: wrong chart. The struck-out progress note indicated the LVN was walking by Resident 2's new room when arguing was heard. The LVN looked inside of the room and saw Resident 1 arguing with Resident 2. The LVN attempted to deescalate the very heated argument. LVN managed to get Resident 2 to step aside so Resident 1 could exit the room. Resident 1 still refused to leave to the LVN stepped in between both residents and attempted to help Resident 1 pass by to exit the room. As Resident 1 was exiting the room they were both calling each other names. As Resident 1 was passing by Resident 2, Resident 1 swung at Resident 2 and hit Resident 2 on the nose. Resident 2 then struck back at Resident 1 and hit Resident 1 on the back of the head. Resident 1 was then pushed out of the room. The LVN stated, The note was struck out because I wasn't sure if I was supposed to document it on Resident 1 or Resident 2's chart. My plan was to go back and document it on Resident 2's chart since Resident 2 was the victim, but it slipped my mind. Resident 1 was in the wheelchair (w/c) when this happened, I am the one who wheeled Resident 1 out of the room. After this we notified the police, and they came and gave both residents an order to stay 25 feet away from each other. I was the charge nurse on 8/11/2025 and I informed the nurses the two residents had a verbal altercation the day before, so they were aware.A record review of Resident 1's Nursing progress note dated 8/10/2025 timed at 3:57 p.m. indicated frequent visual checks to prevent another altercation occurring throughout shift.A record review of Resident 1's Nursing progress note dated 8/11/2025 timed 12:41 a.m. indicated resident was sleeping. No further documentation found indicating monitoring of resident 1.During a concurrent interview and record review on 8/27/2025 at 3:10 p.m. with the director of Nursing (DON). Resident 1's electronic medical record was accessed. No specific record was reviewed. The DON was unable to show a care plan with interventions to prevent another incident after Resident 2 moved to another room. The DON was unable to show evidence of an interdisciplinary team note (IDT) conducted after the Resident 2 switched rooms. The DON was unable to show evidence of monitoring Residents after Resident 2 switched rooms. The DON stated, Can you just give me the deficiency. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management revised 5/30/2024, the P&P indicated, 1.Definitions:a. Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, and physical or chemical restraint not required to treat symptoms, and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Abuse includes the neglect and deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well­being. Abuse also includes verbal abuse, sexual abuse, physical abuse, mental abuse, or abuse facilitated or enabled by the use of technology that causes physical harm, pain, or mental anguish.b. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability.c. Sexual abuse is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.d. Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. It also includes corporal punishment which is physical punishment used to correct and/or control behavior. {.} The administrator or designated representative will provide for a safe environment for the resident as indicated by the situation.i. If the suspected perpetrator is another resident, separate the resident so they do not interact with each other until the circumstances of the reported incident can be clarified.

Based on interview and record review for two of three sampled residents, (Resident 1 and 2) the facility failed to report an incident of verbal abuse to the California Department of Public Health (CDPH) and failed to report an incident of physical abuse timely.This deficient practice placed Residents 1 and 2 at risk for further abuse.Cross Reference: F600.Findings:A review of Resident 1's admission Record indicated the facility originally admitted this [AGE] year old male on 12/2/2024 and most recently on 7/3/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Anxiety disorder (feelings of persistent fear and worry), hypothyroidism (thyroid gland does not produce enough thyroid hormone), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), other abnormalities of gait (walking) and mobility, hyperlipidemia (HLD-high fat in the blood), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), coronary artery ( - a slow progressive separation of the layers of the heart vessels) dissection and atrial fibrillation (heart dysrhythmia).A review of Resident 1's Minimum Data Set (MDS- a resident assessment) dated 7/10/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 1 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper only assists before or after activity) with toileting and showering. Resident was independent (Resident completes activity by themselves with no assistance from helper), with transfers (moving between surfaces) from bed to chair.A review of Resident 2's admission Record indicated the facility admitted this [AGE] year-old male on 7/16/2025 with diagnoses including Osteomyelitis (inflammation of bone or bone marrow, usually due to infection), HLD, difficulty walking, Essential hypertension (HTN-high blood pressure) and DM.A review of Resident 2's MDS dated [DATE] indicated Resident 2's cognition (mental ability to make decisions for daily living) was intact. Resident 2 required moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting, showering and transfers (moving between surfaces) from bed to chair.During a review of Resident 1's SBAR communication form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/31/2025 indicated while unnamed licensed Vocational Nurse (LVN) was in room administering intravenous (IV) medication to Resident 2, Resident 1's table was moved from the walkway. After which Resident 1 became angry and verbally aggressive toward the unnamed LVN. Resident 2 then asked Resident 1 to be nice, and Resident 1 began cursing at both the unnamed LVN and Resident 2. Resident 1 then walked up to Resident 2 and lifted the cane towards Resident 2 as if Resident 1 was going to hit Resident 2 with the cane. Room changes offered, however both residents refused. The medical doctor (MD) 1 was informed however the unnamed LVN was awaiting a response.During a review of Resident 1's SBAR dated 8/10/2025 indicated at 9:05 a.m. Resident 1 was yelling, cursing and accusing Resident 2 of stealing a shirt. Resident 2 then became upset and yelled back at Resident 1, both exchanging verbal, racial remarks. Safety precaution measures were implemented, and residents were relocated to prevent further escalation. MD 1 was informed and recommended to monitor and redirect as needed.During an interview on 8/27/2025 at 1:35 p.m. with the medical doctor (MD). The MD stated Resident 1 should have been discharged a long time ago. Resident 1 had no skilled need to be here. Resident 1 left the facility often driving a vehicle. Resident 1 was very aggressive and attacked multiple residents.During an interview on 8/27/2025 at 2:13 p.m. with LVN. The LVN stated, Resident 2 never stole Resident 1's shirt. Resident 1 had all belongings locked in a closet and Resident 1 was the only one with a key to that closet.A record review of Resident 2's Nursing progress note dated 8/10/2025 timed 4:00 p.m. indicated the unnamed LVN encouraged Resident 2 to switch rooms for safety, Resident 2 initially refused then agreed to move to another room.During an interview on 8/27/2025 at 2:00 p.m. with the Director of Medical Records (DMR). The DMR stated there was no SBAR dated 8/11/2025 found in either Resident 1 nor Resident 2's chart.During a concurrent interview and record review on 8/27/2025 at 3:55pm with the Licensed Vocational Nurse (LVN), Resident 1's Nursing progress dated 8/11/2025 timed at 2:16 p.m. was reviewed. The progress note was struck out indicating a reason: wrong chart. The struck-out progress note indicated the LVN was walking by Resident 2's new room when arguing was heard. The LVN looked inside of the room and saw Resident 1 arguing with Resident 2. The LVN attempted to deescalate the very heated argument. LVN managed to get Resident 2 to step aside so Resident 1 could exit the room. Resident 1 still refused to leave to the LVN stepped in between both residents and attempted to help Resident 1 pass by to exit the room. As Resident 1 was exiting the room they were both calling each other names. As Resident 1 was passing by Resident 2, Resident 1 swung at Resident 2 and hit Resident 2 on the nose. Resident 2 then struck back at Resident 1 and hit Resident 1 on the back of the head. Resident 1 was then pushed out of the room. The LVN stated, The note was struck out because I wasn't sure if I was supposed to document it on Resident 1 or Resident 2's chart. My plan was to go back and document it on Resident 2's chart since Resident 2 was the victim, but it slipped my mind. Resident 1 was in the wheelchair (w/c) when this happened, I am the one who wheeled Resident 1 out of the room. After this we notified the police, and they came and gave both residents an order to stay 25 feet away from each other. I was the charge nurse on 8/11/2025 and I informed the nurses the two residents had a verbal altercation the day before, so they were aware.A record review of Resident 1's Nursing progress note dated 8/10/2025 timed at 3:57 p.m. indicated frequent visual checks to prevent another altercation occurring throughout shift.A record review of Resident 1's Nursing progress note dated 8/11/2025 timed 12:41 a.m. indicated resident was sleeping. No further documentation found indicating monitoring of resident 1.During a concurrent interview and record review on 8/27/2025 at 3:10 p.m. with the director of Nursing (DON). Resident 1's electronic medical record was accessed. No specific record was reviewed. The DON was unable to show a care plan with interventions to prevent another incident after Resident 2 moved to another room. The DON was unable to show evidence of an interdisciplinary team note (IDT) conducted after the Resident 2 switched rooms. The DON was unable to show evidence of monitoring Residents after Resident 2 switched rooms. The DON stated, Can you just give me the deficiency. During a concurrent interview and record review on 8/27/2025 at 4:11 p.m. with the Administrator (Adm). A Fax confirmation page and abuse report dated 8/12/2025 were reviewed. The abuse report indicated physical as the type of abuse being reported. Resident 1 as the abuser and Resident 2 as the victim. The fax confirmation sheets indicated the report was faxed to CDPH, the police department and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). The Adm stated, we reported the incident of physical abuse however we did not report the incident of verbal abuse. The Adm stated, I was aware of both incidents, and all forms of abuse should be reported to CDPH within 2 hours. A review of the facility policy and procedure titled, Abuse Prevention and Management revised 5/30/2024 indicated, 1. Definitions:a. Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, and physical or chemical restraint not required to treat symptoms, and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Abuse includes the neglect and deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well­being. Abuse also includes verbal abuse, sexual abuse, physical abuse, mental abuse, or abuse facilitated or enabled by the use of technology that causes physical harm, pain, or mental anguish.b. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability. {.} Notification of Outside Agencies for All Allegations of Abuse.a. The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours.

Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was closely supervised, monitored, and within staff reach to prevent a fall. The facility was aware that Resident 1 is confused (is the inability to think as clearly or quickly as you normally do), has a history of falls, and impulsive behavior (refers to actions that are taken without sufficient thought or consideration of the consequences) of getting up from the wheelchair (WC) without assistance.This deficient practice resulted in Resident 1 falling on 6/24/2025 at 8:30 PM. On 6/24/2025 at 8:30 PM, Resident 1 was transferred to a General Acute Care Hospital (GACH) emergency room (the department of a hospital that provides immediate treatment for acute (sudden onset) illnesses and trauma[injury]) for further evaluation via 911 (emergency response telephone number). GACH diagnosed Resident 1 with closed fracture (a break in a bone that does not extend through the skin or surrounding tissues) of the left orbital floor (the bony socket around the eye), and swelling and abrasion (a superficial wound caused by the scraping or rubbing away of skin or other surface tissue) of the left eyebrow. During a review of Resident 1's admission Record indicated the facility admitted Resident 1 was admitted on [DATE] with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life), muscle wasting/atrophy (when muscles start to shrink and weaken), difficulty in walking, and mixed incontinence (involuntary leakage of urine). During a review of Resident 1's admission Fall Risk Evaluation record dated 5/28/2025, the fall risk evaluation record indicated that Resident 1's fall risk score was 10 (a score of 10 or greater is an indicator that the resident is at a high risk for falls). The fall risk evaluation record indicated that fall prevention protocol (nonspecific) should be initiated immediately and documented on the care plan. During a review of Resident 1's High Risk for Fall care plan (CP) initiated on 5/29/2025, the CP indicated that Resident 1 is a high risk for falls related to the history of fall, confusion, incontinence (the involuntary loss of urine and stool), poor communication/comprehension, psychoactive drug (a drug or substance that causes changes in mood, awareness, thoughts, feelings, or behavior) use and recent hip surgery (not specified). The High Risk for Fall CP indicated Resident 1 has balance problem while standing and while walking, has decreased muscular coordination, and requires use of assisting device (such as cane, wheelchair, walker, and furniture) for mobility. The High Risk for Fall CP goals included to assist Resident 1 with ambulation and transfers, . and evaluate for fall risk on admission and PRN (as necessary). During a review of Resident 1's Care Plan Report on Status Post Fall (S/P) dated initiated 5/29/2025 and revised on 6/25/2025, indicated Resident 1 fell on [DATE]. The Care Plan Report goals indicated that Resident 1 will be free of falls, will be free of minor injury, and will not sustain serious injury through target date of 9/9/2025. The Care Plan Report interventions included facility to follow the fall protocol (unspecified), frequent visual monitoring, and place the resident in front of the nursing for visual monitoring . and prompt availability of staff (initiated on 6/2/2025). The Care Plan Report interventions also included to review information on past falls and attempting to determine cause of falls. During a review of Resident 1's Multidisciplinary Care Conference (MCC-is a mechanism by which information is shared between various professionals involved in the patient's care) dated 5/30/2025, at 11 A.M., the MCC indicated Resident 1 is a high risk for falls. The MCC interventions included to have the resident's bed in a low position, placing bilateral (both side) floor mats, and supervising Resident 1 closely. The MCC indicated that Resident 1 family member (FM) stated Resident 1 has been having anxiety, has poor impulse control, is high risk for falls, and does not call for assistance. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/4/2025, it indicated Resident 1 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff assistance 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 1's Situation Background Appearance Review and notify (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 6/24/2025 documented by Licensed Vocational Nurse (LVN) 1, the SBAR indicated that on 6/24/2025 at 8:30 P.M. had a witnessed fall and hit her head (Fall witnessed by LVN 1). The SBAR indicated, [Resident 1] stood up from the [WC] attempting to ambulate without assistance. Upon assessment, [Resident 1] alert and responsive. Observed [Resident 1] with left eye swelling and applied ice pack. [Resident 1] able to move all extremities without difficulty. The SBAR indicated that a Medical Doctor (MD) was paged (to call a person using a loudspeaker/electric device) who gave an order to transfer Resident 1 to emergency room (the department of a hospital that provides immediate treatment for acute (sudden onset) illnesses and trauma[injury]) for further evaluation. Orders (MD) taken and carried out. The SBAR indicated Resident 1 was transferred to GACH via 911. During a review of Resident 1's Emergency Department After Visit Summary GACH record dated 6/24/2025, the GACH records indicated, the reason for visit (Resident 1), fall. Diagnoses abrasion of the left eyebrow, ground level fall, closed fracture of the left orbital floor, and injury of the head. During an interview on 7/1/2025, at 12:58 P.M., with LVN 1, LVN 1 stated Resident 1 is dependent on WC for mobility, requires frequent use of the bathroom to urinate and tries to get up from the WC, and attempts to walk. LVN 1 stated Resident 1 has a diagnosis of dementia, which causes Resident 1 to forget that she (Resident 1) is not steady on her feet and that is reason the facility staff instructs Resident 1 to stop getting up when the resident tries to get up from the WC without staff assistance. LVN 1 stated that sometimes Resident 1 listens to the instructions and other times the resident does not. LVN 1 stated the facility staff will quickly get to the resident to prevent the resident from getting up without assistance and does not fall. LVN 1 stated facility staff will have Resident 1 seat at the nursing station, and sometimes behind the nursing station with a staff to ensure that the staff can easily catch the resident to prevent falls when the resident tries to get up from the WC. LVN 1 stated that on 6/24/2025 around 8:15 P.M., LVN 1 stated Resident 1 was seating approximately 8 feet (ft-unit of measurement) in the hallway and across the nursing station between resident room numbers 18 and 20 with no direct access to Resident 1. LVN 1 stated Resident 1 was wearing eyeglasses. LVN 1 stated LVN 1 was seated behind the desk at the nurses station and was the only staff at the nursing station. LVN 1 stated LVN 1 observed Resident 1 suddenly/slowly stood up from the WC and LVN 1 verbalized to Resident 1 to stop getting up from the WC and to seat back down. LVN 1 stated Resident 1 did not stop, and that by the time LVN 1 moved from behind the nursing station desk, Resident 1 was up already, turned to the left, attempted to ambulate by taking maybe one step and then fell to the floor and hit the left side of the face with the eyeglasses still on. LVN 1 stated Resident 1 suffered redness to the corner of the left eye and that the redness progressively increased with swelling. LVN 1 stated she applied ice on the resident's left eye. LVN 1 stated she called 911 to transfer Resident 1 to GACH because the resident was on a blood thinner (did not specified). LVN 1 stated Resident 1 left for GACH on 6/24/2025 at around 8:30 P.M. LVN 1 stated Resident 1 is at risk for falls because the resident is [AGE] years old, very fragile, has dementia, and is on Ativan (a medication primarily used to help people feel calmer and less anxious). LVN 1 stated if LVN 1 had been close enough (arm's length [DA1] - very near or close by, easily reachable) to Resident 1, then LVN 1 would have been able to quickly get to and brace Resident 1's fall because Resident 1 is small enough. LVN 1 further stated LVN 1 should also have placed Resident 1 behind the nursing station next to LVN 1 as LVN 1 has previously done. LVN 1 stated, close supervision means that the resident needs to be watched at all times, at least an arm's length away. During a concurrent interview and record review on 7/1/2025, at 3:05 P.M., with the Director of Nursing (DON), Resident 1's admission Falls risk Evaluation record dated 5/28/2025, high risk for fall care plan dated 5/29/2025, and MCC notes dated 5/30/2025 were reviewed. The DON stated the Resident 1's admission Falls risk Evaluation record, high risk for fall care plan, and MCC notes indicated that Resident 1 was high risk for fall and that the resident required close supervision by staff. The DON stated Resident 1's high risk for fall care plan was not revised after the Interdisciplinary Team (IDT [MCC] - refers to a group of healthcare professionals from different fields who collaborate to provide comprehensive patient care) meeting on 5/30/2025 at 11 AM should include to supervise Resident 1 closely. The DON stated that close resident supervision means that the staff needs to be within the reach of a resident. The DON stated that within reach means at arm's length of the staff. The DON stated that Resident 1's care plan should have been revised based on IDT recommendation which is resident specific which includes resident centered interventions. During a review of the facility policy and procedures (P&P), titled, Fall Management Program, revised 3/13/2021, the P&P indicated, Purpose -To provide residents a safe environment that minimizes complications associated with falls.C. The interdisciplinary Team (IDT) and/or the licensed nurse will develop a care plan according to the identified risk factors and root cause(s) per care area assessment (CAA) guidelines.D. The IDT will initiate, review, and update the resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall and as needed. Post-Fall Response:A. Following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the resident's care plan.Fall Investigation, Reporting, and Documentation:C. IDT will investigate the fall including a review of the resident's medical record .D. IDT will review circumstances surrounding the fall .will review and revise the care plan as necessary.Recurrent Falls:A. A resident who endures more than one fall . will be considered at high risk for falls.B. Monthly, for those (residents) identified as high risk for falls, the IDT will meet to review the fall risk interventions for appropriateness and effectiveness until the frequency of their (residents) falls diminishes.C. The residents' care plans will be updated with the IDT recommendations. During a review of the facility P&P, titled Resident Safety revised on 4/15/2021, the purpose of P&P indicated, To provide a safe and hazard free environment.Policy:Residents will be evaluated on admission quarterly and whenever there s a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident.Procedure:I. During the comprehensive assessment period [NAME] interdisciplinary team (IDT) members will assess the resident's safety (e.g. [example], fall. behavior issues) as well as any other resident specific safety risks.III. After a risk evaluation is completed, a resident centered care plan will be developed to mitigate safety risk factors.IV. The IDT will establish a person-centered observation or monitoring systems for the resident to address the identified risk factors identified.V. To observe the safety and wellbeing of the residents, . The person-centered care plan may require more frequent safety checks.

Cross Referenced F580, F609, F656 Based on interview and record review, the facility failed to implement its policies and procedures by failing to ensure an investigation was completed for any reasonable suspicion of an abuse in accordance with state and federal law for one of eight sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Findings: During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a concurrent interview and record review on 1/29/2025 at 1:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1 ' s PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) did not remember reporting the issue to the Director of Nursing (DON), neither to the Facility Administrator (FA). LVN1 stated that he (LVN1) was supposed to report any possible abuse to the DON and FA and start an investigation. During an interview on 1/29/2025 at 1:26 p.m., with the Registered Nursing Supervisor (RNS)1, RNS1 stated that she (RNS1) was not aware of Resident 1 ' s issue of possible abuse. RNS1 stated that if LVN1 reported it to her (RNS1), RNS1 could have done an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and the Department of Public of Health (DPH). During an interview on 1/29/2025 at 1:28 p.m., with the DON, DON stated that she (DON) was not informed of Resident 1 ' s issue of possible abuse. DON stated that they need to do an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and DPH. DON also stated that even if a resident has episodes of making up stories, they (facility staff) still are mandated reporter and a possible abuse investigation was necessary. During an interview on 1/29/2025 at 1:31 p.m., with the Social Service Director (SSD), SSD stated that she (SSD) was not informed of Resident 1 ' s issue of possible abuse. SSD stated that the facility needs to do a proper investigation regardless of resident ' s condition and facility staff are mandated to report for resident ' s safety. During a review of the facility ' s P&P, titled, Abuse and Neglect, reviewed on 6/19/2024, P&P indicated that the facility will protect the health , safety and welfare of facility residents by ensuring that all reports of residents abuse, mistreatment, neglect, exploitation, injuries of unknown source and suspicion of crimes are promptly reported and thoroughly investigated. Cross Referenced F580, F609, F656 Based on interview and record review, the facility failed to implement its policies and procedures by failing to ensure an investigation was completed for any reasonable suspicion of an abuse in accordance with state and federal law for one of eight sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Findings: During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a concurrent interview and record review on 1/29/2025 at 1:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) did not remember reporting the issue to the Director of Nursing (DON), neither to the Facility Administrator (FA). LVN1 stated that he (LVN1) was supposed to report any possible abuse to the DON and FA and start an investigation. During an interview on 1/29/2025 at 1:26 p.m., with the Registered Nursing Supervisor (RNS)1, RNS1 stated that she (RNS1) was not aware of Resident 1's issue of possible abuse. RNS1 stated that if LVN1 reported it to her (RNS1), RNS1 could have done an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and the Department of Public of Health (DPH). During an interview on 1/29/2025 at 1:28 p.m., with the DON, DON stated that she (DON) was not informed of Resident 1's issue of possible abuse. DON stated that they need to do an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and DPH. DON also stated that even if a resident has episodes of making up stories, they (facility staff) still are mandated reporter and a possible abuse investigation was necessary. During an interview on 1/29/2025 at 1:31 p.m., with the Social Service Director (SSD), SSD stated that she (SSD) was not informed of Resident 1's issue of possible abuse. SSD stated that the facility needs to do a proper investigation regardless of resident's condition and facility staff are mandated to report for resident's safety. During a review of the facility's P&P, titled, Abuse and Neglect, reviewed on 6/19/2024, P&P indicated that the facility will protect the health , safety and welfare of facility residents by ensuring that all reports of residents abuse, mistreatment, neglect, exploitation, injuries of unknown source and suspicion of crimes are promptly reported and thoroughly investigated.

Cross Referenced F609, F610, F656 Based on interview and record review, the facility staff failed to notify the physician when a resident had a change of condition (CIC) for one of eight sampled residents (Resident 1). This deficient practice had the potential to result in delayed provision of necessary care, treatment and services to Resident 1. Findings: During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a concurrent interview and record review on 1/29/2025 at 1:39 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1 ' s PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) was supposed to report to the physician and document Resident 1 ' s COC via SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition). LVN1 also stated that he (LVN1) was not sure why it was not completed. During a review of the facility ' s policy and procedures (P&P) titled, Change of Condition Notification, reviewed on 6/19/2024, P&P indicated, that Facility to ensure residents, family, legal representatives and physicians are informed of changes in the resident ' s condition in a timely manner . COC related to attending physician notification is defined as when the attending physician must be notified when any sudden and marked adverse change in the resident ' s condition in which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in the treatment plan. Cross Referenced F609, F610, F656 Based on interview and record review, the facility staff failed to notify the physician when a resident had a change of condition (CIC) for one of eight sampled residents (Resident 1). This deficient practice had the potential to result in delayed provision of necessary care, treatment and services to Resident 1. Findings: During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a concurrent interview and record review on 1/29/2025 at 1:39 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) was supposed to report to the physician and document Resident 1's COC via SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition). LVN1 also stated that he (LVN1) was not sure why it was not completed. During a review of the facility's policy and procedures (P&P) titled, Change of Condition Notification, reviewed on 6/19/2024, P&P indicated, that Facility to ensure residents, family, legal representatives and physicians are informed of changes in the resident's condition in a timely manner . COC related to attending physician notification is defined as when the attending physician must be notified when any sudden and marked adverse change in the resident's condition in which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in the treatment plan.

Cross Referenced F580, F610, F656 Based on interview and record review, the facility failed to implement policies and procedures (P&P) to ensure reporting of a reasonable suspicion of an abuse in accordance with state and federal law for one of eight sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Findings: During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a concurrent interview and record review on 1/29/2025 at 1:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1 ' s PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) did not remember reporting the issue to the Director of Nursing (DON), neither to the Facility Administrator (FA). LVN1 stated that he (LVN1) was supposed to report any possible abuse to the DON and FA. During an interview on 1/29/2025 at 1:26 p.m., with the Registered Nursing Supervisor (RNS) 1, RNS1 stated that she (RNS1) was not aware of Resident 1 ' s issue of possible abuse. RNS1 stated that if LVN1 reported it to her (RNS1), RNS1 could have done an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and the Department of Public of Health (DPH). During an interview on 1/29/2025 at 1:28 p.m., with the DON, DON stated that she (DON) was not informed of Resident 1 ' s issue of possible abuse. DON stated that they need to do an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and DPH. DON also stated that even if a resident has episodes of making up stories, they (facility staff) still are mandated reporter and a possible abuse investigation was necessary. During an interview on 1/29/2025 at 1:31 p.m., with the Social Service Director (SSD), SSD stated that she (SSD) was not informed of Resident 1 ' s issue of possible abuse. SSD stated that the facility needs to do a proper investigation regardless of resident ' s condition and facility staff are mandated to report for resident ' s safety. During a review of the facility ' s policy and procedures (P&P) titled, Reporting Abuse, reviewed on 6/19/2024, P&P indicated that facility to ensure compliance with federal, and state laws and regulations regarding reporting of incidents and suspected incidents of abuse, neglect and mistreatment of residents. P&P also stated that facility staff are mandatory reporters. During a review of the facility ' s P&P, titled, Abuse and Neglect, reviewed on 6/19/2024, P&P indicated that the facility will report all allegations of abuse and criminal activity, as required by law and regulations, to the appropriate agencies. P&P also indicated that, allegations of abuse .are to be reported to the administrator or designated representative immediately. Cross Referenced F580, F610, F656 Based on interview and record review, the facility failed to implement policies and procedures (P&P) to ensure reporting of a reasonable suspicion of an abuse in accordance with state and federal law for one of eight sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse. Findings: During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a concurrent interview and record review on 1/29/2025 at 1:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) did not remember reporting the issue to the Director of Nursing (DON), neither to the Facility Administrator (FA). LVN1 stated that he (LVN1) was supposed to report any possible abuse to the DON and FA. During an interview on 1/29/2025 at 1:26 p.m., with the Registered Nursing Supervisor (RNS) 1, RNS1 stated that she (RNS1) was not aware of Resident 1's issue of possible abuse. RNS1 stated that if LVN1 reported it to her (RNS1), RNS1 could have done an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and the Department of Public of Health (DPH). During an interview on 1/29/2025 at 1:28 p.m., with the DON, DON stated that she (DON) was not informed of Resident 1's issue of possible abuse. DON stated that they need to do an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and DPH. DON also stated that even if a resident has episodes of making up stories, they (facility staff) still are mandated reporter and a possible abuse investigation was necessary. During an interview on 1/29/2025 at 1:31 p.m., with the Social Service Director (SSD), SSD stated that she (SSD) was not informed of Resident 1's issue of possible abuse. SSD stated that the facility needs to do a proper investigation regardless of resident's condition and facility staff are mandated to report for resident's safety. During a review of the facility's policy and procedures (P&P) titled, Reporting Abuse, reviewed on 6/19/2024, P&P indicated that facility to ensure compliance with federal, and state laws and regulations regarding reporting of incidents and suspected incidents of abuse, neglect and mistreatment of residents. P&P also stated that facility staff are mandatory reporters. During a review of the facility's P&P, titled, Abuse and Neglect, reviewed on 6/19/2024, P&P indicated that the facility will report all allegations of abuse and criminal activity, as required by law and regulations, to the appropriate agencies. P&P also indicated that, allegations of abuse .are to be reported to the administrator or designated representative immediately.

Cross Referenced F580, F609, F610 Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of eight sampled residents (Resident 1) by failing to ensure a care plan was completed when Resident 1 stated to Licensed Vocational Nurse (LVN) 1, that Resident 1 was raped and touched by a Certified Nursing Assistant (CNA). This deficient practice had the potential to result negative impact on Resident 1 ' s health and safety, as well as the quality of care and services received. Findings: During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a review of Resident 1's Care Plan (CP), as of 1/29/2025, CP indicated no documentation when Resident 1 stated to Licensed Vocational Nurse (LVN) 1, that Resident 1 was raped and touched by a CNA. During a concurrent interview and record review on 1/29/2025 at 1:39 p.m., with LVN1, Resident 1 ' s Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1 ' s PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) was supposed to ensure an individualized care plan was completed for Resident 1. LVN1 also stated that he (LVN1) was not sure why it was not completed. During a review of the facility ' s policy and procedures (P&P) titled, Comprehensive Person-Centered Care Planning, reviewed on 6/19/2024, P&P indicated, that the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition; iii. In preparation for discharge; iv. To address changes in behavior and care; and v. Other times as appropriate or necessary. During a review of the facility ' s P&P titled, Change of Condition Notification, reviewed on 6/19/2024, P&P indicated, under documentation that, A licensed nurse will document and update the care to reflect the resident ' s current status. Cross Referenced F580, F609, F610 Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident's individual assessed needs for one of eight sampled residents (Resident 1) by failing to ensure a care plan was completed when Resident 1 stated to Licensed Vocational Nurse (LVN) 1, that Resident 1 was raped and touched by a Certified Nursing Assistant (CNA). This deficient practice had the potential to result negative impact on Resident 1's health and safety, as well as the quality of care and services received. Findings: During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand). During a review of Resident 1's Care Plan (CP), as of 1/29/2025, CP indicated no documentation when Resident 1 stated to Licensed Vocational Nurse (LVN) 1, that Resident 1 was raped and touched by a CNA. During a concurrent interview and record review on 1/29/2025 at 1:39 p.m., with LVN1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) was supposed to ensure an individualized care plan was completed for Resident 1. LVN1 also stated that he (LVN1) was not sure why it was not completed. During a review of the facility's policy and procedures (P&P) titled, Comprehensive Person-Centered Care Planning, reviewed on 6/19/2024, P&P indicated, that the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition; iii. In preparation for discharge; iv. To address changes in behavior and care; and v. Other times as appropriate or necessary. During a review of the facility's P&P titled, Change of Condition Notification, reviewed on 6/19/2024, P&P indicated, under documentation that, A licensed nurse will document and update the care to reflect the resident's current status.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) was monitored and supervised to prevent fall and injuries as evidenced by failing to: 1. Ensure Resident 4's bed was in low position based on Resident 4's fall care plan and physician order. 2. Ensure Resident 4 had floor mats based on Resident 4's fall care plan and physician order. 3. Ensure Resident 4 was not left unattended by Certified Nursing Assistant 4 (CNA 4) while the bed was in high position , and the bed rails (also called side rails; are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths) are in position (on). These deficient practices resulted in Resident 4 had a fall sustaining a head injury and laceration (a deep cut or tear in skin or flesh) to the left eyebrow on 5/6/2024 where she was transferred to General Acute Care Hospital 1 (GACH 1). Findings: A record review of the Admission Record (Face Sheet) indicated Resident 4, was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, disorder of bone density (amount of bone mineral in the bone) and structure, cachexia (a general state of ill health involving great weight loss and muscle loss), hypertension (high blood pressure), and malignant neoplasm (cancer tumor) of the thymus (a small organ that lies in the upper chest under the breastbone). A record review of Resident 4's Bed Rail Assessment, dated 9/30/2023, indicated Resident 4's level of consciousness fluctuates (rise and fall irregularly). The Bed Rail Assessment indicated Resident 4 had an altered safety awareness due to cognitive (involve the ability to acquire factual information) decline, had displayed poor mobility or difficulty moving to a sitting position on the side of the bed, and had difficulty with balance or poor trunk control (ability to hold the body upright when sitting or moving). The Bed Rail Assessment indicated interventions to lower the bed to the floor and provide restorative care to enhance Resident 4's abilities to safely stand and walk. The Bed Rail Assessment indicated side rail placement recommendations of bilateral (both sides) side rails, which are indicated to serve as an enabler to promote independence. A record review of Resident 4's Fall Risk Evaluation, dated 1/11/2024, indicated Resident 4 scored an 8. The evaluation indicated that a total score of 10 or higher identifies the resident as a high risk for potential falls. A record review of Resident 4's Minimum Data Set (MDS, a comprehensive assessment tool), dated 4/3/2024, indicated Resident 4 had severe cognitive impairment. The MDS also indicated Resident 4 was dependent on staff (helper does all effort. Resident does none of the effort to complete activity. Assistance of two or more helpers are required for the resident to complete the activity) on eating, oral hygiene, toileting, bathing, upper body dressing, lower body dressing, putting on and taking off footwear and personal hygiene. The MDS also indicated Resident 4 was dependent on staff when changing positions from rolling left and right, sitting to lying, lying to sitting on side of bed, bed to chair transfer, toilet transfer, and shower transfer. A record review of Resident 4's Physician Order, dated 3/27/2024, indicated an order for floor mat with low bed. The order identified Resident 4 as fall risk. A record review of Resident 4's care plan titled Resident on low bed with floor mat to decrease potential risk for injury, initiated on 4/15/2024, indicated a goal to prevent fall and injury until the next review date of 7/2/2024. The care plan indicated interventions of providing Resident 4 with frequent supervision and to provide Resident 4 a low bed with floor mats as ordered. A record review of Resident 4's care plan titled The resident has impaired cognitive function / or impaired thought process r/t (related to) difficulty making decisions, impaired decision making, psychotropic (drug or other substance that affects how the brain works) drug use, BIMS (Brief Interview for Mental Status; a mandatory tool used to screen and identify the cognitive condition of residents) score of 6, (score of 6 indicates severe cognitive impairment), initiated on 4/15/2024, indicated a goal for Resident 4 to maintain current level of cognitive function through the review date of 7/2/2024. One of the interventions included in the care plan is to cue, reorient and supervise Resident 4 as needed. A record review of Resident 4's care plan titled The resident has an alteration in musculoskeletal (part of the body that includes the muscle, bones, ligaments and tendons) status r/t (related to) disorder of bone density and structure, cachexia initiated on 4/15/2024, indicated a goal for Resident 4 to remain free of injuries or complications until the next review date of 7/2/2024. Interventions included in the care plan was to anticipate and meet Resident 4's needs, to be sure call light is within reach, to respond promptly to all of Resident 4's requests for assistance, to monitor and document for risk of falls and to educate resident, family and caregivers on safety measures that need to be taken in order to reduce risk of falls. A record review of Resident 4's Situation, Background, Assessment and Recommendation (SBAR, a tool used to facilitate prompt and appropriate communication between the healthcare team) Communication Form and Progress Note, dated 5/6/2024, indicated Resident 4 had a change in condition of fall. The SBAR Communication Form indicated Resident 4 was found on the floor with a laceration to the left eyebrow and hematoma (a mass of usually clotted blood that forms in a tissue, organ, or body space) to the right eyebrow. Resident 4 was assessed and sent to GACH 1 via emergency medical transport. A record review of Resident 4's Skilled Nursing Facility (SNF) to Hospital Transfer Form, dated 5/6/2024, indicated Resident 4 was transferred to GACH 1 on 5/6/2024 at 11:05 am because of a fall. The SNF to Hospital Transfer Form indicated Resident 4 was totally dependent on staff on all ADLs ( Activities of Daily Living) including bathing, dressing, toileting, transfers and eating. A record review of the Emergency Department Provider Note, dated 5/6/2024 at 11:19 am, indicated Resident 4 was diagnosed with head injury and a laceration of the left eyebrow. The physical assessment part of the note indicated a 1-centimeter (cm, unit of measurement) laceration to the left eyebrow. Resident 4 underwent a Computed Tomography scan (CT, a medical imaging scan used to obtain detailed internal images of the body) of the head and spine and X rays (medical imaging that creates pictures of bones and soft tissues, such as organs) of both humerus (bone of the upper arm) and was treated with a laceration repair where she received three sutures (a strand or fiber used to sew parts of the living body). A record review of Resident 4's CT of the head result from GACH 1, dated 5/6/2024, indicated frontal scalp soft tissue swelling. A record review of Resident 4's Post Fall Risk evaluation, dated 5/6/2024, indicated Resident 4 scored an 11. The evaluation indicated that a total score of 10 or higher identifies the resident as a high risk for potential falls. A record review of Resident 4's Post Fall Evaluation, dated 5/6/2024, indicated Resident 4 had an unwitnessed fall in her room that resulted to an injury of laceration to the left eyebrow and hematoma above her right eyebrow. The Post Fall Evaluation identified the improper height of the bed as one of the contributing factors of the fall. The Post Fall Evaluation indicated there was no floor mat on the floor. The Post Fall Evaluation also indicated Resident 4 complained of pain and exhibited facial expressions of pain to the head after the fall. A record review of Resident 4's Health Status Note, dated 5/6/2024, indicated Resident 4 returned to the facility from GACH 1 with three stitches on the left eyebrow / forehead. A record review of Resident 4's Weekly Skin/ Wound Assessment, dated 5/6/2024, indicated Resident 4 returned from GACH 1 with three (3) stitches in the left eyebrow / forehead, discoloration with hematoma in the center forehead, discoloration on the right eye, multiple discoloration on the left arm, multiple discoloration on the right arm with scab and right shin (front parts of your legs between knees and ankles) scratch. A record review of Resident 4's Health Status Note, dated 5/7/2024, indicated Resident 4 returned to the facility from GACH 1 with a left eyebrow laceration with three sutures, right periorbital (around the eyes) discoloration, forehead hematoma, right upper extremity (right arm) and left upper extremity (left arm) discoloration and a right forearm skin tear measuring at 1.1 cm x 0.3 cm. A record review of Resident 4's Physician Orders, dated 5/7/2024, indicated the orders of: [Treatment] L (left) eyebrow laceration w/ (with) sutures: Cleanse with NSS (normal saline solution, a cleansing solution made up of water and salt), pat dry and LOA (leave open to air) every day shift for 14 days and [Treatment] R (right) forearm skin tear: Cleanse with NSS, pat dry, apply xeroform (a petrolatum-based fine mesh gauze containing 3% bismuth tribromophenate [Medication that has antimicrobial properties]), and cover with foam dressing every day shift for 14 days. A record review of Resident 4's Progress Note, dated 5/7/2024 at 5:19 am, indicated Resident 4 complained of pain of 3/10. Resident 4 refused pain medications but was offered ice pack on her forehead for comfort measures. A record review of Resident 4's Interdisciplinary Progress Note (IDT, a group of healthcare professionals from various areas working together to set goals and make decisions) for Fall, dated 5/7/2024, indicated that the IDT met to discuss Resident 4's fall on 5/6/2024. The IDT Note indicated Resident 4 rolled out of bed after the CNA (later identified as Certified Nursing Assistant 4) provided ADL care. The IDT note indicated CNA 4 placed Resident 4 in the center of the bed, placed a fourth of the side rails up and went to the doorway to call for help with repositioning Resident 4 when suddenly Resident 4 was found on the floor next to her bed. The IDT note indicated CNA 4 immediately called for help and Resident 4 was assessed and was transferred to GACH 1 for evaluation. The IDT note indicated Resident 4 has behaviors of aggressions, striking at staff and moving abruptly. The IDT note indicated The IDT believes the resident was possibly angry regarding having care provided and moved abruptly in her bed due to her feelings and suddenly came off her bed. During an interview on 6/5/2024 at 2:50 pm, Resident 3 stated Resident 4 fell on [DATE] around 10 am in the morning. Resident 3 stated a curtain is separating her and Resident 4 when she heard a bang. Resident 3 pulled the curtain divider and saw Resident 4 on the floor, on the right side of the bed between the bed and the wall. Resident 3 stated she observed Resident 4's head bleeding after the fall. Resident 3 stated when Resident 4 fell , the side rails were up and not down, and the bed was also high because CNA 4 was changing Resident 4 before the fall happened. Resident 3 stated at the time of the fall, Resident 4 did not have floor mats beside her bed. Resident 3 stated Resident 4 left the facility to the hospital and came back with a right black eye and a cut on her left eyebrow. Resident 3 stated she is disappointed because Resident 4 fell because staff left her. During an interview on 6/5/2024 at 3 pm, Responsibly Party 1 (RP 1) stated the facility informed her of Resident 4's fall on 5/6/2024 at 11 am. RP 1 stated she visits Resident 4 every day and she has not seen floor mats placed beside her bed before the fall. RP 1 confirmed they were placed after the fall. RP 1 stated she observed Resident 4 withdrawn after the fall. RP 1 stated she believes the fall could have been prevented if two assistants were present when changing Resident 4 and if the side rails were not left up (not in position). During an interview on 6/5/2024 at 4:20 pm, Licensed Vocational Nurse 3 (LVN 3) stated and confirmed Resident 4 fell out of her bed on 5/6/2024. LVN 3 stated she heard a loud bang and went to Resident 4's room where she found Resident 4 on her back in between her bed and the wall. LVN 3 confirmed Resident 4 did not have floor mats and the height of the bed was high at hip level because CNA 4 was changing the resident before the fall. LVN 4 stated she observed Resident 4 was bleeding from her left eyebrow due to a laceration. LVN 4 stated when Resident 4 came back from GACH 1, she also observed Resident 4 with a black eye (discoloration) on her right eye and a bump on the middle of her forehead. LVN 3 stated she asked CNA 4 what happened and CNA 4 informed her she (CNA 4) stepped out of the room when Resident 4 fell . LVN 3 stated Resident 4's bed side rails should have been down and the height of the bed should be low. LVN 3 stated she believes the fall could have been prevented if CNA 4 placed the side rails in position. LVN 3 further stated that instead of leaving Resident 4, CNA 3 could have yelled for help. During a phone interview on 6/5/2024 at 5:03 pm, CNA 4 stated Resident 4 fell on [DATE]. CNA 4 stated It was really a mistake on my end. CNA 4 stated she had Resident 4's bed high while changing Resident 4 during incontinent care. CNA 4 stated after changing Resident 4, she stepped away from Resident 4's bedside to the door to ask for help to pull up (reposition) Resident 4. While waiting for someone to help, CNA 4 stated Resident 4 was kicking to the side of the bed, which prompted her to reposition Resident 4's leg back to the middle of the bed. CNA 4 stated while she was at the door, Resident 4 fell . CNA 4 stated she believes Resident 4 turned over while trying to kick and then fell . CNA 4 confirmed the height of the bed was high and the side rails were up. CNA 4 stated Resident 4 was screaming after the fall. CNA 4 stated Resident 4 also had a cut on her forehead and was bleeding after the fall. CNA 4 stated Resident 4's fall could have been prevented if she placed the side rails down and if she lowered the bed close to the floor for safety. CNA 4 stated it is important to have the side rails down and the bed low to prevent falls and to prevent the resident from rolling out of bed. During an interview on 6/5/2024 at 5:32 pm, the Interim Director of Nursing (IDON) stated a resident's height of the bed should be low and side rails down (in position) to ensure safety. The IDON stated side rails aid with mobility and repositioning. The IDON also stated side rails help with repositioning changes so residents do not slide out of bed. The IDON stated the bed being low is important so if the residents slide out of bed, the impact, which the IDON defined as the contact of the body to the floor, would be less. During a follow up interview on 6/5/2024 at 6:20 pm, CNA 3 stated the side rails is not the usual side rails set up that we used, if say the side rails are up, the resident can fall; while say if the side rails are down it protects the resident from rolling out of bed. CNA 3 stated leaving the side rails up defeats the purpose of protecting the resident from falling. A review of the facility's policy titled Fall Management Program, reviewed on 5/17/2023, indicated that the facility will provide residents a safe environment that minimizes complications associated with falls. A review of the facility's policy titled Resident Safety, reviewed on 5/17/2023, indicated that the purpose of the policy is to provide a safe and hazard free environment to the residents. The policy indicated that after a risk evaluation is completed, a resident-centered care plan will be developed to mitigate safety risk factors. A record review of the facility's policy titled Physician Orders, reviewed on 5/17/2023, indicated Whenever possible, the licensed nurse receiving the order will be responsible for documenting and carrying out the order.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents (Resident 1), who was assessed at risk for fall by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) provided two-person physical assistance (had help from another staff member) when turning Resident 1 in bed as indicated in Resident 1's Minimum Data Set (MDS- a required standardized assessment and care planning tool) dated 12/20/2023. 2. Ensure CNA 1 checked Resident 1's Low Air Loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) to make sure the LAL mattress was on static mode (firm surface set in place and unlikely to move) before CNA 1 turned Resident 1 to Resident 1's right side while giving Resident 1 a bed bath. As a result, Resident 1 fell from Resident 1's bed to the floor, on 01/19/2024, at 11:30 AM, Resident 1 sustained a fracture (break in a bone) of the right distal (a part of the body that is farther away from the center of the body) femur (thigh) and experienced pain (unrated) on the right leg. Findings: A review of Resident 1's Admission Record (background information; a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including multiple sclerosis (MS - a long lasting and disabling disease in which the body attacks itself affecting the brain and spinal cord [a long ropelike structure that sends commands from the brain to the body and vice versa]), abnormalities of gait (a person's manner of walking) and mobility (ability to move freely and easily), and quadriplegia (paralysis [complete or partial loss of muscle strength], that affects all four limbs and body from the neck down). A review of Resident 1's untitled Care Plan, initiated on 12/21/2021, and revised on 1/19/2024 indicated Resident 1 was at risk for falls related to the disease processes of impaired mobility, abnormalities of gait, muscle weakness, right arm weakness, and paraplegia (paralysis of the legs and lower body). The goal was for Resident 1 to be free from falls and the intervention was to provide a safe environment for Resident 1. A review of Resident 1's untitled Care Plan, initiated on 12/21/2021, and revised on 7/27/2023 indicated Resident 1 had self-care performance deficit (falling short of a desired amount) related to MS, muscle weakness, difficulty walking, and paraplegia. The goal was for Resident 1 to maintain current level of function in activities of daily living (ADL). The interventions were for Resident 1 to receive assistant from one to two staff for bed bath, turning, and repositioning in bed. A review of Resident 1's Fall Risk Evaluation, dated 11/26/2023, indicated Resident 1 was at risk for falls due to inability to perform gait (pattern of walking) and stand or move without falling. The goal was for Resident 1 to be free from falls and the intervention was to implement fall risk precautions. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 had moderately impaired cognition (mental ability to make decisions of daily living). Resident 1 had impairment (loss of part or all physical ability) on one side of the upper extremity (arm) and both sides on the lower extremities (legs). Resident 1 required substantial/maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs) when rolling from lying on back to left and right side and returning to lying on back on the bed. The MDS indicated Resident 1 was dependent on two or more staff for shower/bathing, dressing, personal hygiene, and lying down. A review of Resident 1's Nurses Progress Notes, dated 01/19/2024, at 10:21 PM, indicated Resident 1 complained of lower legs and lower back pain (unrated) after a fall. The notes indicated a Medical Doctor (MD) was notified and the MD ordered to transfer Resident 1 to a general acute care hospital (GACH) for a stat (immediate) X-ray (medical imaging technique that provide detailed images of the inside of the body) of the lower back and both lower extremities (legs). A review of Resident 1's Change in Condition (COC - a decline or improvement in a resident's mental, psychosocial, or physical functioning that requires a change in the resident's comprehensive plan of care) Evaluation completed by the DON, dated 01/19/2024 at 12:19 PM, indicated on 01/19/2024, Resident 1 was receiving a bed bath and CNA 1 was repositioning Resident 1 when the resident slipped from CNA 1's hands and fell to the floor. A review of the facility's fall investigation report, dated 01/24/2024, indicated CNA 1 failed to ensure Resident 1's LAL mattress was on a static/firm mode while turning Resident 1 in bed on 1/19/2024.The report indicated Resident 1 fell out of bed and sustained a fracture of the right distal femur. Resident 1 was immediately transferred to the hospital due to pain (unrated). The hospital informed the facility that Resident 1 had a right distal femur fracture. On 1/22/2024, Resident 1 was readmitted to the facility with half cast, (the hard part of a splint [a rigid or flexible device that maintains in position a displaced or movable part] also used to keep in place and protect an injured part does not wrap all the way around the injured area. A review of GACH Patient Report for Resident 1, dated 01/29/2024, indicated, right knee follow-up Xray report indicated fracture distal femur unchanged. The Xray was in comparison with right knee Xray completed on 01/19/2024. During an observation in Resident 1's room and concurrent interview with Resident 1 on 02/01/2024 at 3:26 PM, Resident 1 was lying in bed. Resident 1 was not moving the right arm and the lower extremities. Resident 1 stated she was partially blind (very limited vision) in my right eye because of MS. Resident 1 stated she was not able to move her lower body (from the waist down), Resident 1 stated Resident 1's right arm was very weak, and the left arm was weak. Resident 1 stated that during bed bath (on 119/2024), CNA 1 was standing behind Resident 1 and assisted Resident 1 with turning from Resident 1's back onto Resident 1's right side. Resident 1 stated, I fell off the bed as soon as I turned over. Resident 1 stated several nurses came into the room after CNA 1 called for help. Resident 1 stated, I told everyone that my leg was hurting, I said it many times immediately after the fall. Resident 1 stated a nurse (unidentified) gave Resident 1 Percocet (controlled medication for pain relief) to control the pain on Resident 1's right leg. Resident 1 stated Resident 1's right leg was still hurting a lot. Resident 1 stated only 1 staff (in general) provided bed bath for her. During an interview with CNA 1 on 02/02/2024 at 11:30 AM, CNA 1 stated on 1/19/2024, CNA 1 was providing a bed bath to Resident 1 assisting Resident 1 turn to Resident 1's right side away from CNA 1, and Resident 1 fell from the bed to the floor. CNA 1 stated Resident 1 was on a LAL mattress CNA 1 stated CNA 1 saw some kind of movement/motion and that's when Resident 1 fell . CNA 1 stated Resident 1 was on the floor facing up and the resident's head was near the foot of the bed. CNA 1 stated Resident 1 could not move Resident 1's legs and her arms due to weakness CNA 1 stated a second person/staff should have assisted her to turn and bathe Resident 1. CNA 1 stated, it's so easy for [Resident 1] to fall. CNA 1 stated she did not ask another staff to assist with Resident 1's bed bath due to no one was available. During an interview with LVN 2 on 02/02/2024 at 12:44 PM, LVN 2 stated that on 01/19/2024 morning (unable to recall the time), LVN 2 heard CNA 1 calling for help. LVN 2 stated LVN 2 went into Resident 1's room and saw Resident 1 lying on the floor facing up. LVN 2 stated Resident 1 was lifted off the floor and transferred back to bed. LVN 2 stated having another staff (any nursing staff) assist CNA 1 due to Resident 1 has MS and Resident 1 could not perform ADL due to weakness on all extremities (arms and leg). LVN 2 staff two staff providing bed bath for Resident 1 could have prevented Resident 1 from falling. During an interview with LVN 1 on 02/02/2024 at 4:02 PM, LVN 1 stated Resident 1's arms were weak, and Resident 1 was unable to move lower extremities. LVN 1 stated Resident 1 needed two people/staff to perform ADLs. During an observation in Resident 1's room and a concurrent interview with the DON on 02/02/2024 at 5:55 PM, the DON stated, two CNAs (in general) were supposed to perform ADLs on Resident 1. A review of the facility's policy and procedures (P&P) titled, Positioning and Body Alignment, dated 01/01/2012, indicated, staff must be aware of any limitation a resident may have in positioning. A review of the Low Air Loss (LAL) Mattress Instruction Manual Guide, undated, indicated staff must be carefully assessed for the best ways to keep the residents from harm, such as falling. Staff must identify safety risks involving the bed, mattress. The LAL mattress instruction indicated static mode was when the redistribute body mass over a greater surface area at the constant air pressure base on the resident comfort weight setting, and alternating pressure mode was alternating cell cycle with periodic pressure relief (pressure disturbed in wavelike movements). A review of the facility's P&P titled, Fall Management Program, dated 03/31/2021, indicated, The purpose of fall management program was to provide residents a safe environment that minimizes complications associated with falls. Licensed nurse will complete a fall risk evaluation and document interventions for every Resident regardless of fall risk evaluation score.

Based on interview and record review, the facility failed to provide necessary care and treatment for urinary tract infection (UTI, an infection in the drainage system for removing urine) due to failure to promptly (with little or no delay) notify a physician and or a nurse practitioner (NP - a nurse with a graduate degree in advanced practice nursing) of a urinalysis (UA - urine test used to check for infection or kidney problems) test results positive for bacteria on [DATE] and failure to place an order for urine culture and sensitivity (C&S -a test to diagnose germs such as bacteria or fungus [yeast or mold] that can cause an infection and checks on the appropriate medicine, such as an antibiotic [medication to treat infection]) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled, Laboratory -Critical values (laboratory results that are outside the normal range to a degree that may constitute an immediate health risk to the individual or require immediate action on the part of the ordering physician), revised ,d+[DATE]. As a result, on [DATE] at 10:30 A.M., Resident 1 developed altered mental status (AMS -change in mental function that maybe as a result of illness or injuries) and Resident 1 was transferred to a general acute care hospital (GACH) via 911 (telephone number used to reach emergency medical, fire, and police services). Resident 1 was treated for sepsis (a life-threatening medical emergency and the body's extreme response to an infection which causes organ damage) and UTI. Resident 1 was admitted to telemetry unit (a floor in a hospital where patients undergo continuous cardiac [heart] monitoring). Resident 1 died on [DATE]. Cross Reference 773 Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and generalized muscle weakness (lack of physical or muscle strength). A review of Resident 1's Minimum Data Set (MDS-a standardized screening tool) dated [DATE], indicated Resident 1 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required limited assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 1's history and physical (H&P) dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 was able to make needs known but could not make medical decisions. A review of Resident 1's complete blood count (CBC -blood test that checks for infection) report collected on [DATE], indicated Resident 1's neutrophils (white blood cells or WBC -body cells that protect against illness and disease) count was high at 80.2 percent (% - unit of measure, normal range is 45.0 % to 70.0 %). A review of Resident 1's Registered Nurse (RN) Note dated [DATE] at 11:46 A.M., indicated pending urine results for urinalysis and urine C&S for Resident 1. The nurses' notes indicated to inform the NP of the urine results once received. A review of Resident 1's UA report dated [DATE], indicated urine collection time not provided. The UA report indicated that Resident 1's urine sample was slightly cloudy (indicates presence of an infection, blood, pus, protein [normal urine color is pale/light/clear yellow]), white blood cells (WBC - are part of CBC that help fight infections) count was high at 5 (five) per high power field (HPF- diagnostic evaluation such as the quantification), (reference range [RR] is zero to two [,d+[DATE]]), and protein was 100 milligrams per deciliter (mg/dL-unit of measurement (RR negative or none)). The UA indicated presence of bacteria (RR is none) and moderate mucus (RR is none to few). A review of Resident 1's interfacility transfer form dated [DATE] at 2:40 P.M., indicated at 10:30 A.M., Resident 1's family member (FM) approached the charge nurse (not identified) stating Resident 1 had AMS. On assessment, charge nurse found Resident 1 with AMS, unable to answer simple questions which is not within her baseline and her blood pressure (BP) was recorded low at ,d+[DATE] millimeters of mercury (mmHg -unit of measure [normal BP is ,d+[DATE] mmHg]) and pulse (heart rate) was 61 beats per minute (bpm -number of times the heart beats per minute).The facility called 911 and Resident 1 was transferred to GACH at 11 A.M. A review of GACH Emergency Provider (a physician who evaluates/manages/treats people with severe injuries or sudden illnesses) Note for Resident 1 dated [DATE] at 11:20 A.M., indicated Resident 1 was brought in by Emergency Medical Services (EMS - a team of medical professionals who respond to 911 (a telephone number that links the public to the police and mobile rescue units to provide emergency care) calls and treat and transport people in crisis health situations) to the Emergency Department (ED - is the part of a hospital where people who have severe injuries or sudden illnesses are taken for emergency treatment) for evaluation of sudden AMS. Resident 1 was alert, awake and oriented times one (AOx1 - Resident 1's baseline). Resident 1 was last seen normal at 8:30 A.M. Resident 1's blood pressure (BP) was ,d+[DATE] mmHg, temperature (Temp) was low at 35.1 degrees Celsius (C - a scale for measuring temperature RR is 36.1 C and 37.2 C). Resident 1 was in acute distress (life threatening) and was moaning (a long, low sound of pain, suffering). Resident 1's abdomen was distended (enlarged, swollen from internal pressure). The ED notes indicated laboratory test results for Resident 1 indicated the following: 1. Blood culture (blood test to look for germs/bacteria) test was positive for gram positive cocci (bacteria) 2. Urine for UA indicated clarity as hazy, protein one plus (1+) (RR is negative), blood 1+ (RR is negative), leukocyte esterase (a urine test for the presence of white blood cells and other abnormalities associated with infection) 1+ (RR is negative), WBC ,d+[DATE], bacteria few, mucus moderate . 3. Blood Urea Nitrogen (BUN - is what forms when protein breaks down and is filtered out by the kidneys and removed from the body in urine) was 110 milligrams per deciliter (mg/dL- unit of measurement (RR ,d+[DATE] mg/dL[high BUN indicates that the kidneys are not working well and can lead to kidney failure]). 4. Creatinine (breakdown of muscle tissue which is removed from the blood through the kidneys) was 4.99 mg/dL (RR is 0.60- 1.10 mg/dL). High Creatine is a sign of kidney problems, such as kidney damage or failure, infection, or reduced blood flow, loss of body fluid (dehydration), and muscle problems, such as breakdown of muscle fibers. High creatinine can cause chronic (ongoing) kidney failure. 5. Phosphorus (a mineral) was 6.5 mg/dL (RR is 2XXX,d+[DATE].9 mg/dL). High phosphorus is often a sign of kidney damage which may lead to increased risk of heart attack, stroke or death. A review of the Emergency Provider Notes dated [DATE] at 11:20 A.M., indicated Resident 1 on physical exam, was somnolent (drowsiness or strong desire to fall asleep), groaning constantly, responsive to painful stimuli (a thing or event that evokes a specific functional reaction) but not able to localize. Resident 1's BP was ranging between ,d+[DATE] mmHg to ,d+[DATE] mmHg. Resident 1 was found with UTI and sepsis and was administered lactated ringers (LR- intravenous [IV - into a vein] 1 (one) liter and was started on IV cefepime and vancomycin antibiotics (medications to treat infection). Inpatient palliative care (a specialized medical care for people living with serious illness) consult was placed for Resident 1. A review of the Emergency Provider Notes dated [DATE] at 11:20 A.M., indicated Computerized Tomography (CT- a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) was recommended because Resident 1 had abdominal distention and abdominal pain on exam. Resident 1 remained in critical condition and required constant monitoring and attendance of care. Resident 1 had a high probability of imminent deterioration (decline) threatening life or limb, required immediate attending physician's attention/intervention .particularly concerning for hypotension (low BP) . had a high probability of respiratory compromise (a high likelihood of respiratory insufficiency and failure, respiratory arrest [stop] or death). The emergency provider note indicated Resident 1 had acute renal (kidney) failure, acute cystitis (inflammation of the bladder (a hollow organ in the lower abdomen that stores urine), usually caused by a bladder infection), urinary retention (a condition in which a person is unable to empty all the urine from his/her bladder), . CT abdomen indicated urinary catheter (a flexible tube inserted in the bladder to drain urine) in place and the bladder was empty for Resident 1. Resident 1's condition was critical (injury or illness is life threatening). A review of the Emergency Provider Notes dated [DATE] at 11:20 A.M., indicated Resident 1's condition was discussed with a family member (FM). FM wanted Resident 1 to be full code (if a person's heart stopped beating and/or the person stopped breathing, all resuscitation[process of correcting physiological disorders such as lack of breathing or heartbeat] procedures will be provided to keep the person alive). Per FM, Resident 1 had been altered for several days. Resident 1 had severe uremia (a dangerous condition that occurs when waste products associated with decreased kidney function build up in your blood). GACH admitted Resident 1 to telemetry unit (a floor in a hospital where patients undergo continuous cardiac (heart) monitoring) for further treatment and management. Resident 1 will be treated for sepsis. A review of the GACH history and physical (H&P) dated [DATE] at 3:31 P.M., under assessment/plan of the H&P indicated . sepsis. Meets two of four (,d+[DATE]) criteria (for sepsis - temperature above 38 degrees centigrade [36 degrees Celsius], pulse greater than 90 beats per minute [p/min], respirations greater than 20 breaths p/min, neutrophils count greater than 10%) with hypotension (low blood pressure), hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce, causing dangerously low body temperature). The H&P indicated will sepsis and then re-evaluate. A review of GACH notes for Resident 1 dated [DATE] at 8:07 P.M., indicated GACH discharged Resident 1 to home on palliative care with FM. On [DATE] at 9:30 A.M., during an interview with FM, FM stated Resident 1's mind was okay the first week Resident 1 was admitted at the facility. FM stated that on [DATE], she visited Resident 1 and noticed Resident 1's, mind was off. FM stated she went to nurses' station and informed a head nurse (does not know the charge nurse's name) and the head nurse told FM that Resident 1 may have UTI and would have laboratory (lab) tests done on Resident 1. FM stated she decided to visit Resident 1 daily and followed up daily on the lab results with the nurses seated at the nurses' station (does not know their names). FM stated she never found out the lab results for Resident 1. On [DATE] at 9:30 A.M., during the interview with FM, FM stated as she continued to visit Resident 1 at the SNF, she noticed Resident 1's mind continued to decline. FM stated that on [DATE] at 10:30 A.M to 11 A.M. , she went to the facility to visit Resident 1 and waited outside the door because Resident 1's door was shut. FM stated that on [DATE] at around 10:30 A.M., and 11 A.M., she entered Resident 1's room after a certified nurse assistant (CNA) came out of Resident 1's room. FM stated that upon entering resident 1's room, she noticed that Resident 1 was not alert (when a person is awake/aware and can respond to the environment around them independently), was groaning and was saying, please, please, help me. FM stated she went to the nurses' station and told a nurse that Resident 1 did not seem right. FM stated the nurse told FM that Resident 1 may have UTI and the facility called paramedics (medical professionals who specialize in emergency treatment). On [DATE] at 9:30 A.M., during the interview with FM, FM stated she was very frantic (wild or distraught with fear, anxiety) and Resident 1 was transferred to GACH on [DATE] at 11 a.m. FM stated that GACH told her that Resident 1 was really sick, had UTI, was septic (the body's extreme response to an infection. It is a life-threatening medical emergency), Resident 1's bladder was full of urine, and that the kidneys (organs found on either side if the spine that filter waste material out of the blood) were shutting down (kidney failure - a condition where one of both kidneys no longer work on their own), and that Resident 1 did not have long to live. On [DATE] at 9:30 A.M., during the interview with FM, FM stated a medical doctor (MD) at GACH informed her to have Resident 1 on hospice (care that focuses on comfort and quality of life of a person with a serious illness who is approaching the end of life). FM stated that on [DATE] (a day and half after discharge to home from GACH), Resident 1 died . FM stated the facility was negligent in providing care to Resident 1 as a result, Resident 1 developed UTI. On [DATE] at 4:23 P.M., during a concurrent interview and record review with the Infection Preventionist Nurse (IPN) and Medical Records (MR), Resident 1's UA results dated [DATE], nursing progress notes dated [DATE], and medical charts were reviewed. IPN stated elevated neutrophils in CBC and the elevated WBC in urine sample are indicators of an infection and need to be reported to a resident's care provider for possible treatment and transfer to a GACH. IPN stated potential adverse outcome of not treating the infection may lead to a lot of things going wrong including sepsis. IPN confirmed and stated there was no documented evidence that UA results for Resident 1, were reported to a care provider. MR confirmed and stated there was no documented evidence that the facility followed up on the UA and C&S results for Resident 1. MR confirmed and stated there was no documented evidence that the facility followed up on the urine C&S results, placed an order for C&S for urine or notified a care provider the urine C&S results for Resident 1. On [DATE] at 5 P.M., during an interview with NP, NP stated she could not recall receiving UA lab results from the facility for Resident 1. NP stated that elevated blood neutrophils and elevated WBC in the urine could result in leukocytosis (elevated WBC) which requires treatment with antibiotics or transfer to a GACH. NP stated if left untreated, leukocytosis could result in sepsis. A review of the facility's P&P titled, Alert Charting Documentation, revised [DATE], indicated, . The licensed nurse must note the change of condition that justifies alert charting when assessing the resident and thereafter: document the findings in the nursing notes; notify the physician and the responsible party. A review of the facility's P&P titled, Change of condition Notification revised [DATE], indicated, .Purpose is to ensure residents .physicians are informed of changes in the resident's condition in a timely manner .condition which is manifested by signs and symptoms different than usual. A review of the facility's P&P titled, Laboratory -Critical values, revised ,d+[DATE], indicated, . The purpose of the policy is to ensure the resident's attending physician/prescriber is promptly informed of critical laboratory values requiring immediate evaluation . Critical laboratory values are those that, if left untreated, could be threatening or could place the resident at serious risk.

Based on observation, interview, and record review, the facility failed to provide a safe environment to prevent accident for one of three sampled residents (Resident 1). The facility failed to ensure: 1. The specific lift machine (designed to lift and transfer patients from one place to another) was identified based on Resident 1's assessed needs for a safe transfer and as per the lift machines manufacturer's Operational Manual and the facility's policy and procedure (P&P) on Sit-to-Stand Lift and the P&P on Transfer of Residents. 2. The specific lift machine and the number of staff needed in the transfer procedure was documented and care planned in Resident 1's clinical record to prevent the staff from using the wrong lift machine. 3. Certified Nursing Assistant 1 (CNA 1) received training on the safe operation of a sit-to-stand lift machine (helps residents with mobility problems that can bear some weight and lack strength or muscle control to rise to a standing position; it has a wide adjustable base, strong slings, and electrical motorized lifting mechanisms) for safe transfer in accordance with the facility's policy and procedures (P&P) on Sit-to-Stand Lift. 4. Two staff were present when performing surface transfers for Resident 1 in accordance with the facility's P&P titled, Total Mechanical Lift dated 4/2023. As a result, on 6/17/2023 at 4:30 p.m., while CNA 1 was transferring Resident 1 from his wheelchair (W/C) to bed using the sit-to-stand lift machine, the resident fell hitting his head on the floor sustaining an abrasion (a superficial rub or wearing off the skin) on the left forehead. On the same day, Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where he was diagnosed with a displaced fracture (one in which two or more portions of broken bone come out of proper alignment) of the right lateral (side) maxillary sinus wall (the cheek area next to the nose). Findings: A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 5/20/2020 with diagnoses including hemiplegia (muscle weakness or paralysis [inability to move and feel] on one side of the body affecting the arms, legs, and facial muscles) and hemiparesis (loss of strength on one side of the body) after cerebral vascular infarction (a stroke caused by interruption or blockage of blood flow to the brain), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), contractures (thickening of tissues overtime that causes the hands to pull inward uncontrollably without the ability to straighten) of the left and right hand, and history of falling. A review of Resident 1's Fall Risk Evaluation Form, dated 3/6/2023, indicated Resident 1 had a score of 14 indicating a high fall risk. A review of Resident 1's Minimum Date Set (MDS - a standardized assessment care-screening tool) dated 5/17/2023, indicated Resident 1 was unable to understand and make decisions, required one-person physical extensive assist with bed mobility, surface-to-surface transfers, locomotion (movement on and off the unit), dressing, toilet use, personal hygiene, and eating. Resident 1 was not steady and was only able to stabilize, move from seated to standing position, and transferring from surface-to-surface with staff assistance. Resident 1 could not walk, could not move on one side of the body, and used a wheelchair for mobility. A review of Resident 1's Care Plan revised on 5/31/2023, indicated Resident 1 was at risk for falls related impaired mobility, Alzheimer disease, contractures, and a history of falling. The interventions included anticipating Resident 1's needs and keep the environment free of clutter. A review of Resident 1's nursing Interact Change in Condition Evaluation form, dated 6/17/2023, indicated at 4:30 pm., CNA 1 used a sit-to-stand lift machine to transfer Resident 1 from W/C to bed. During the transfer Resident 1 moved his arm out of the sling and started to go down. CNA 1 caught Resident 1 by his pants and assisted Resident 1 to the ground hitting the left side of his forehead on the floor. The MD was informed, and the orders included to keep the wound clean. At 4:45 pm., when Family Member 1 (FM 1), was notified FM 1 stated she was calling 911 (telephone number to call for emergency medical services) to have Resident 1 transported to a hospital. A review of Resident 1's GACH 1 Emergency Department (ED) notes, dated 6/17/2023, indicated Resident 1's computerized tomography (CT - a series of X-ray images and a computer to obtain detailed internal images of the body) scan of the maxillofacial (face and jaw) bones result dated 6/17/2023, indicated Resident 1 had an age-indeterminate (not sure how long ago the fracture occurred [new or old]), likely acute (new) displaced fracture of the right lateral maxillary sinus wall. No acute surgical interventions were recommended. Resident 1 was sent back to the facility the same day (6/17/2023) and was prescribed Augmentin (antibiotic - medication to treat / prevent infection) and Afrin (medication to treat / prevent nose congestion). Resident 1's discharge diagnoses included closed head injury, closed fracture of right side of maxilla (upper jaw bone) and fall. On 6/21/2023 at 11:11 am., Resident 1 was observed in his room sitting up in high back W/C. Resident 1 had a small abrasion on the forehead over his left eye and a swelling with slight purplish discoloration around the left eye. Resident 1 was unable to respond to simple questions. On 6/21/2023 at 2:53 pm., during an interview, the Director of Staff Development (DSD) stated she was working as the DSD at the facility for three months and on 6/3/2023, she provided one in-service training on the use mechanical lifts on the residents. The DSD stated she could not find any documented records of in-service training related to mechanical lifts prior to 6/3/2023. The DSD stated the in-service included how to use the total lift and the sit-to-stand lift machines. The DSD stated she did not use the manufacturer's operation manual when providing the in-service training to the CNAs. The DSD stated she taught staff residents must have upper body stability and be able to sit at the edge of the bed to use the sit-to-stand lift, otherwise they should use the total lift machine. The DSD stated the physical therapist (PT - healthcare professional that treats of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) initially assessed the residents to determine if a lift machine is needed for safe transfers and nursing decides what specific lift machine to use. A review of the facility's In-Service Training for CNAs Attendance Sign in Record for the course titled, Safe transfer / mechanical lift, dated 6/3/2023, indicated CNA 1 did not attend the training. On 6/21/2023 at 3:20 pm., during an interview, CNA 2 stated on 6/17/2023 (unable to remember the time), CNA 1 called her on her cellphone to assist her in Resident 1's room. CNA 2 stated upon arrival Resident 1 was lying on the floor on his left side next to the bed, the sit-to-stand lift machine was off to the side of the bed and CNA 1 was the only staff in the room with Resident 1. On 6/21/2023 at 3:54 pm., during an interview, CNA 1 stated on 6/17/2023, at the time of Resident 1's fall, she used the sit-to-stand lift machine by herself to transfer Resident 1 from W/C to bed when suddenly he moved his arm out of the sling and began to fall, CNA 1 grabbed his pants, he slid down and hit his head on the floor. CNA 1 stated she was trained on the use of the lift machine and was told to use two people but everyone else was busy, so, I just did it myself. On 6/21/2023 at 3:56 pm., during an interview, Registered Nursing Supervisor (RNS) stated she was trained on the use of mechanical lifts but did not recall being told the need of two persons to use lifts. RNS stated that on 6/17/2023, at 4:30 pm., CNA 2 called her to Resident 1's room and she assessed the resident. RNS stated that when informing the MD, he did not feel Resident 1 needed to be transferred to the hospital. The RNS stated FM 1 was not happy with the MD's decision and decided to call 911. On 6/22/2023 at 10:31 am., during in Resident 1's room, CNA 3 and CNA 4 were observed using the sit-to-stand lift to transfer Resident 1 from bed to a W/C. Resident 1 was sitting at the edge of bed with the sling placed underneath his contracted arms. CNA 4 stood behind Resident 1 holding the grip handle on the back of the sling. Resident 1's upper body was swaying as she adjusted her grip. CNA 3 was in front of Resident 1 securing the loops of the sling to the machine and placed Resident 1's legs into the leg holders securing them with the straps. CNA 3 used the Sit-to-Stand remote control to take Resident 1 from a sitting to a standing position and simultaneously, CNA 4 went in front of Resident 1, engaged, and locked the W/C brakes. CNA 3 then lowered Resident 1 into the W/C. CNA 3 and CNA 4 removed the slings and straps from under Resident 1. Resident 1 did not move or lift his contracted arms at any time during the transfer. On 6/22/2023 at 12:15 pm., during an interview, the Director of Rehabilitation (DOR) stated during the initial PT evaluation, the PTs determine if a resident needs to be transferred with one or two-person assist and if a mechanical lift is needed but nursing decide which lift to use. This was verbalized and not documented. The DOR stated the sit-to-stand lift required for the resident to be able to grasp the handles to self-stabilize and should be able tolerate weight bearing on the legs. The DOR further stated for Resident 1, the CNAs should have used the total lift machine because the resident could not grasp the handles on the sit-to-stand lift and could not stand unassisted. On 6/22/2023 at 12:30 p.m., during an interview, the Director of Nursing (DON) confirmed PT did not recommend nursing which lift machine to use in transferring residents. The DON could not provide documentation about what type of lift should have been used with Resident 1 and confirmed the specific lift machine and the number of staff needed to transfer Resident 1 were not included in Resident 1's care plan or in any other document in the clinical record. A review of the lift machine manufacturer's Operation Manual for the total lift/sit-to-stand lift machine indicated the total lift machine was intended for patients who are non-weight bearing and require total lifting. The sit-to-stand lift machine should only be used with patients that can bear the requisite amount of weight as determined by your facility. It also required that residents possessed more advanced motor and cognitive skills than for the total lift. It is important to first determine the appropriateness of this piece of equipment for a particular patient. A review of the facility's policy and procedures (P&P) titled, Sit-to-Stand Lift, revised 1/1/2012, indicated the sit-to-stand lift machine may be used for residents who have difficulty rising from a sitting position or who are unsteady on their feet, but still could sit upright and support their own weight while standing. A review of the facility's P&P titled, Transfer of Residents, dated 4/2023, indicated the resident will be lifted or transferred according to the assessment and needs of residents. Provide the form of transfer best suited to the residents' needs and to maintain resident / staff safety during the procedure. A review of the facility P&P titled, Total Mechanical Lift dated 4/2023, indicated two staff are required for the total lift machine.A review of the facility P&P titled, Total Mechanical Lift dated 4/2023, indicated two staff are required for the total lift machine.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was dependent on staff for dressing, personal hygiene, and incontinent care, was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). On 6/1/2022, Resident 1 was left unattended for five hours (from 8:30 a.m. to 1:41 p.m.), disheveled (untidy, disordered), partially naked exposing his private parts, on a bare mattress without linen, covers, and pillows. Resident 1 ' s right foot wound dressing was soiled with brown-colored stain. On the floor, by Resident 1 ' s bed there was liquid stool, a soiled incontinent brief and soiled linen. As a result, Resident 1 was shivering from being cold and based on the reasonable person concept, due to Resident 1 ' s severely impaired cognition and medical condition, an individual subjected to neglect, may have psychological effects including feelings of hopelessness, helplessness and humiliation. Findings: A review of Resident 1 ' s Admission Record indicated the facility originally admitted the resident on 3/4/2022 with a readmitted d 4/15/2022. Resident 1 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 4/22/2022, indicated Resident 1 ' s cognition was severely impaired (unable to understand, remember, and make decisions). Resident 1 required extensive to total assistance with all activities of daily living, (ADLs, such as bed mobility, transfer, dressing, eating, toilet use and personal hygiene). Resident 1 was incontinent (unable to control) bowel (stool) and bladder (urine) functions. A review of Resident 1 ' s Care Plan, initiated on 3/9/2022 for the resident ' s ADLs self-care performance deficit, indicated interventions included to provide assistance with ADL care as needed, the resident requires total assistance from staff to dress . the resident requires total assistance from staff to maximize independence with personal hygiene/oral care. On 6/1/2022 at 1:41 p.m., during an observation and a concurrent interview with the Director of Nursing (DON), in Resident 1 ' s room Resident 1 was in bed, partially naked with genital (private parts) exposed, disheveled, shaking/shivering, lying sideways at the foot of the bed on a Low Air Loss Mattress (LALM - a special mattress designed to relieve pressure to prevent and promote healing of bedsores) laying directly onto a blue plastic like material of the LALM. Resident 1 was wearing a hospital gown with no undergarments or incontinent brief. There was stool-like liquid material, soiled linen, and soiled incontinence brief on the floor. Resident 1 ' s right foot wound dressing was soiled with brown-colored stain. Resident 1 ' s call light was not within the resident ' s reach. The Evaluator asked Resident 1 if he was cold and he nodded and stated Yes. The DON confirmed the liquid material was loose stool. The DON stated Resident 1 should be properly dressed and covered and clean linen applied on his bed. The DON instructed Certified Nursing Assistant 1 (CNA 1) to bring clean bed linen, blankets, pillowcases to cover Resident 1 and make the bed. Licensed Vocational Nurse 1 (LVN 1) entered the room to check on the resident. On 6/1/2022 at 1:50 p.m., during an interview, CNA 1 stated he was assigned Resident 1. CNA 1 stated the last time he checked on Resident 1 was around 8:30 a.m. CNA 1 stated he had seven other residents assigned and was unable to assist or check on Resident 1 from 8:30 a.m. until 1:41 p.m. A review of facility ' s document titled, Nursing Staffing Assignment dated 6/1/2022, indicated CNA 1 has a total of eight residents assigned to him. On 6/1/2022 at 3:20 p.m., during an interview, LVN 1 stated Resident 1 required constant observation and checking every two hours or more often because the resident moved around the bed and was at risk for falls. LVN 1 stated she gave Resident 1 his morning medication at around 8:00 a.m. On 6/17/2022 at 3:50 p.m., during an interview, Family Member 1 (FM 1) stated witnessing staff leaving Resident 1 alone in the room for a long time (time not specified). FM 1 stated frequently finding Resident 1 soiled. A review of the facility ' s policy and procedures (P&P) titled Abuse - Prevention, Screening, & Training Program, revised 7/2018, indicated The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The same policy also indicated, the facility assures that residents are free from neglect by having the structures and processes to provide needed care services. A review of the facility ' s P&P titled Resident Rooms and Environment, revised 1/1/2012, indicated the facility provides residents with a safe, clean, comfortable, and homelike environment. And facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents ' comfort, independence, and personal needs and preferences. A review of facility ' s P&P titled, Positioning and Body Alignment, revised on 1/2012 indicated, each resident who is partially or totally dependent will be positioned in good body alignment. A review of facility ' s P&P titled, Incontinence Care, revised on 9/2014 indicated, residents who are incontinent of urine, feces, or both, will be kept clean, dry, and comfortable. The same policy also indicated, disposable briefs are placed in a plastic bag and disposed of in a designated receptacle. A request was made on 6/17/2022 for an updated facility ' s policy and procedures from the DON twice and the DON was unable to provide any updated policies and procedures.

Based on interview and record review, the facility failed to provide timely incontinent care (cleaning the resident from stool and urine) for one of two sampled residents (Resident 1), who was left soiled of stool for two hours and twenty minutes prior to receiving incontinent care. This deficient practice resulted in Resident 1 laying in wet and soiled incontinent brief for one hour and twenty minutes, and felt frustrated, neglected, and embarrassed and had sacral blister and inner thigh moisture-associated skin damage (MASD, a skin damage that develops from prolonged exposure to urine and/or stool). Findings: A review of the admission record, dated 4/15/2021, indicated Resident 1 was admitted to the facility on [DATE], for short term skilled nursing and rehabilitative care with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 2/26/2021, indicated Resident 1 was cognitively (ability to learn, remember, and make decisions of daily living) intact, and was totally dependent and required full staff performance every shift 7 (seven) day period with transfer, dressing, toilet use and bathing. The MDS further indicated Resident 1 was frequently incontinent (having no or insufficient voluntary control) of urine, and always incontinent of bowel (stool). The MDS further indicated Resident 1 was at risk for developing pressure ulcers. A review of the Resident 1 facility's Health and Physical (H&P), dated 3/2/2021, indicated Resident 1 had the capacity to understand and make decisions. A review of another H&P, dated 3/2/2021, indicated Resident 1 was multiple fractures secondary to pedestrian versus motor vehicular accident (MVA). The H&P further indicated Resident 1 skin was warm, dry, with no rashes, ulcers, or [CONDITION(S)] (abnormal tissue), and right upper thigh intact. A review of Resident 1's SBAR (Situation, Background, Assessed or Observed, Recommendation/Communication) notes dated 4/7/2021, no time, indicated Resident 1 had change of condition (COC) because Resident 1 needed to be cleaned after bowel movement (BM, stool), and was incontinent of BM. A review of the Resident 1's Care Plan, dated 4/7/2021, indicated Resident 1 was at risk for disruption of resident psychosocial wellbeing related to call light not answered in a timely manner. Interventions included to perform a full body check on Resident 1. A review of Resident 1's Braden Scale Risk Assessment (an assessment tool that evaluates a resident's risk of developing a pressure ulcer), for Predicting Pressure Sore (skin breakdown) Risk, dated 4/9/2021, indicated Resident 1 was very limited sensory (feel) perception, mobility and, friction and shear (sliding over one another) was a potential problem. The Braden scale also indicated Resident 1 was bed or chair fast. A review of Resident 1's Department Notes Category Wound Assessment Notes, dated 4/9/2021, timed 11:27 a.m., indicated new treatment (TX) orders upon body assessment sacral (tail bone area) blister (a collection of fluid underneath the top layer of the skin), cleanse with normal saline (cleaning solution) pat dry, apply [MEDICATION(S)] (antiseptic solution used on skin to reduce bacteria) leave open to air daily times (X) 14 das then reevaluate. Inner thigh MASD (moisture associated skin disorder, a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, .) redness cleanse with soap and water pat dry apply [MEDICATION(S)] powder (medication to treat infection) open to air x 14 days then revaluate. A review of the Resident 1's care plan, dated 4/9/2021, indicated a problem of MASD on bottom and inner thighs. Another care plan, dated 4/9/2021, indicated a fluid filled blister in sacrum approximately 0.5 centimeters (cm, unit of measurement) x 0.8 cm. A review of the Facility's Departmental Notes, dated 4/9/2021, indicated an assessment for sacral blister and inner thigh moisture-associated skin damage (MASD). A review of the Physician's Telephone Order, dated 4/9/2021, indicated treatment orders for the sacral blister and MASD of inner thigh for 14 days. A review of the Treatment Administration Record (TAR), for April 2021, indicated Resident received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Facility's Investigation Summary, dated 4/11/2021, indicated: 1. Certified Nurse Assistant 3 (CNA 3) left for lunch without checking on her residents. Resident 1 had his call light on for a long period of time before he received help. 2. Resident 1 pressed his call light on 4/6/2021 at 6:40 p.m. for incontinent care. Resident 1 was not changed until 8:00 p.m. The Director of Staff Development (DSD) was aware CNA 3 and 4 were out for lunch. 3. CNA 1 was aware Resident 1's call light was on for a while. CNA 1 stated CNA 3 and CNA 4 left the facility to pick up their food and then came back to clock out for lunch. CNA 1 stated CNA 3 clocked out for lunch instead of checking on her patients. 4. Licensed Vocational Nurse 2 (LVN 2) was aware Resident 1 needed to be changed and she paged CNA 3 for help multiple times. 5. CNA 3 informed CNA 2 she would need his help to change Resident 1 after her lunch. CNA 3 apologized to Resident 1 that he wasn't changed on time. 6. CNA 2 saw Resident 1's call light at 6:40 p.m. CNA 2 stated she saw CNA 3 around 7:00 p.m. and told her Resident 1 needed to be changed. CNA 3 told CNA 2 she is taking her lunch at 7:00 - 7:30 p.m., and CNA 2 said he took his lunch at 7:30 - 8:00 p.m. When CNA 2 came back from lunch, Resident 1 was still not changed. 7. In conclusion, the facility is not satisfied with the quality of care that was reported. A review of the Behavioral note by the Psychologist, Patient Visit Information note, dated 4/13/2021, indicated Resident 1 presented with agitation and anxious, frustrated mood that the resident experienced neglect by a CNA. She apparently ignored his call bell when the resident needed incontinent brief (a piece of absorbent material wrapped around the bottom and between legs to absorb and retain urine and feces) changed. Resident 1 expressed his feelings of frustration and anger towards his mistreatment. The note indicated the primary psychological diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/15/2021 at 3:30 p.m., Resident 1 stated he had a BM, and called for incontinent care on 4/6/2021 at 5:50 p.m. Resident 1 stated he called for help multiple times and nurses came in to acknowledge his call light but did not provide incontinent care. Resident 1 stated he was sitting on stool for two hours until he received incontinent care at 8:10 p.m. Resident 1 stated he felt neglected, embarrassed and his character degraded. Resident 1 also stated and confirmed he developed a rash and blister on his buttocks after this incident, which was treated with an ointment. During an interview on 4/15/2021 at 4:30 p.m., Treatment Nurse 1 stated and confirmed that during Resident 1's skin assessment on 4/9/2021, she found a new sacral blister and inner thigh MASD. During a phone interview on 4/23/2021 at 1:37 p.m., the Director of Nursing (DON) stated Resident 1 was upset because he sat on his stool for two hours and nobody provided incontinent care. The DON stated and confirmed that a skin check was done on 4/9/2021, which revealed Resident 1 had developed a blister on the sacrum and MASD on the inner thigh. The DON stated Resident 1 was incontinent of bowel, and because of his MVA injuries, he was unable to clean himself and needed two-person assistance. During an interview on 5/24/2021 at 3:57 p.m., the Facility Administrator (FA) stated and confirmed CNA 3 was assigned Resident 1 on 4/6/2021. The FA stated CNA 3, together with CNA 4, obtained permission from the DSD to buy their lunch at 6:30 p.m., left the facility and returned at 7:00 p.m., and clocked out for lunch at 7:00 p.m. to 7:30 p.m. The FA stated and confirmed multiple staff including CNA 2 and LVN 1 were aware of Resident 1's needs but could not find assistance for Resident 1. The FA stated CNA 2 and CNA 3 did not provide Resident 1 with incontinent care until 8:00 p.m. The FA stated Resident 1 was upset because he waited a long time to be cleaned. The FA stated CNA 3, CNA 4, LVN 1 and DSD no longer employees of the facility. During an interview with CNA 2 on 5/24/2021 at 4:32 p.m., CNA 2 stated he answered Resident 1's call light at 6:40 p.m. and Resident 1 stated he had a bowel movement and needed to be cleaned. CNA 2 stated he attempted to ask LVN 2 for help, but LVN 2 was on break. CNA 2 stated he asked CNA 3 to assist with Resident 1, but CNA 3 stated she was also on break. CNA 2 stated CNA 3 returned from break at 7:30 p.m. and did assist CNA 3 to clean Resident 1 because it was time for CNA 2 to go for break. CNA 2 stated and confirmed both CNA 2 and CNA 3 did not clean Resident 1 until 8:00 p.m. A review of the facility's policy and procedures, titled Incontinence Care, revised on 9/1/2014, indicated Residents who are incontinent of urine, feces, or both, will be kept clean, dry and comfortable .Incontinence care is provided when the resident is wet or soiled. A review of the facility's policy and procedures, titled Communication - Call System, revised on 1/1/2012, indicated In answering to request, nursing staff will return to resident with the item or reply promptly. Assistant will be offered before leaving.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for weight loss and required extensive assistance with eating, received care and services in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. Monitor Resident 1 for dehydration (condition caused by the loss of too much fluids from the body, for the body functions to work properly) signs and symptoms (thirst, dry mouth, urinating less than usual, dark-colored urine, dry skin, and dizziness) via intake and output log, 2. Refer Resident 1 to Dietary Manager or for Registered Dietitian (RD) consult to assess nutrition and hydration as needed. These deficient practices resulted in Resident 1 having a change in condition (a decline in Activities of Daily Living -ADL, and a loss of appetite), requiring transfer to General Acute Care Hospital 1 (GACH 1) on [DATE] for further evaluation, where she was diagnosed with [REDACTED]. Resident 1 expired at GACH 1 two days later [DATE]. Findings: A review of the Admission Record (face sheet) indicated Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly Nutritional Evaluation form dated [DATE], indicated the Dietary Manager did not conduct timely quarterly nutritional evaluations for Resident 1. The quarterly form indicated several evaluations were conducted late or missing. There was no evaluation conducted for [DATE] or [DATE]. A review of Resident 1's Care Plan on Nutrition and Hydration, updated [DATE], indicated Resident 1 was at risk for weight loss due to a history of weight loss, dysphagia (difficulty swallowing), and poor appetite. The interventions included maintaining intake (what the person takes in including fluids and food) and output (fluid voided) log as indicated, monitoring for signs and symptoms of dehydration, notifying the physician, referring resident for dietary consult, and the RD to assess nutrition and hydration as needed. According to a review of the Activities Daily Living (ADLs) Flowsheet dated ,[DATE] Resident 1 was eating ,[DATE] % of meals. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and tool), dated [DATE], indicated Resident 1 had a clear speech, difficulty communicating, and required extensive assistance from staff with eating, dressing, and personal hygiene. A review of Resident 1's Change of Condition notes dated [DATE], timed at 12:45 p.m., indicated Resident 1 had a decline in ADLs and a loss of appetite. The note did not address notification to the Dietary Manager or RD for evaluation and recommendations. A review of Resident 1's Licensed Personnel Weekly Progress Note, dated [DATE], for the 3 p.m. to 11 p.m. shift, indicated Resident 1 was monitored for a decline in ADLs, loss of appetite, and Resident 1 had eaten about 40% of the meal. There was no further documentation related to Resident 1's change of condition for the next 40 hours, on [DATE] for the 11 p.m. to 7 a.m. shift; on [DATE] for the 7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m. shifts; and on [DATE] for the 7 a.m. to 3 p.m. shift. According to a review of Resident 1's ADLs Flowsheet dated [DATE], Resident 1 refused breakfast and lunch. There was not documentation substitutes or alternative meal was offered. A review of Resident 1's Speech Therapy Evaluation and Plan of Treatment, dated [DATE], indicated Resident 1 had poor oral intake and was recommended swallowing evaluation to assess the swallowing function and determine the need for a least restrictive diet. Resident 1 was unable to cooperate and exhibited limited alertness for exam. A review of Resident 1's ADLs Flowsheet dated [DATE], indicated Resident 1 refused dinner and refused the substitute or alternative meal offered. According to a review of Resident 1's Licensed Personnel Weekly Progress Note dated [DATE], Resident 1 had a decrease in appetite. The ADLs Flowsheet did not include Resident 1's fluid intake or output. There was no other record to indicate the intake and output was monitored. A review of Resident 1's radiology and laboratory report dated [DATE], indicated a chest Xray with [MEDICAL CONDITION] congestion. Resident 1's sodium level (an essential electrolyte that helps maintain the balance of water in and around your cells) was elevated at 178 (normal level ,[DATE] milliequivalents per liter (mEq/L). The [MEDICATION NAME] level (protein needed to keep growing and repairing tissues) was 3.1 (normal level 3.4 - 5.4 grams per deciliters- g/dL). Resident 1's oxygen saturation (the amount of oxygen-saturated the red blood carry for the proper functioning of the different organs) was 80% (normal is above 95%). A review of Resident 1's physician's orders [REDACTED]. A review of the GACH 1's ED Physical Examination, dated [DATE], indicated Resident 1 appeared chronically ill and cachectic (a physical wasting with loss of weight and muscle mass). A review of the GACH's History and Physical (H&P) note, dated [DATE], indicated Resident 1 was severely dehydrated, severe temporal wasting, mucous membranes dry, and five second skin tenting (a delay in the return of pinched skin to a flat position, after it has been tugged, elevated above the rest of the skin and released, which indicates dehydration). The laboratory results indicated Resident 1 had an abnormal elevated sodium ([MEDICAL CONDITION] - common causes are insufficient fluid intake and too much water loss) level of 177 mEq/L (normal range between 135 and 145 mEq/L) and an abnormal [MEDICATION NAME] (a blood protein that makes up a significant portion of the blood plasma. Plasma is the liquid portion of the blood that holds the proteins and blood cells) level of 2.9 g/dL (normal range 3.4 to 5.4 g/dL) suggesting malnutrition. According to a review of Resident 1's GACH 1's Critical Care Physician Consultants' Notes, dated [DATE], Resident 1 had severe malnutrition, acute kidney injury and hypoxic (not having enough oxygen in the blood) [MEDICAL CONDITION]. A review of Resident 1's GACH 1's Discharge Summary Note, dated [DATE] indicated Resident 1 expired on [DATE]. During an interview with the Dietary Manager, on [DATE] at 1:11 p.m., she stated she did not do the quarterly nutritional evaluation for Resident 1 every four months (quarterly). During an interview, on [DATE], at 8:45 a.m., Licensed Vocational Nurse 3 (LVN 3) stated staff should monitor residents for 72 hours after a change of condition and document in the nursing notes as per facility's policy. LVN 3 stated if the change of condition was related to a loss of appetite, the Dietary Manager would be notified. During an interview with RD 1 on [DATE], at 11:45 a.m., RD 1 stated she was not notified of Resident 1's loss of appetite and would have assessed the resident if made aware. During an interview on [DATE], at 12:20 p.m., Registered Nurse 1 (RN 1) stated Resident 1 should have been monitored for 72 hours or until the problem was resolved. RN 1 stated each nursing shift should have documented their findings related to Resident 1's loss of appetite in the Licensed Nurse's Progress Notes. RN 1 further stated, Resident 1 may have weight loss and weakness if staff failed to monitor/assess and document. During an interview with the Dietary Manager, on [DATE], at 12:30 p.m., the Dietary Manager stated she was not notified of Resident 1's change of condition regarding a loss of appetite. The Dietary Manager further stated if she was made aware of Resident 1's loss of appetite she would have notified the Registered Dietitian. During an interview with RN 1 on [DATE] at 12:50 p.m., after reviewing Resident 1's clinical record, RN 1 confirmed there was no referral to RD, nursing staff were not measuring the fluids intake and output, there was no monitoring every shift during the 72-hour period after the change of condition. RN 1 failed to provide additional documentation after numerous requests. During interview with the Director of Nursing (DON) on [DATE] at 1:30 p.m., she stated it was not necessary for Resident 1 to have intake and output documented. However, Resident 1's care plan interventions indicated to maintain intake and output log. The facility policy and procedure titled, Change of Condition Notification, dated [DATE], indicated a licensed nurse will document each shift for at least seventy-two (72) hours. Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the twenty-four-hour report. The facility policy and procedure titled, Alert Charting Documentation, dated [DATE], indicated the facility will place all newly admitted residents, residents whose condition is unstable, and residents who have a change in their condition on alert charting. Alert charting is required for changes in medical condition, difficulty swallowing, and changes in mental / behavior condition. Licensed nurses on each shift are responsible for assessing residents, including vital signs and documenting the resident's status related to the change of condition. The policy indicated notes pertaining to the change of condition will be maintained in the resident's medical record as narrative notes. The facility policy and procedure titled, Quarterly Nutritional Evaluation and Progress Notes, dated [DATE] indicated the Dietary Manager will complete a quarterly nutritional evaluation for residents to reflect current nutritional needs. Additional documentation of nutritional needs between quarterly evaluations should be documented on the nutritional progress notes. The facility policy and procedure titled, Evaluation of Weight and Nutritional Status, revised [DATE] indicated in connection with the assessments the RD and the Interdisciplinary Team will further assess nutritional needs and goals of the resident within the context of his/her overall condition, including oral intake of foods and fluid.