Every finding on record at Marin Post Acute

Based on observations, interviews, and record reviews the facility failed to ensure necessary grooming and personal hygiene services were provided for three of six sampled residents (Resident 3, Resident 5, and Resident 6) when nail care was not provided as documented and resident nails were in poor condition, and one resident (Resident 3) was not bathed for 8 days. This failure put residents at risk for infections, skin tears, for skin breakdown to go unnoticed, and had the potential to affect residents' self-esteem.A review of Resident 3's admission record indicated Resident 3 was admitted in 11/2020 with the diagnoses of left sided Hemiplegia (the total or severe loss of voluntary movement on the left side of the body, caused by damage to the right hemisphere of the brain) after a stroke, Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior) and Major Depressive Disorder.A review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 8/13/26, indicated Resident 3 had a BIMS (Brief Interview for Mental Status- a 0 to 15 point test used in long-term care and skilled nursing facilities to check a person's memory, learning, and orientation, 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 cognitively intact) score of 11.During a concurrent observation and interview on 8/24/26 at 1:00 p.m. with Resident 3 in her room, Resident 3 was seen eating her lunch atop a towel on her chest. Resident 3's nails were long, jagged, with brown and black debris under the length of the nails. Resident 3 was using her fingers and fork to eat her lunch. Resident 3 stated staff rarely cleaned or trimmed her nails, and she could not do it independently. Resident 3 further stated she received a bed bath yesterday but had waited eight to ten days without one prior to this. Resident 3 stated she preferred bed baths to showers and had never refused a bed bath. A review of Resident 3's Nail Care POC Response History for the last 30 days indicated Resident 3 had received nail care on 8/24/26 at 9:31 a.m. There were no documented refusals by Resident 3.A review of Resident 3's Bathing POC Response History for the last 30 days indicated Resident 3 went 4 days without a bath from 8/2-8/5, again for 4 days from 8/9-8/12, and 8 days without a bath from 8/14-8/22. There were no documented refusals by Resident 3.A review of Resident 3's Shower Sheet, dated 8/22/26, indicated Resident 3 had a full body sponge bath, her nails had been clipped and cleaned, and there were two new areas of skin redness noted on her back.A review of Resident 5's admission record indicated Resident 5 was admitted in 03/25 with the diagnoses of Rhabdomyolysis (a serious medical condition where damaged skeletal muscle tissue breaks down rapidly) and Dementia.A review of Resident 5's MDS indicated Resident 5 had a BIMS score of 05 with severe cognitive impairment.During an observation on 8/25/26 at 1:10 p.m. just outside the elevator door on the second floor, Resident 5 was seen in her wheelchair and as she reached out her nails were observed to be long and jagged with sharp edges, and Resident 5 had 2 small cuts on the top of her hands.A review of Resident 5's Nails POC Response History, indicated Resident 5 had received nail care on 8/24/26 at 10:45 p.m.A review of Resident 6's admission record indicated Resident 6 was admitted in 01/26 with the diagnoses of a Fractured pelvis and Ilium (breaks in multiple pelvic bones) and cognitive communication deficit.A review of Resident 6's MDS, dated [DATE], indicated Resident 6 had a BIMS score of 11 with moderate cognitive impairment.During a concurrent observation and interview on 8/25/26 at 12:45 p.m. in Resident 6's room, Resident 6 was seen eating lunch and her nails were long with sharp edges and yellow discoloration. Resident 6 stated she would have liked to have her nails trimmed and filed and had asked staff many times, but nobody ever came. Resident 6 stated, I am not sure who I have to ask to make it happen.A review of Resident 6's Nails POC History, indicated Resident 6 had received Nail Care on 8/24/26 at 2:36 p.m.During an interview on 8/24/26 at 12:55 p.m. with Certified Nursing Assistant C (CNA C), CNA C stated they felt staffing was insufficient and this meant nails, toothbrushing, putting lotion on skin, and other small but time-consuming tasks were often missed. CNA C expressed feeling frustrated with being unable to deliver the best care for residents because there was not enough time to get to it all.During a concurrent interview and record review on 8/25/26 at 3:25 p.m. in the conference room with the Director of Nursing (DON), the DON stated Nail Care should be done daily and as often as needed. DON viewed pictures of Resident 3, Resident 5, and Resident 6's nails and stated their current condition did not meet her expectations and put the residents at risk for infections and skin tears. DON further stated bathing should be offered as scheduled three times per week and any refusals should be reported and documented. The DON stated Resident 3 not receiving a bed bath for 8 days was unacceptable and did not meet her expectations.A review of a facility policy titled Fingernails/Toenails, Care Of, dated 2001, indicated The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Nail care includes daily cleaning and regular trimming.A review of a facility policy titled Bath, Shower/Tub, dated 1/26, indicated Residents will be offered bathing or showering services according to their care plan, preferences, and physician orders, and more frequently if needed to maintain comfort and hygiene.

Based on observation, interview, and record review, the facility failed to provide consistent care to prevent pressure injury for two of six sampled residents (Resident 1 and Resident 2) when both bed-bound, high-risk residents were not effectively repositioned at time intervals consistent with their care plans or facility policy.This failure put Resident 1 and Resident 2 at risk for pressure injuries and impaired skin integrity.A review of Resident 1's admission record indicated Resident 1 was admitted in 05/23 with the diagnoses of Functional Quadriplegia (the complete inability to move the limbs or walk due to severe physical debility, frailty, or end-stage chronic illness), Central Cord Syndrome (the most common type of incomplete spinal cord injury, characterized by significantly more weakness and loss of fine motor control in the arms and hands than in the legs), and Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior).A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 8/14/26, indicated Resident 1 had a BIMS (Brief Interview for Mental Status- a 0 to 15 point test used in long-term care and skilled nursing facilities to check a person's memory, learning, and orientation, 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 cognitively intact) score of 05.A review of Resident 1's current Care Plan indicated Resident 1 was at risk for skin breakdown related to being bedbound and incontinence, and she should have been turned and repositioned every 2 hours.During an observation on 8/24/26 at 11:29 a.m. Resident 1 is seen asleep in her bed, flat on her back, HOB (head of bed) elevated at 15-30 degrees.During an observation on 8/24/26 at 11:55 a.m. Resident 1 is seen asleep in her bed, flat on her back, HOB elevated at 15-30 degrees.During an observation on 8/24/26 at 12:30 p.m. Resident 1 is seen asleep in her bed, flat on her back, HOB elevated at 15-30 degrees.During an observation on 8/24/26 at 2:10 p.m. Resident 1 is seen asleep in her bed, flat on her back, HOB elevated 15-30 degrees.During a concurrent observation and interview on 8/24/26 at 3:25 p.m. Resident 1 was awake, flat on her back with the HOB 15-30 degrees. Resident 1 stated she was on her back in bed most days and had not been up in a chair for years.A review of Resident 1's POC Response History, for Turning and Repositioning for the last 30 days indicated Resident 1 was repositioned two to three times a day or every 8 to 12 hours on average. On 8/24/26 Resident 1 was repositioned at 5:16 am, again at 9:22 a.m. four hours later, again at 4:43 p.m. seven hours later, and again at 11:21 p.m. six hours later. A review of Resident 2's admission record indicated he was admitted in 07/26 with the diagnoses of Parkinsonism (an umbrella term for a neurological syndrome defined by core movement signs, including slowed movement, muscle stiffness, tremors, and balance or walking problems), Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior) and Dysphagia (difficulty swallowing).A review of Resident 2's MDS, dated [DATE], indicated he had a BIMS score of 08 indicating moderate cognitive impairment.A review of Resident 2's current Care Plan indicated Resident 2 was at risk for skin breakdown related to Dementia, decreased mobility in bed, and recent significant weight loss, and should have been turned and repositioned as indicated/tolerated. During an observation on 8/24/26 at 11:35 a.m. Resident 2 is observed in bed on his back/left side with his knees bent and to the left and the HOB elevated at 35-45 degrees with pillows behind his head and both arms.During an observation on 8/24/26 at 12:45 p.m. Resident 2 is observed in bed on his back/left side with knees bent and to the left and pillows behind his head and both arms. The HOB was elevated to 50-60 degrees for feeding assistance.During an observation on 8/24/26 at 2:05 p.m. Resident 2 is observed in bed on his back/left side with knees bent and to the left with pillows behind his head and both arms and HOB is elevated 35-45 degrees.During an observation on 8/24/26 at 3:20 p.m. Resident 2 is observed in bed on his back/left side with knees bent and to the left with pillows behind his head and both arms and HOB is elevated 35-45 degrees.During an observation on 8/24/26 at 3:48 p.m. Resident 2 is observed in bed on his back/left side with knees bent and to the left with pillows behind his head and both arms and HOB is elevated 35-45 degrees.A review of Resident 2's POC Response History for Turning and Repositioning for the last 30 days indicated Resident 2 was repositioned two to three times a day or every 8 to 12 hours. On 8/24/26, Resident 2 was repositioned at 6:59 a.m., again at 7:57a.m. two hours later, and again at 5:06 p.m. nine hours later.During an interview on 8/24/26 at 12:55 p.m. with Certified Nursing Assistant C (CNA C), CNA C stated staff tried to reposition resident's as often as they could, but this was not as frequent as it should have been, approximately once each shift.During an interview on 8/24/26 at 2:45 p.m. with the Director of Staff Development (DSD), the DSD stated all residents should be turned and repositioned every 2 hours and staff should document this in the record.During an interview on 8/24/26 at 3:30 p.m. with Licensed Nurse A (LN A), LN A stated high risk residents should be repositioned every 2 hours and nurses should confirm this by talking to the CNA staff. LN A could not verbalize where else nurses should refer to verify repositioning was being done and LN A could not confirm how frequently Resident 1 had been repositioned today.During an interview on 8/25/26 at 3:45 p.m. with the Director of Nursing (DON) in the conference room, the DON stated residents who were bed bound, had dementia, or weight loss with bony prominences, were considered high risk and should be turned and repositioned every 2 hours as they were at risk for pressure injury and skin breakdown.A review of a facility document titled, Repositioning, dated 2001, indicated, Repositioning is critical for a resident who is immobile or dependent on staff for repositioning. Residents who are in bed should be on at least every 2-hour repositioning schedule.

Based on observation, interview, and record review the facility failed to ensure adequate hydration levels for two of six sampled residents (Resident 1 and Resident 2) when both residents were recently hospitalized with symptoms of dehydration and facility staff were observed only offering fluids to residents during mealtimes.This failure put Resident 1 and Resident 2 at risk for ongoing dehydration concerns.During an interview on 8/21/26 at 10:37 a.m. with the Ombudsman, Ombudsman stated she had received multiple complaints from residents and family concerning dehydration requiring hospitalization. Ombudsman stated Resident 1's family had reached out to her, and she was told Resident 1 had been hospitalized for Urinary Tract Infection (UTI caused by bacteria that enter through the urethra, often exacerbated by dehydration) and Sepsis (a life-threatening immune response in the blood due to infection), with signs of dehydration.During an interview on 8/24/26 at 9:03 a.m. with Resident 1's Representative (RP), RP stated they were at the hospital with Resident 1 on 8/7/26 and the physician there said they had never seen urine so thick, dark, and cloudy, it barely moved in the specimen cup. RP stated she did not understand why her mother was so dehydrated and a severe infection that had gone unnoticed by staff. RP stated when they visit Resident 1 several times a month they stayed for hours, and staff never came in and offered water to Resident 1.A review of Resident 1's admission record indicated Resident 1 was admitted in 05/23 with the diagnoses of Functional Quadriplegia (the complete inability to move the limbs or walk due to severe physical debility, frailty, or end-stage chronic illness), Central Cord Syndrome (the most common type of incomplete spinal cord injury, characterized by significantly more weakness and loss of fine motor control in the arms and hands than in the legs), and Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior).A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 8/14/26, indicated Resident 1 had a BIMS (Brief Interview for Mental Status- a 0-to-15-point test used in long-term care and skilled nursing facilities to check a person's memory, learning, and orientation, 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 cognitively intact) score of 05.A review of Resident 1's POC Response History (POC-plan of care task documentation for direct care staff), of Fluid Intake for the last 30 days indicated severely inadequate fluid volume intake from 7/28/26 through 8/7/26, the period just before hospitalization. Fluid intake was documented to be between 240ml (milliliters-a unit of measurement for fluids) per day to 580ml per day which is less than 50% of the required 1200ml/day (milliliters of fluids in one day) minimum per facility policy when there is no specific physician or dietician order.A review of all Nurses Progress Notes indicated no documentation concerning poor fluid intake or signs of dehydration being reported by staff.A review of Nurses Progress Notes dated 8/7/26 indicated Resident 1' reported not feeling well, was cold and clammy, and her Blood Pressure (BP) was 86/53 (normal BP is 120/80) indicating hypotension (very low blood pressure) secondary to low blood volume from dehydration and Resident 1 was sent to the Emergency Department (ED).A review of Resident 1's ED Note dated 8/7/26, indicated Resident 1 improved with 500 ml of fluid resuscitation in route to the ED and was diagnosed with Lactic Acidosis (a condition where lactic acid builds up in the body from lack of oxygen and can be caused by dehydration, infection, anemia) and a bacterial Urinary Tract Infection and Sepsis. The physician documented Resident 1's urine was Turbid (murky, hazy, or milky instead of clear) and grossly infected (an infection is highly severe, extensive, and immediately visible to the naked eye without requiring a microscope or laboratory test to confirm its presence) . A review of Resident 1's current Care Plan indicated no focus, goals, or interventions for prevention of dehydration.A review of Resident 2's admission record indicated he was admitted in 07/26 with the diagnoses of Parkinsonism (an umbrella term for a neurological syndrome defined by core movement signs, including slowed movement, muscle stiffness, tremors, and balance or walking problems), Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior) and Dysphagia (difficulty swallowing).A review of Resident 2's MDS, dated [DATE], indicated he had a BIMS score of 08 indicating moderate cognitive impairment.A review of Resident 2's Acute Care Hospital Record indicated Resident 2 had been hospitalized on [DATE] for hypernatremia (dangerously elevated sodium levels) secondary to poor oral intake and dehydration.A review of Resident 2's (Name)(Facility Medical Group) Physician Progress Note dated 7/21/26 indicated Resident 2 had a prior hospitalization for hypernatremia and metabolic encephalopathy (when the body lacks sufficient fluid, it triggers dangerous imbalances in blood chemistry, electrolytes (such as sodium), and blood flow to the brain, leading to confusion, altered mental status) secondary to dehydration on 4/11/26-4/16/26. Physician notes multiple discussions with facility staff about strong encouragement of oral fluid intake and documented despite this Resident 2 was hospitalized repeatedly for complications due to dehydration. Physician Notes indicated hydration protocol was to be followed by the facility staff with fluids offered every 4 hours with the goal of 2,000ml/day.A review of Resident 2's current Care Plan indicated no current focus, goals, or interventions for prevention of and monitoring for dehydration. Special instructions are noted at the top of the Care Plan to Push Fluids 1:1 (an intensive intervention indicating that staff must actively encourage fluid intake through direct, individual interaction to treat or prevent severe dehydration).A review of Nurses Notes dated 8/11/26 indicated Resident 2's family called to ensure an MD order was placed for 1800ml/day of fluids.A review of Nurses Notes dated 8/15/26 indicated ongoing concerns from Resident 2's family regarding dehydration due to elevated environmental temperatures.During an interview on 8/24/26 at 12:55 p.m., CNA C stated fluids should be offered throughout the shift but due to poor staffing and time constraints fluids were most often offered during mealtimes.During an interview on 8/24/26 at 1:20 p.m. with CNA D in Resident 2's room, CNA D stated Resident 2 was at risk for dehydration and fluids were offered during meals and documented in the medical record under plan of care tasks.Observations of Resident 1 on 8/24/26 at 11:29 a.m., 11:55 a.m., 12:30 p.m., 12:55 p.m., 1:25 p.m., 2:10 p.m. and 3:25 p.m. indicated fluids were only observed being offered to Resident 1 during the lunch meal at 1:25 p.m.A review of Resident 1's POC Response History for Fluid Intake, dated 8/24/26, indicated she was offered fluids three times that day at 5:16 a.m., again at 2:53 p.m. nine hours later, and again at 8:44 p.m. six hours later, with a total of 889 ml/day which is below the required 1200ml/day minimum per facility policy. Observations of Resident 2 on 8/24/26 at 11:35 a.m., 11:45 a.m., 12:45 p.m., 1:20 p.m., 2:05 p.m., 3:20 p.m., and 3:48 p.m. indicated fluids were only observed being offered to Resident 2 during the lunch meal at 1:20 p.m. A review of Resident 2's POC Response History for Fluid Intake, dated 8/24/26, indicated he was offered fluids three times that day at 6:59 a.m., again at 1:39 p.m. six and a half hours later, and again at 10:51 p.m., eight hours later. During a concurrent interview and record review on 8/24/26 at 2:45 p.m. with the DSD, DSD presented a recent In-Service (training) agenda dated 8/21/26 and confirmed that fluids should be offered at the beginning of the shift and encouraged throughout the shift as frequently as possible.During an interview on 8/25/26 at 3:25 p.m., the DON stated her expectation was for fluids to be offered during mealtimes, during medication passing, and while completing other daily tasks with residents. The DON stated 1800ml/day was the expected minimum and anything less, unless specifically ordered by the physician, could put residents at risk for dehydration.A review of a facility document titled, Resident Hydration and Prevention of Dehydration, dated 2001, indicated, Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical record, and aides will report intake of less than 1200ml/day to nursing staff.

Based on observation, interview, and record review, the facility failed to ensure a dignified existence for one of six sampled resident's (Resident 2), when Resident 2's room was found unkept, disorganized, and impersonal. Care delivery items were not clean, personal items were found on the floor. Resident 2's call light was out of reach and Resident 2 could not demonstrate independent use of use of the call light. Resident 2's view of the hallway, and in turn, staffs view of Resident 2 was obstructed by the open bathroom door at the end of Resident 2's bed.This failure conveyed a lack of respect for Resident 2 and had the potential to affect his access to care and quality of life.A review of Resident 2's admission record indicated he was admitted in 07/26 with the diagnoses of Parkinsonism (an umbrella term for a neurological syndrome defined by core movement signs, including slowed movement, muscle stiffness, tremors, and balance or walking problems), Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior) and Dysphagia (difficulty swallowing).A review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 8/17/26, indicated he had a BIMS (Brief Interview for Mental Status- a 0 to 15 point test used in long-term care and skilled nursing facilities to check a person's memory, learning, and orientation, 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 cognitively intact ) score of 08.During an observation on 8/24/26 at 11:35 a.m. in Resident 2's room, there was no decor or pictures on the walls, a white bed sheet was pinned to the wall covering the window in place of a curtain. Resident 2's folded flat sheet was crumpled underneath him and he had dried brown liquid on his hospital gown. Resident 2's call light was wedged between the bed and the wall and was out of reach. A fall mat was crumpled behind the bed and had white sticky residue/spots all over it and Resident 2's water jug had drips of white sticky substance down the side and covering the lid. Resident 2's bedside table drawers were wide open, and the rolling table was astray in the middle of the room. Resident 2's identification bracelet was on the floor, and the bathroom door was open blocking Resident 2's view into the hallway and the ability of staff to see Resident 2 from the hallway.During a concurrent observation and interview on 8/24/26 at 11:45 a.m. with Licensed Nurse A (LN A) in Resident 2's room, LN A stated the call light's fell all the time and confirmed Resident 2's room did not represent how a residents room should look or feel .During a concurrent observation and interview on 8/24/26 at 11:50 a.m. with Hospice Nurse B (HN B) and Resident 2, HN B translated the interview with Resident 2. Resident 2 stated , staff did what they could but could not answer other direct questions. HN B stated Resident 2's room was not clean or comfortable. HN B asked Resident 2 if he could demonstrate how he used his call light button, Resident 2 could not utilize his call button independently.A review of Resident 2's Care Plan indicated Resident 2 was at risk for ADL (activities of daily life) decline and required assistance due to Dementia and Parkinson's disease and should be monitored for changes in condition or declines in ability to participate in ADL's. It further indicated to encourage Resident 2 to use the call light for assistance. There was no documentation about Resident 2's inability to use the call light or compensatory strategies. The Care Plan further indicated Resident 2 was at risk for falls and should have been kept within supervised view as much as possible. During a concurrent interview and record review on 8/25/26 at 3:25 p.m. with the Director of Nursing (DON) in the conference room, DON looked at pictures of Resident 2's room and stated the room was not orderly, clean, or homelike, and did not meet her expectations. DON stated if Resident 2 could not use the call light, then frequent checks should have been on his Care Plan, and the bathroom door should not have obscured him from staff's view. DON stated Resident 2's room and disposition did not promote dignity and put Resident 2 at risk for his needs going unnoticed and unattended.A review of a facility policy titled Dignity, reviewed 05/26, indicated Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents private space and property are respected at all times. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment for nine of thirteen sampled residents (Resident's 1,2,4,5,6,7,8,9,12), when room temperatures reached above 81degrees ( ) Fahrenheit (F) during a summer heat wave.This failure resulted in residents feeling hot and uncomfortable and increased the potential for heat-related illnesses such as heat stroke, dehydration and impaired skin integrity in an already vulnerable population.On 7/30/26, the department entered the facility to investigate a complaint related to power outages in the facility. The weather report that day indicated a temperature high of 84 F.A review of a new AFL (All Facilities Letter-communication from California Department of Public Health to Skilled Nursing Facilities), dated 7/30/26, issued a Hot Summer Weather Advisory reminding all health care facilities that the elderly and other health compromised individuals are more susceptible to temperature extremes and possible dehydration.During a telephone interview on 7/30/26 at 9:35 a.m. with the local Ombudsman, the Ombudsman stated she received complaints about hot temperatures at the facility and had visited the facility last week. The Ombudsman stated when she checked room temperatures on the second floor of the facility the temperatures were between 81-85 F.During a concurrent observation and interview on 7/30/26 at 2:00 p.m., Resident 1 is seen in bed with damp moist skin on his face and neck and is wearing a thin hospital gown with a fan running above the TV pointed at him. Resident 1 stated when it was hot outside and with 3 residents in a small room, it got very hot and the fans didn't always help, and it was hard to cool down.During a concurrent observation and interview on 7/30/26 at 2:10 p.m. Resident 2 is in bed near the window in a thin hospital gown with a thin sheet over him. The sun is shining through the gaps in the blinds and Resident 2 had no fan available, his lips and skin appeared dry and flaky. Resident 2 stated it got too hot in the room, and it was worse by the window. Resident 2 stated his mouth was dry and he was dry all over.A review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 6/26/26, indicated Resident 2 had a BIMS (Brief Interview for Mental Status- score measures a person's thinking and memory, ranging from 0 to 15 points based on three categories: 13-15 (cognitively intact), 8-12 (moderate impairment), and 0-7 (severe impairment) score of 13.During an interview on 7/30/26 at 2:28 p.m. with Certified Nursing Assistant A (CNA A), CNA A stated the facility had swamp coolers at the end of each hallway, but CNA A felt the cooler air could not reach inside the rooms. CNA A stated there had been complaints from residents about the heat.During a concurrent observation and interview on 7/30/26 at 2:30 p.m. Resident 4 was in bed near the window, the window was cracked, sun was shining through the window, and Resident 4 was wearing a thin hospital gown with damp moist skin on her face and neck. The fan above the TV in the center of the room was off. Resident 4 stated the fan in the room did not oscillate and did not reach her bed. Resident 4 stated she had to have her brother buy her a small fan she could keep at bedside. Resident 4 stated it was summer and got very warm, some days it was uncomfortable, and she wished the facility would do more to keep residents cool.A review of Resident 4's MDS, dated , 7/1/26, indicated Resident 4 had a BIMS score of 12 with moderate cognitive impairment.During a concurrent observation and interview on 7/30/26 at 2:40 p.m. Resident 5 was seen wearing a tube top with bare arms, her hair was up and wet at the base of her neck, and her skin was damp and moist. Resident 5 stated it got hot in the room and the fan did not help on very hot days. Resident 5 stated her mouth and nose were dry sometimes and she was always sweating. Resident 5 felt residents who had beds closest to the window had it the worst.A review of Resident 5's MDS, dated [DATE], indicated Resident 5 had a BIMS score of 10 with moderate cognitive impairment.During an interview on 7/30/26 at 2:51 p.m. with Resident 6 in her room, Resident 6 stated she did not like to complain but got hot being by the window and was uncomfortable, and the fan in the room didn't reach her.During a concurrent observation and interview on 7/30/26 at 3:02 p.m. with Licensed Nurse A (LN A), LN A appeared flushed and the skin on her face and neck were moist. LN A stated it was hot on the second floor and was worse in the afternoons on hot days. LN A stated the cooler air from the units at the end of the halls could not reach inside the rooms and even the nurse's station got hot. LN A stated this was a problem for many residents and LN A did not want anyone to get dehydrated.During a concurrent observation and interview on 7/30/26 at 3:20 p.m. Resident 7 had all curtains drawn, window blinds closed and had a personal Air Conditioning (AC) unit connected to the closed window. The AC unit was on, but no air could be pulled from the closed window and the temp display on the AC unit read 86 F. Resident 7 was slumped down in bed, and the skin on her face had beads of moisture. Resident 7 stated the AC unit wasn't working and the room got so hot she was uncomfortable and couldn't stand it.A review of Resident 7's MDS, dated [DATE], indicated Resident 7 had a BIMS score of 14 with no cognitive impairment.During a concurrent observation and interview 7/30/26 at 3:35 p.m. Resident 8 had side curtains drawn, a fan above the TV in center of room was running, all lights were off. Resident 8 was in bed in a hospital gown and was thin and frail. Resident 8 stated it was so very hot in the room some days. Resident 8 stated the fan only dried the sweat off and days like today got very uncomfortable and made her tired and hot.A review of Resident 8's MDS, dated [DATE], indicated Resident 8 had a BIMS score of 11 with moderate cognitive impairment.During a concurrent observation and interview on 7/30/26 at 3:40 p.m. Resident 9 was seen sitting up in bed in a hospital gown only, hair was up and wet at the base of her neck, beads of moisture on her forehead. The window was open and there was a fan running behind her bed facing towards the window. Resident 9 stated she felt sweaty and tired and got too hot in her room. Resident 9 stated she kept the window open and used the fan to try and blow the hot air out. Resident 9 stated the heat made her ALS (Amyotrophic lateral sclerosis (ALS) a progressive nervous system disease that destroys motor neurons in the brain and spinal cord. High heat can severely impact adults by worsening muscle fatigue, increasing systemic stress, accelerating dehydration, and in some studies, correlating with an elevated risk of severe health complications or mortality during sudden temperature spikes) worse and her body struggled to regulate her temperature. Resident 9 stated it felt like it was 98 F in the room and the facility had not taken any action to help her or other residents.A review of Resident 9's MDS, dated [DATE], indicated Resident 9 had a BIMS score of 15 with no cognitive impairment.During a concurrent observation and interview on 7/30/26 at 4:10 p.m. Resident 12 was in bed near the window, all blinds and curtains were closed. Resident 12 was in hospital gown with a thin sheet up to her waist, the skin on her face was moist. There was a fan in the middle of the room above the TV that was not running. Resident 12 stated she asked for an oscillating fan 3 weeks ago and had not received one. Resident 12 stated the fan in the room did not oscillate, so only one resident could benefit at a time. Resident 12 stated the room was hot and she felt sweaty and uncomfortable.A review of Resident 12's MDS, dated [DATE], indicated Resident 12 had a BIMS score of 11 with moderate cognitive impairment.A review of Resident's 1, 2,4,5,6,7,8,9, and 12's Care Plans, indicated these residents were already at risk for dehydration, fluid and electrolyte imbalances and impaired skin integrity.During a concurrent observation and interview on 7/30/26 at 4:30 p.m. with both the Maintenance Director (MD) and the Administrator (ADM), all rooms of sampled residents were checked for current temperatures by the MD using an infrared gun. The readings indicated Resident 1 and Resident 2's room was 86.5 F, Resident 4's room was 82.6 F, Resident 5 and Resident 6's room was 82.8 F, Resident 7 and Resident 8's room was 84.4 F, Resident 9's room was 82.8 F, and Resident 12's room was 82.4 F. The MD and ADM confirmed the temperature readings and agreed they were above the required 81 F maximum.During concurrent interview and record review on 7/30/26 at 4:50 p.m. with the MD, MD reviewed his temperature logs for the last 2 months, which indicated room temperatures between 70-76 F. MD stated he measured room temperatures every Monday morning and did not have any afternoon readings from hotter times of the day. MD agreed the logs were not an accurate representation of room temperatures throughout the day.During an interview on 7/31/26 at 2;30 p.m. the Director of Nursing (DON) stated ensuring comfortable temperatures below 81 F was important for all residents as higher temperatures put residents at risk for heat stroke, dehydration and skin issues.A review of a facility policy titled, Homelike Environment, revised 02/26, indicated, The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable and safe temperatures between 71 F and 81 F.

Based on interview and record review, the facility failed to ensure the Social Service Director (SSD) met the minimum qualifications of their position per federal regulations for a census of 135, when the SSD did not have a Bachelor's degree in Social Work or in a Human Services field.This failure decreased the facility's potential to meet the social service needs of the residents.A review of the facility's license, dated 6/1/26 to 5/31/27, indicated the facility had 168 beds.During an interview on 6/25/26 at 9:02 a.m. with the SSD, the SSD stated she had a Bachelor's Degree in Communications.During a concurrent record review and interview on 6/25/26 at 1:35 p.m., with the Human Resources Director (HRD), the HRD confirmed the SSD's job description requires a Bachelor's degree in Social Work or a Human Services field and two years of supervised social work experience in a healthcare setting. The HRD further stated he did not verify the SSD's Bachelor's degree in Communications as it was stated on her resume.Record review of a document titled, Job Description: Social Services Director Prepared by Human Resources, revised 12/25, indicated, Qualification .Education and/or Experience .Bachelor's Degree in Social Work or in Human Services and 2 years of supervised social work experience in a health care setting working directly with individuals.

Based on interview and record review, the facility failed to protect the residents' right to receive written notice of a room change for two of four sampled residents reviewed for resident rights (Resident 1 and Resident 2) when the residents were notified of a room change verbally and not in writing.This failure resulted in the residents feeling upset, angry and confused about the change of rooms. Findings: A review of Resident 1's admission record indicated she was admitted in 3/26 with the diagnosis of fracture of the neck (upper portion) of the right femur (thigh bone) and was her own responsible party (RP, healthcare decision maker). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/20/26, indicated she had no memory impairment. A review of Resident 2's admission record indicated she was last admitted in 11/25 with the diagnosis of peripheral autonomic neuropathy (damage to the nerves outside of the brain and spinal cord that control involuntary, automatic bodily functions) and was her own RP. A review of Resident 2's MDS, dated [DATE], indicated she had no memory impairment. During an interview on 6/16/26 at 10:38 a.m. with Resident 1, Resident 1 stated on 6/4/26 she had been notified in person by the Social Services Director (SSD) that her room was being changed that day from room [ROOM NUMBER] on the first floor to room [ROOM NUMBER] on the second floor of the facility. Resident 1 stated she was angry and upset and not given an opportunity to discuss the move until after she had been moved. Resident 1 stated she was not given anything in writing regarding the room change prior to the move. During an interview on 6/16/26 at 10:42 a.m. with Resident 2, Resident 2 stated she was told by staff right before dinner on 6/4/26 that her room was changing and recalled she asked staff, After dinner? and was told, No, right now. Resident 2 stated she remembered being told a new resident was coming that needed to be in isolation (infection control measures used to prevent the spread of germs in healthcare settings) and the room was needed. Resident 2 stated she did not ask for the room change, was given no advance notice and was given nothing in writing about the room change. Resident 2 stated she had felt, Like luggage, and staff put her clothes in garbage bags for the move. During an interview on 6/16/26 at 11:41 a.m. with the SSD, the SSD stated when the facility needed to move residents to different rooms she went to the residents and verbally gave them notice, an hour or two prior to the move, and explained why the facility was requesting them to change rooms. The SSD stated residents were often moved to accommodate new admissions to the facility. The SSD stated she had spoken with Resident 1 and Resident 2 regarding the room change, recalled it was because a new admission needed to be in isolation and did not provide the residents with a written notice prior to the room change. The SSD stated Resident 1 and Resident 2 were not happy with the move and did not want to be on the second floor of the facility. The SSD agreed the residents had the right to a homelike environment and moving their room to a different floor with little notice did not promote a homelike environment for them. During an interview on 6/16/26 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the timeframe within which residents were notified of the facility requesting them to change rooms depended on new admissions and that it was usually a matter of a couple of hours. The DON confirmed residents were notified of the requested change verbally, no written notice was given. During a review of the facility's policy titled, Room Change/Roommate Assignment, dated 12/06, the policy stipulated, Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives [sponsors] will be given a ___hour/day advance notice of such change .The notice of a change in room or roommate assignment may be oral or in writing, or both and will include the reason(s) for such change.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was provided the right to immediate access by family members, as required when the facility restricted Resident 1 from receiving visits and telephone communication from one of her daughters (DTR 3) and her son in law (SIL 1), based solely on another daughter's (DTR 1) designation as health care decision maker. The facility did not verify Resident 1's wishes, and there was no clinical, legal, or safety justification for restricting contact.This failure resulted in Resident 1 being denied communication and visitation with family members of her choosing, with the potential for psychosocial harm.A review of Resident 1's admission Record (facility demographic) indicated Resident 1 was originally admitted to the facility on [DATE] with an admitting diagnosis of pelvic fractures (breaks or disruptions in the bones that make up the pelvis, which is the ring-like structure located at the base of the spine).During a phone interview on 5/07/26 at 9:02 a.m., Resident 1's family member (DTR 3) reported the facility restricted her from communicating and visiting with Resident 1. DTR 3 stated she was upset because her family members (DTR 1 and DTR 2), who were listed as Resident 1's health care agents, instructed the facility to restrict her and her husband (SIL 1) from contacting Resident 1. DTR 3 stated she had called the facility multiple times, but nursing staff refused to allow her to speak with Resident 1.During a review of a one-page document titled, RESIDENT CAPACITY STATEMENT., dated 1/15/26, a Medical Doctor indicated Resident 1 had the capacity to make healthcare decisions.During an interview on 5/07/26 at 11 a.m., the Social Services Director (SSD) confirmed the facility had restricted communication and visitation from DTR 3 and SIL 1. After reviewing the medical record, the SSD stated there was no documented evidence that Resident 1 ever refused contact with them. The SSD confirmed the medical record contained no court order or clinical/safety justification supporting the restriction. The SSD stated she had never interviewed Resident 1 to determine her wishes regarding communication or visitation. The SSD acknowledged staff informed her that DTR 3 and SIL 1 had been upset on at least two occasions after being denied contact. The SSD reported that an Ombudsman visited the facility on 5/06/26 to inform staff that Resident 1's Advance Directive (a legal document that outlines an individual's preferences for medical treatment if he/she becomes too ill or injured to speak for him/herself) naming DTR 1 as primary agent and DTR 2 as alternate, did not authorize restricting Resident 1's communication or visitation with other family members. The SSD stated that after this clarification, the facility understood they could not restrict DTR 3 and SIL 1 if Resident 1 wished to see or speak with them. During the interview, the SSD displayed Resident 1's profile in the medical record, which still contained incorrect instructions to restrict DTR 3 and SIL 1. The SSD stated she did not know who entered or edited the information.During a review of a progress note in Resident 1's medical record dated 5/05/26, authored by Licensed Nurse 1 (LN 1), she indicated SIL 1 called requesting to visit the facility and bring food to Resident 1. LN 1 documented she denied the request based on the restriction listed in Resident 1's medical record, and instructed SIL 1 to contact DTR 1 and DTR 2 for clarification before transferring the call to the SSD.During an interview on 5/07/26 at 12:24 p.m., LN 1 stated she was unfamiliar with Resident 1 but saw the restriction in her profile and denied SIL 1's visit request based solely on that information. LN 1 reported she had been told the SSD received an email from DTR 1 and DTR 2 stating that DTR 3 and SIL 1 were not permitted to visit or communicate with Resident 1.During an interview on 5/07/26 at 12:47 p.m., the facility's Admissions Director (FAD) stated he had spoken with DTR 3 previously after she submitted a message through the facility website requesting to contact Resident 1. The FAD stated DTR 3 was very upset that nursing staff told her she could not speak with Resident 1 when she attempted to call and speak with her. The FAD acknowledged he followed the instructions listed in Resident 1's profile directing staff to restrict DTR 3.During an interview on 5/07/26 at 1:20 p.m., with Resident 1, using an interpreter (INT 1), Resident 1 stated that she wanted to continue communicating and visiting with all three of family members (DTR 1, 2, and 3), in addition to SIL 1. Resident 1 expressed distress about not knowing why the facility had restricted contact from DTR 3 and SIL 1. Resident 1 stated she wished to remain in the facility long term but wanted ongoing communication and visits with all her family members.During an interview on 5/07/26 at 1:48 p.m., the Director of Nursing (DON) acknowledged at least two incidents where Resident 1 was improperly restricted from contact with DTR 3 and SIL 1. The DON stated the issue had been cleared up, but acknowledged Resident 1's medical record still contained incorrect instructions directing staff to restrict contact. The DON confirmed Resident 1's Advance Directive did not authorize restricting access with DTR 3 and SIL 1, and that previous restrictions were made solely at the request of DTR 1 and DTR 2. The DON acknowledged the potential for psychosocial harm from restricting Resident 1's access to her family.A review of the facility policy titled, Resident Rights, revised February 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, misappropriation of property, and exploitation;. f. communication with and access to people and services, both inside and outside the facility; . h. be supported by the facility in exercising his or her rights;. i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility;. m. exercise rights not delegated to a legal representative;. p. be informed of, and participate in, his or her care planning and treatment;. aa. access to a telephone, mail and e-mail;. bb. communicate in person and by mail, e-mail and telephone with privacy .

Based on staff interviews and record review, the nursing staff failed to initiate and implement a person-centered care plan within seven days of admission and notify the physician and Registered Dietician (RD) for one resident (Resident 1) of three sampled residents, when Resident 1 was not weighed as ordered by the physician and lost 7 pounds in 13 days.This failure resulted in a significant loss of weight for Resident 1 and decreased the facility's potential to ensure accurate communication among its care team.Findings:A review of Resident 1's face sheet indicated admission to the facility on 3/25/26 with a diagnosis that included Dysphagia (a language disorder characterized by partial loss of the ability to produce or understand speech, caused by brain injury or disease) following a Cerebrovascular Disease (conditions affecting blood vessels supplying the brain, often causing reduced blood flow, oxygen deprivation, or hemorrhaging), Muscle Wasting and Atrophy, and Wernicke's Encephalopathy (a life-threatening acute neurological emergency caused by severe thiamine (Vitamin B1) deficiency, most commonly related to alcohol misuse, malnutrition, or prolonged vomiting).A review of Resident 1's Braden Scale [an assessment tool used by healthcare professionals to predict a resident's risk of developing pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence)] Observation/Assessment dated 3/25/26 at 7:08 p.m. indicated Resident 1's usual food intake pattern was adequate (he ate over half of most meals).A review of Resident 1's admission assessment dated [DATE] at 10:40 p.m. indicated Resident 1 needed assistance with eating.A review of Resident 1's Minimum Data Set (an assessment tool) dated 3/26/26 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a screening tool used to measure cognition [the ability to think and problem-solve]) score of 8 which indicated moderate cognitive impairment. A review of Resident 1's Nutritional Risk Assessment dated 4/1/26 at 7:18 p.m. indicated the Registered Dietician (RD) assessed that Resident 1 had a chewing/swallowing problem, his ideal body weight was 148 pounds (lbs.), and his goal weight as 125 to 130 lbs. The RD's recommendations included that staff weigh Resident 1 per the facility's protocol. The RD also indicated Resident 1's nutrition goal was No significant weight changes, [for staff to] monitor [Resident 1's] weight trend.[and for Resident 1 to eat more than] 65% of all meals. A review of Resident 1's Weight and Vitals Summary report dated 3/25/26 to 4/6/26, indicated Resident 1 weighed 128.1 lbs. upon admission on [DATE] and lost approximately 12.1 lbs. 12 days later when staff documented his weight as 116 lbs. on 4/6/26. This document further indicated the following warning to nursing staff, -5.0% change [Comparison Weight 3/25/26, 128.1 lbs., -9.4%, -12.1 lbs.].A review of Resident 1's Medication Administration Record (MAR) dated March 2026 indicated Resident 1 had the following order starting on 3/30/26 at 7 a.m., admission weekly weights x [for] 4 weeks, then Monthly Weights. Every day shift every Mon [Monday] for 4 weeks. This MAR further indicated nursing staff did not obtain a weight for Resident 1 on 3/30/26 as instructed in the physician's order.A review of Resident 1's MAR dated April 2026 indicated nursing staff weighed Resident 1 on 4/6/26 and he weighed 128.1 lbs.A review of Resident 1's progress notes dated 3/25/26 to 4/6/26 showed no documented evidence that nursing staff notified the physician or the RD of Resident 1's weight loss.A review of Resident 1's progress note dated 4/7/26 at 9:30 p.m. indicated, BLS [Basic Life Support ambulance] came to pick up [Resident 1].Writer called [hospital] ED [Emergency Department] and.[gave] report.A review of Resident 1's care plan regarding his high risk for nutritional concern was initiated on 4/10/26 indicated staff was expected to weigh Resident 1 weekly for four weeks upon admission and then monthly if his weight was stable. This care plan did not include Resident 1's need for assistance when eating, monitoring the percentage of food Resident 1 ate during meals, or any indication that Resident 1 refused meals.A review of Resident 1's hospital documentation regarding his stay from 4/7/26 to 4/14/26 indicated Resident 1 weighed 121 lbs. when he arrived at the ED (a 5.54% weight loss in 13 days) and Resident 1 was discharged from the hospital to a different skilled nursing facility.In an interview with Certified Nursing Assistant 1 on 4/16/26 at 1:20 p.m., CNA 1 stated she took care of Resident 1. CNA 1 stated Resident 1 would refuse to eat at times and that CNA 1 had to push Resident 1 to eat his breakfast and lunch.In an interview with Licensed Nurse 3 (LN 3) on 4/16/26 at 2:11 p.m., LN 3 stated she took care of Resident 1. LN 3 stated Resident 1 would refuse to eat at times.During a telephone interview on 4/22/26 at 3p.m., LN 1 stated if there was a change in a resident's weight she would report to the nurse manager, notify the physician and the dietician, and start a change of condition (COC) report.During a telephone interview on 4/22/26 at 4:35 p.m., LN 2 stated she had taken care of Resident 1 a few times and took care of him on 4/7/26 when he was transferred to the hospital. LN 2 stated she spoke with the RD on 4/7/26 and stated the documented weight must have been an error and she planned to retake Resident 1's weight when he returned. LN 2 stated for any significant weight change she would have retaken the weight, notified the physician and RD and started a COC report. LN 2 confirmed that Resident 1's weight change was not documented in the progress notes or reported to the physician.During a record review and concurrent interview on 4/23/26 at 11:30 a.m., the Director of Nursing (DON), acknowledged Resident 1's weight loss variance and stated she expected t staff to report any weight changes to the physician, RD, and to start a COC document. The DON confirmed there was no documented evidence that nursing staff notified the physician or the Inter-disciplinary team (IDT) of the weight change, nor was there documented evidence of a revision of the care plan. A review of the facility's policy titled Weight Assessment and Intervention revised, March 2022, indicated, Weight Assessment.Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation .If the weight is verified, nursing will immediately notify the dietician in writing. Evaluation.The physician and the multidisciplinary team identify conditions and medications that may be causing. weight loss Care Planning.Individualized care plans shall address to the extent possible.the identified causes of weight loss. goals and benchmarks for improvement. and.time frames and parameters for monitoring.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered dated March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical.and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical.well-being, including.services that would otherwise be provided for the above.reflects currently recognized standards of practice for problem areas and conditions.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.A review of the American Medical Directors Association (AMDA) Clinical Practice Guidelines for Long Term Care (LTC) Facilities article titled Altered Nutritional Status in the Long-Term Care Setting dated 2011 indicated, At any time during the patient's stay in a LTC facility, observation of any one of the following conditions should trigger a prompt initiation of an assessment of the patient's nutritional and fluid status.weight change of 5% in one month.Decline in food or fluid intake over several days.Consumption of less than 75% of the patient's meals is the most common symptom associated with weight loss.

Based on observations, interviews and record review, the facility failed to provide adequate supervision for two of three sampled residents (Resident 1 and Resident 2), when:Resident 1 was able to leave the facility unnoticed by staff (elope), through the front doors in his wheelchair on [DATE], making it down a steep hill before being found deceased on the sidewalk in front of the building and next to a busy street, being discovered by a passerby who notified paramedics, who in turn notified facility staff, who was not aware Resident 1 had left the facility. Resident 2 was observed unsupervised and wandering around an area next to unlocked doors that led to a wet deck, a steep decline and a parking lot. These failures potentially contributed to Resident 1 being found outside the facility by a passerby, and pronounced dead by paramedics who notified facility staff, who were not aware Resident 1 was not in the facility, and had the potential to lead to injuries for Resident 2.Findings: On [DATE] at 9 a.m., the facility was observed to be three stories and was located on the side of a hill. The basement level of the facility was located on the lower level parking lot that faced the street. A very steep set of stairs was observed to get from the lower-level parking lot to the main entrance of the facility on the first floor. The entrance of the facility was accessible at the top of the stairs as well as a steep asphalt driveway with an uneven surface (see photograph). There were no secured gates to prevent a resident from leaving the sitting area outside the front doors of the facility and attempting to go down the steep driveway in wheelchairs.During an interview on [DATE] at 9:35 a.m., the Administrator stated he was informed on [DATE], by staff at the facility that Resident 1 had been in the main lobby of the facility and had been able to leave through the main double doors held open by a facility visitor. The Administrator stated, He was apparently found at the bottom of the driveway slumped over in his wheelchair. The Administrator stated somebody had called the paramedics, they arrived and attempted Cardiopulmonary Resuscitation (CPR) and declared him, Dead on Arrival. (DOA). The Administrator stated facility staff became aware Resident 1 was not in the facility when the paramedics came into the facility and requested information for Resident 1 around 5 p.m. The Administrator stated there was no receptionist in the front lobby by the main entrance on [DATE] at 4:53 p.m., when Resident 1 exited the facility. He stated there was usually a receptionist staffed by the main doors in the front lobby from 2 p.m. to 8 p.m., but she had recently quit.During an observation on [DATE] at 11:15 a.m., at the main entrance of the facility, the reception desk in the lobby was empty. Four people, without visible badges identifying them as employees if the facility or uniforms, entered the facility through the front lobby doors.Review of a facility document titled, admission Record, not dated, revealed Resident 1 was admitted to the facility [DATE], and expired [DATE]. He was admitted with diagnoses that included CEREBRAL INFARCTION (stroke), ATAXIA (poor muscle control), DYSPHAGIA (Difficult swallowing), MAJOR DEPRESSIVE DISORDER, RIGHT ABOVE-THE-KNEE AMPUTATION and MUSCLE WEAKNESS, DYSARTHRIA (motor speech disorder from poor muscle control) and ANARTHRIA (a more severe form of Dysarthia with complete inability to speak, though comprehension and writing are usually intact), among others. During an interview on [DATE] at 9:45 a.m., the Administrator stated he reviewed facility video surveillance of the incident of [DATE] at 4:49 p.m., when Resident 1 was observed self-propelling himself in his wheelchair from the elevator towards the lobby. The Administrator stated, at 4:53 p.m., visitors to the facility opened the front door to the facility, and Resident 1 went outside. The Administrator stated the front doors were not locked. He stated he did not save the video surveillance from [DATE]. The Administrator stated Resident 1 was his own Responsible Party and could leave if he wanted to.During an interview on [DATE] at 11:15 a.m., at the main entrance of the facility, the Assistant Director of Nursing observed the front lobby and reception desk and stated, No one was monitoring the residents and the front doors of the facility. She stated there was supposed to be staff, and there was no active monitoring of residents. The Assistant Director of Nursing stated the risk to resident safety was that a resident could leave because no one was at the front desk monitoring, and the doors were not locked either.During an observation on [DATE] at 1:10 p.m., on the second floor of the facility outside the elevator, Resident 2 was in an unattended common area, with an unlocked sliding door on the right side that led out to a wet deck which overlooked a steep incline to the first level of the facility. To the left were unlocked double doors leading out to the parking lot across the hallway. Resident 2 appeared awake and did not communicate. She was walking around the room turning the lights on and off, opening cabinets and rearranging furniture without apparent reason. She walked continuously around the area and hallway from 1:10 p.m. to 1:50 p.m. No staff were checking on her or monitoring her behavior during this time.During an interview on [DATE] at 1:50 p.m., on the second floor of the facility, the Nurse Consultant stated the sliding doors in the common area where Resident 2 had been wandering were supposed to be locked. He stated the doors on the other side of the hallway, with a ramp leading to the parking lot, were supposed to be locked. He stated there was a risk Resident 2 could have gone out on the deck and slipped and fell on the wet leaves. He stated Resident 2 was being monitored remotely by the activity staff in the next room. He stated the activity staff were supposed to be supervising her. He stated the activity staff could not see her from where they were seated in the next room.Review of a facility document titled, admission Record, not dated, revealed Resident 2 was admitted [DATE], with diagnoses that included Dementia with behaviors (A loss of cognitive functioning), Muscle Weakness, Abnormality of gait and mobility (Changes in walking patterns), Glaucoma (eye condition leading to progressive vision loss and potential blindness), among others. During an interview with Unlicensed Staff C on [DATE] at 2 p.m., she stated residents in the facility could not leave on their own, and if residents wanted to leave, Unlicensed Staff C would tell a nurse. She stated residents who leave should have someone with them for their own safety. She stated Resident 1 left the second floor without being noticed and went outside the facility. She said she did not know how he made it down the driveway on his own, in a wheelchair, because it was so steep and uneven. She stated she could not have safely made it down the steep driveway if she were in a wheelchair.During an interview on [DATE] at 10:12 a.m., the Director of Staff Development (DSD) stated he was not working at the facility on the date Resident 1 expired in the lower parking lot. He stated he had received a phone call between 5 p.m. and 6 p.m., from the nursing supervisor who informed him Resident 1 had died unexpectedly in the lower parking lot of the facility. He stated the supervisor was informed by the paramedics they found Resident 1 unconscious in the lower parking lot, by the electric vehicle chargers, and had performed CPR. The DSD stated he reviewed the surveillance video with the Administrator, and stated the video indicated Resident 1 was observed getting into the elevator on the second floor and was then observed to head directly from the elevator down a long hallway directly to the front doors of the facility on the first floor. The DSD stated the video indicated Resident 1 sat and waited at the front doors of the main entrance until somebody came in the doors, and they held the doors open for him and let him go outside. He stated the last frame of the video indicated Resident 1 leaving the sitting area, onto the driveway and heading down the steep incline very slowly.During an interview on [DATE] at 12:52 p.m., the Director of Nursing (DON) stated the role of the person sitting at the front desk near the main entrance was to watch and monitor the residents who sat in the lobby. She stated they were supposed to monitor if a resident attempted to leave and either encourage them to come back in or to call for help. If someone wanted to leave the facility, against medical advice, the nurse would try to convince them to stay, call the Physician, and then try to arrange for someone to come pick them up. The DON stated they could not just walk out. During an interview with Administrator at 12:53 p.m., the Administrator stated elopement was somebody without capacity leaving the building without permission. Administrator stated Resident 1 had capacity.During an interview on [DATE] at 1:45 pm., Resident 3 stated he was really sad to hear about the death of his friend and roommate Resident 1. He stated Resident 1, Hated it here. Resident 3 stated he did not understand how Resident 1 made it down the driveway in his wheelchair because it was steep and dangerous. He said, even if Resident 1 had made it down the driveway, he would have never been able to make it up the hill to come back. Resident 3 stated he had observed Resident 1 in the hallway prior to his elopement and stated he wore a red flannel shirt, something grey on his leg and a shoe. Resident 1 was a right above the knee amputee.A review of a document from a web site titled WORLD of WEATHER, indicated for [DATE] the weather in the evening, was 48 degrees Fahrenheit, and raining, with northwest winds at 7.4 miles per hour.Review of a facility document titled, admission Record, not dated, revealed Resident 3 was admitted to the facility [DATE]. Review of Resident 3's medical record indicated a BIMS score of 12. During an interview on 1//8/26 at 2:28 p.m., Physician B stated she was Resident 1's primary care doctor. She stated she was really sad about what happened to Resident 1, and it never should have happened. She stated Resident 1 hated it at the facility and was really unhappy there. She stated Resident had expressive aphasia and was able to make his needs known if staff would have taken the time for him to use his communication board or write something down. She stated it was hard to think of him all alone in the parking lot when it was cold and raining outside and dying there all alone. She stated, He should have only left with a responsible party for safety reasons, no one should be able to just leave. He never should have been able to leave the building alone. She stated there was an order that he could only leave with a facility pass and a responsible party.Review of a document titled Order Summary Report dated [DATE], printed [DATE] (after Resident 1 passed away) revealed a physician order, dated [DATE] (date of admission) Resident may go out on pass with responsible party for dr appointments only. The order status indicated Discontinued, however, no end date was documented. During a phone interview on [DATE] at 1:29 p.m., Family Member A stated she was the emergency contact for Resident 1 and had not been informed by the facility that Resident 1 had died. She stated she heard about Resident 1's death from Resident 1's friend. Family Member A stated this was very upsetting.Record review of a document titled, Progress Notes*NEW*, dated [DATE] at 9 p.m. indicated, LATE ENTRY Note Text: per activity staff, resident stated he wants to die and tried going out the ramp door but was redirected and brought back to his room by activity staff. Then resident went out to the balcony (on the second floor) and told activity staff he wants to leave this place and will jump off the balcony. They brought the resident back to his room. LN went to this resident and asked what happened that made him upset. Resident said, he was trying to asked for help for his bedridden roommate but nobody is helping. Record review of a document titled, Progress Notes*NEW*, dated [DATE], indicated, Nursing observations, evaluation, and recommendations are: resident had suicidal thought, and verbalized wanting to die and jump off the balcony, redirected and brought back to his room. When asked by LN (Licensed Nurse) what happened, resident said he did not mean what he said and he was just upset because his roommate is not getting any help from the staff. Review of a document titled: Care plan report, not dated, for Resident 1, revealed a Focus area indicating Behavior Monitor d/t (due to) suicidal ideation/thought, and staff were to Continuously monitor for suicidal thoughts as well as Check resident every hour per facility protocol. Review of facility Policy & Procedure titled, Wander and Elopement, revised 3/2019, indicated, 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.A review of the facility Policy & Procedure titled, Safety and Supervision of Residents, revised 7/2017, indicated, Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on observation, interview and record review the facility failed to ensure accuracy of assessments when one of three sampled resident's (Resident 1) assessments did not reflect his correct status mental capacity status, and his fall risk assessment was not completed. These failures had the potential for lack of coordination of care with the health team and not providing the care and services necessary to ensure residents were safe and achieving their highest level of day-to-day life.Findings: During an interview on [DATE] at 10:12 a.m., Director of Staff Development stated he had conducted the investigation for the death of Resident 1 incident with Administrator. He reviewed the BIMS score and the last quarterly summary score indicated 01. He stated could not understand how he had a score of 01 because as a Licensed Nurse he knew the resident and he was alert and oriented. During a concurrent interview and medical record review, for Resident 1, on [DATE] at 11:31 a.m., MDS stated when she had performed an assessment on him during the last quarter, she would have scored his Brief Interview of Mental Status (BIMS) (An assessment to evaluate how cognitively intact a resident was.) score at a 3. (A score of 13 to 15: Normal thinking and memory (no or very little impairment) 8 to 12: Moderate problems with thinking and memory. 0 to 7: Severe problems with thinking and memory.) She reviewed the medical record document titled BRIEF INTERVIEW FOR MENTAL STATUS, dated [DATE], for Resident 1, and it indicated a score of 1 on [DATE]. She stated the social services staff completed the evaluation and scored it wrong. She stated Resident 1 had capacity to make his own decision and was his own responsible party. During a medical record review, a document titled Physician Orders for Life-Sustaining Treatment (POLST)( A medical document that documents a patient's specific wishes for end-of life care like CPR, Ventilation and feeding tubes.) dated [DATE], indicated Patient Has Capacity. The document was signed by Resident 1.Record Review for a document titled NURSING -FALL RISK OBSERVATION / ASSESSMENT, for Resident 1, dated [DATE], indicated a score of 18 (High Risk 16-42), and had not been completed and was signed by MDS on [DATE].Record Review for Resident 1 titled NURSING - ELOPEMENT AND WANDERING RISK OBSERVATION ASSESSMENT, dated [DATE], MOBILITY STATUS, indicated Able to move or propel themselves in a wheelchair with some assistance from others. COMMUNICATION - Does the resident have any communication, hearing or vision deficiencies? No. INTERVENTIONS Has the care plan been initiated / updated to reflect interventions aimed at reducing the risk of unsafe wandering or an elopement? Yes. Record Review for Resident 1 titled NURSING - ELOPEMENT AND WANDERING RISK OBSERVATION ASSESSMENT, dated[DATE], HISTORY OF ELOPEMENT ATTEMPTS Resident expressed that they plan to leave but has not attempted to leave facility. COMMUNICATION, indicated Resident 1 did not have any communication, hearing or vision deficiencies. INTERVENTIONS Has the care plan been initiated / updated to reflect interventions aimed at reducing the risk of unsafe wandering or an elopement? Yes.

Based on interview and record review, the facility failed to report an event of unknown source which resulted in a resident's death, when one resident (Sampled Resident 1) was found deceased by paramedics in the facility's driveway on [DATE], within the mandatory timelines. Findings:During an interview on [DATE] at 9:20 a.m., the Administrator stated someone had called 911 for a facility resident that was slumped over in his wheelchair in the lower parking lot on [DATE]. He stated the facility first became aware of the resident death after paramedics performed Cardiopulmonary Resuscitation, had pronounced the resident dead and then notified the nurses who were working in the facility. The Administrator stated he did not report this resident death to the Department because he did not consider it to be an unusual occurrence. During an interview on [DATE] at 9:57 a.m. the Administrator stated he did not have to report it to the Department. He stated he had not concluded his investigation and did not have interviews with staff who responded to the incident. During an interview with the Director of Staff Development on [DATE] at I0:12 a.m., he stated the death of Resident 1 was an unusual occurrence and should have been reported to the Department. During an interview Director of Nursing on [DATE] at 12:53 p.m., she stated she understood an unusual occurrence to be something like a fire flood or the sudden death of a resident. She stated the death of Resident 1 was definitely an unusual occurrence and it should have been reported.Review of a facility Policy & Procedure titled Unusual Occurrence Reporting, dated 2001, indicated As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Our facility will report the following events to appropriate agencies: .d. Death of a resident, employee or visitor because of unnatural causes (e.g., suicide, homicide, accidents, etc.). 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.

Based on observation, interview, and record review the facility failed to follow professional standards of practice when nursing staff left medications at the bedside for four residents (Resident 1, Resident 2, Resident 3, and Resident 4) of four sampled residents.This failure had the potential to increase the risk of medication errors, misuse and/or accidental ingestion of medication by the resident or others.A review of Resident 1's admission record indicated admission to the facility on 1/24/25 with diagnoses including Amyotrophic Lateral Sclerosis (ALS - a progressive disease affecting the nerve cells in the brain and spinal cord that control voluntary muscles), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (nerve pain), and chronic pain syndrome. A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 10/2/25 indicated no cognitive impairment with a BIMS (Brief Interview for Mental Status-an assessment tool facilities used to screen and identify memory, orientation, and judgement status of the resident) score of 14.A review of Resident 2's admission record indicated admission to the facility on 4/23/24 with diagnoses including cerebral ischemia (a condition where there is insufficient blood flow to the brain), chronic hepatitis (long lasting inflammation of the liver), heart failure (a condition where the heart cannot pump blood effectively), and chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste and toxins from the blood). A review of Resident 2's MDS dated [DATE] indicated severe cognitive impairment with a BIMS score of 4.A review of Resident 3's admission record indicated admission to the facility on 8/15/25 with diagnoses including acute respiratory failure (a sudden inability of the lungs to provide enough oxygen to the blood) and acute kidney failure (a sudden loss of kidney function). A review of Resident 3's MDS dated [DATE] indicated severe cognitive impairment with a BIMS score of 5.A review of Resident 4's admission record indicated admission to the facility on [DATE] with diagnoses including dementia (a chronic, progressive decline in cognitive function), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (a condition where a person has a high level of fats in their blood). A review of Resident 4's MDS dated [DATE] indicated moderate cognitive impairment with a BIMS score of 10.During a concurrent observation and interview on 12/16/25 at 12:15 p.m., Resident 1 had two small plastic cups on top of a closed water container on her tray table. Resident 1 stated one cup contained a 10 mg (milligram - a unit of measure) tablet of oxycodone (a strong opioid (a broad group of pain-relieving medications that work with your brain cells) medication used to treat severe pain) and the second cup contained a 100 mg capsule of gabapentin (a prescription medication used to treat neuropathy (nerve pain)) and a 400 mg capsule of gabapentin for a total of 500 mg of gabapentin. Resident 1 stated Licensed Nurse 1 (LN 1) delivered her medications and left them in the two small cups around 11 a.m. Resident 1 also stated pills had been left for her all the time.During an interview on 12/16/25 at 12:37 p.m., Resident 2 stated sometimes the nurse left his pills on the table and told him they were there.During an interview on 12/16/25 at 12:42 p.m., Resident 3 stated sometimes the nurse left the medication cup on his tray. Resident 3 stated sometimes the nurse returned to see if he had taken the medication and sometimes the nurse had not returned.During an interview on 12/16/25 at 12:50 p.m., Resident 4 stated occasionally the nurse left his pills in a cup and had not come back to see if he took the pills.During an interview on 12/16/25 at 12:52 p.m., Resident 2 stated after the nurse left the pills they had not come back to see if he had taken them.During a concurrent observation and interview on 12/16/25 at 12:55 p.m., LN 1 stated he had stayed with the residents and watched them take their medications. LN 1 entered Resident 1's room and observed with surveyor that Resident 1 had two pill cups on her tray table with medications in the cups. LN 1 stated he had dropped off the pill cups at 11:49 a.m. LN 1 stated one cup contained oxycodone which had been scheduled to be administered at noon. LN 1 stated the second cup contained gabapentin which had been scheduled to be administered at 2 p.m. LN 1 stated Resident 1 did not have an order for self-administration of medications.During an interview on 12/16/25 at 1:50 p.m., the Director of Staff Development (DSD) stated it was Absolutely not OK to leave medications at the bedside.During an interview on 12/16/25 at 2:33 p.m., the Director of Nursing (DON) stated it was, Absolutely not OK for nurses to leave medications at the bedside. The DON stated the facility had many in-services about medication administration. The DON stated the training included instructions to stay with the residents until all medications were taken. The DON stated anyone could have accidentally taken medications left at the bedside or the resident might not have taken the medications at all.A review of a facility policy and procedure titled, Administering Oral Medications, dated 2001, indicated, Remain with the resident until all medications have been taken.

Based on observation, interview, and record review the facility failed to report an allegation of abuse and failed to submit the results of their investigation to the California Department of Public Health (the Department) within the required timeframe.This failure impeded the ability of the Department to conduct a timely investigation and ensure the safety and well-being of the residents.A review of Resident 1's admission record indicated admission to the facility on 1/24/25 with diagnoses including Amyotrophic Lateral Sclerosis (ALS - a progressive disease affecting the nerve cells in the brain and spinal cord that control voluntary muscles), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (nerve pain), and chronic pain syndrome.A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 10/2/25 indicated no cognitive impairment with a BIMS (Brief Interview for Mental Status-an assessment tool facilities used to screen and identify memory, orientation, and judgement status of the resident) score of 14.A review of Resident 5's admission record indicated admission to the facility on 1/16/25 with diagnoses including atrial fibrillation (a type of irregular heart rhythm) and delirium (a sudden, severe change in mental status).A review of Resident 5's MDS dated [DATE] indicated Resident 5 had severe cognitive impairment with a BIMS score of 3.A review of Resident 6's admission record indicated original admission to the facility on 8/12/24 and most recent admission on [DATE]. Resident 6 was admitted with a diagnosis of malignant neoplasm of colon (colon cancer).A review of Resident 6's MDS dated [DATE] indicated Resident 6 had no cognitive impairment with a BIMS score of 15.During an interview on 12/16/25 at 12:15 p.m., Resident 1 stated a CNA told her that Resident 6 hit Resident 5, a nurse had taken a video of the incident, and the nurse had shown it to the Administrator, the upstairs Director of Nursing (DON) and the downstairs DON.During an interview on 12/16/25 at 1:10 p.m., Resident 5 stated she did not recall anyone hitting her.During an interview on 12/16/25 at 1:12 p.m., Resident 6 stated he hit Resident 5 in self-defense. Resident 6 did not recall the date of the incident, but it was before Thanksgiving. Resident 6 stated when he wacked Resident 5, she woke up from a flashback.During an interview on 12/16/25 at 1:50 p.m., the Director of Staff Development (DSD) stated he had not heard about the incident where Resident 6 hit Resident 5. When asked about cameras in the hallways, the DSD stated the Human Resource Director (HRD), the Director of Nursing (DON), and the Administrator (ADM) had access to the camera recordings.During an interview on 12/16/25 at 2 p.m., the HRD stated he witnessed Resident 6 hit Resident 5. The HRD stated Resident 5 was in her wheelchair (WC) in the hallway by the nurse's station. The HRD stated Resident 6 came down the hall in his WC. The HRD stated Resident 5 cut off Resident 6 with her WC and Resident 6 then hit the left side of her face. The HRD also stated he immediately separated the two residents and then he notified the floor nurse, the DON, and the Administrator. The HRD stated he did not remember the date of the incident, but it was recorded on video.During an interview on 12/16/25 at 2:20 p.m., the DON stated she did not recall the incident where Resident 6 hit Resident 5. The DON also stated staff were expected to separate the residents, report the incident to her, the Social Services Director (SSD), and the ADM if a resident-to-resident altercation occurred. The DON stated the next step would be for the nurse to do an assessment, the SSD to do an interview, and the ADM to report the event or allegation to the Department. The DON also stated nursing staff were expected to have followed up with a change of condition report and monitor both residents every shift for 72 hours. When asked about a video recording of the incident, the DON confirmed they had a video, but she did not know how long it saved.During an interview on 12/16/25 at 2:30 p.m., the HRD stated he had pulled up the video on the facility computer, and it showed the incident had occurred on Halloween (10/31/25) at 10:37 a.m.During a concurrent record review and interview on 12/16/25 at 3:23 p.m., the DSD reviewed the progress notes for Resident 5 from 10/16/25 to 11/15/25 and verified there was not a note about the resident-to-resident altercation on 10/31/25. The DSD reviewed the care plans for Resident 5 and verified there had not been a care plan updated for the incident on 10/31/25. The DSD also reviewed the progress notes for Resident 6 from 10/16/25 to 11/15/25 and verified there was not a note about the resident-to-resident altercation on 10/31/25. Lastly, the DSD reviewed the care plans for Resident 6 and verified there had not been a care plan updated for the incident on 10/31/25.During a concurrent observation and interview on 12/16/25 at 3:47 p.m., the HRD pulled up a video of the resident-to-resident altercation. This surveyor watched the video with the HRD. The video was date stamped at 10/31/25 and time stamped at 10:37 a.m. The video clearly showed Resident 6 hit Resident 5 in the face and the HRD immediately separated the two residents.During an interview on 12/16/25 at 4:15 p.m., the DON stated she left the facility in the afternoon on 10/31/25 which was why the altercation between Resident 5 and Resident 6 had not been reported.A review of the facility's Licensed Daily Staffing Schedule, dated 10/31/25, indicated the ADM, the DON, the Assistant Director of Nursing (ADON), and two MDS Coordinators (Multiple Data Set Coordinators - specialized nurses in long-term care facilities who manage comprehensive resident assessments) were the management team present in the facility that day.A review of the Department's record of Facility Reported Incidents indicated no allegations of abuse were reported between 10/11/25 and 12/2/25.A review of a facility policy and procedure titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 2001, indicated, Identify and investigate all possible incidents of abuse.Investigate and report any allegations within timeframes required by federal requirements.

Based on observation and interview, the facility failed to protect one resident (Resident 5) of six sampled residents from physical abuse when Resident 6 hit Resident 5 in the face.This failure had the potential to cause physical injury and emotional distress for Resident 5.A review of Resident 5's admission record indicated admission to the facility on 1/16/25 with diagnoses including atrial fibrillation (a type of irregular heart rhythm) and delirium (a sudden, severe change in mental status).A review of Resident 5's Minimum Data Set (MDS- an assessment tool) dated 10/9/25 indicated Resident 5 had severe cognitive impairment with a BIMS score of 3.A review of Resident 6's admission record indicated admission to the facility on 8/12/25. Resident 6 was admitted with a diagnosis of malignant neoplasm of colon (colon cancer).A review of Resident 6's MDS dated [DATE] indicated Resident 6 had no cognitive impairment with a BIMS score of 15.During an interview on 12/16/25 at 1:10 p.m., Resident 5 stated she did not recall anyone hitting her.During an interview on 12/16/25 at 1:12 p.m., Resident 6 stated he hit Resident 5 in self-defense. Resident 6 did not recall the date of the incident, but it was before Thanksgiving. Resident 6 stated when he wacked Resident 5, she woke up from a flashback.During an interview on 12/16/25 at 2 p.m., the Human Resource Director (HRD) stated he witnessed Resident 6 hit Resident 5. The HRD stated Resident 5 was in her wheelchair (WC) in the hallway by the nurse's station. The HRD stated Resident 6 came down the hall in his WC. The HRD stated Resident 5 cut off Resident 6 with her WC and Resident 6 then hit the left side of her face. The HRD also stated he immediately separated the two residents and then he notified the floor nurse, the Director of Nursing (DON), and the Administrator (ADM). The HRD stated he did not remember the date of the incident, but it was recorded on video.During a concurrent observation and interview on 12/16/25 at 3:47 p.m., the HRD pulled up a video of the altercation between Resident 5 and Resident 6. This surveyor watched the video with the HRD. The video was date stamped on 10/31/25 and time stamped at 10:37 a.m. The video clearly showed Resident 6 hit Resident 5 in the face and the HRD immediately separated the two residents.A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001, indicated, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents form abuse.by anyone including.other residents.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when:1. 3 of 3 pill crushers contained a white and black colored powder-like substances.2. The licensed staff did not wear a gown while checking vital signs (measurement of body functions) for Resident 36, who was in an isolation room that had signage posted on his room door to indicate Enhanced Barrier Precautions (EBP- gown and glove use, required during high contact resident care activities, designed to reduce transmission of organisms). 3. Resident 17's nebulizer tubing (used to inhale medication) was not changed weekly.These failures had the potential to result in the spread of infectious diseases for the facility's residents and staff.Findings:1. During a concurrent observation and interview on 12/02/25 at 4:12 p.m. with Registered Nurse (RN) 1, the pill crusher on the blue medication cart was coated with white and black colored powder-like substances. RN 1 used the pill crusher to administer medication for Resident 21. RN 1 stated the pill crusher appeared dirty with a mixture of dust and medication residue. RN 1 stated sometimes the medication bag would rip which caused the residue to build up.During a concurrent observation and interview on 12/2/25 at 4:28 p.m. with Licensed Vocational Nurse (LVN) 1, the pill crusher on the purple medication cart was coated with white and black colored powder-like substance. LVN 1 stated the pill crusher was dirty with medication residue. LVN 1 stated the pill crusher should be clean to prevent cross-contamination.During a concurrent observation and interview on 12/2/25 at 4:30 p.m. with LVN 2, the pill crusher on the green medication cart was coated with white and black colored powder-like substance. LVN 2 stated the pill crusher was dirty with medication residue. LVN 2 stated the pill crusher should be clean to prevent cross-contamination.During an interview on 12/4/25 at 10 a.m. with the Infection Preventionist (IP), IP stated the pill crushers should have been cleaned once per shift and as needed. IP stated the purpose of cleaning the pill crusher was to prevent infection and contamination.During a review of the Instruction for Using (IFU) [Brand Name] pill crusher titled Cleaning and Maintenance Instructions, undated was reviewed. The IFU indicated, .May be cleaned regularly with a damp cloth .Using a damp cloth, wipe clean the [Brand Name] Pill Crusher using a normal detergent and water. Wipe down with dry cloth .2. During an observation on 12/1/25 at 3:11 p.m., Resident 36's room door had EBP signage posted. Resident 36 was observed lying in bed while LVN 2, who was ungowned, checked his vital signs. During an interview on 12/1/25 at 3:22 p.m., with LVN 2, LVN 2 stated Resident 36 was on EBP because he had a urinary catheter (a catheter tube inserted into the bladder through the urethra to allow urine to drain into a collection bag). LVN 2 stated that he should have worn a gown while checking Resident 36's vital signs to prevent cross-contamination.During a review of Resident 36's admission Record, undated, the admission Record indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included obstructive uropathy (blockage in the urinary tract). During an interview on 12/4/25 at 9:56 a.m. with the Infection Preventionist (IP), the IP stated that any high touch activities require a gown in the EBP isolation room. The IP stated for EBP nursing staff should wear gloves and gowns when checking vital signs.During a review of the policy and procedure titled, Enhanced Barrier Precautions, dated 12/2024, indicated, .Gloves and gown are applied prior to performing the high contact resident care activities .3. During a concurrent observation and interview on 12/2/25 at 9:50 a.m. with Resident 17, Resident 17's nebulizer tubing was dated 11/23/25 (nine days ago). Resident 17 stated she used the nebulizer daily and that the tubing had not been changed. Resident 17 stated she did not want to get sick and wanted the tubing to be changed.During an interview on 12/2/25 at 9:59 a.m. with LVN 4, LVN 4 confirmed Resident 17's nebulizer tubing was dated 11/23/25 and stated the tubing should have been changed.During an interview on 12/4/25 at 9:58 a.m. with the Infection Preventionist (IP), the IP stated that nebulizer tubing should be changed weekly or as needed to prevent the spread of infection.During a review of the policy and procedure titled, Departmental (Respiratory Therapy) Prevention of Infection dated 11/2011, indicated, .Change the oxygen .tubing every (7) days, or as needed .

Based on observation, interview, and record review, the facility failed to safely store drugs and supplies in accordance with acceptable standards of practice when: 1. One medication cart (Medication Cart A) was left unlocked and unattended.2. One treatment cart (Treatment Cart A) was left unlocked and unattended.These failures had the potential for residents and staff to have unauthorized access to medications and treatments.Findings:1. During a concurrent observation and interview on 12/1/25 at 3:31 p.m., with LVN 2, Medication Cart A was left unlocked and unattended next to the Beauty Shop against the wall. LVN 2 walked out of room [ROOM NUMBER] towards Medication Cart A and confirmed Medication Cart A was unlocked. LVN 2 stated that Medication Cart A should have been locked when unattended to prevent unauthorized access. 2. During a concurrent observation and interview on 12/2/25 at 4:27 p.m. with Registered Nurse (RN) 1, Treatment Cart A was unlocked and unattended. RN 1 stated Treatment Cart A should have been locked when unattended to prevent unauthorized access. During a concurrent interview and record review on 12/3/25 at 3:46 p.m. with the Director of Nurses (DON), the facility's policy and procedure titled, Medication Labeling and Storage, dated 2023 was reviewed. The policy indicated, .The facility stores all medications and biologicals in locked compartments .Compartments .containing medications and biologicals are locked when not in use .carts .are not left unattended . The DON stated medication carts and treatment carts should be locked when unattended to prevent unauthorized access.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free of accident and hazards for 3 of 30 sampled residents (Residents 4, 17, and 53) when:1. A portable space heater was on the floor in the middle of Resident 4,17, and 53's shared room. This failure had the potential to result in a fire and tripping hazard for the residents.2. Resident 53's, who was at risk for falls, floor pad was not on the floor as ordered. This failure had the potential to result in significant injuries for the resident. Findings:1. During a concurrent observation and interview on 12/1/25 at 2:32 p.m. with Resident 17, in Resident 17's room (shared by Resident 4 and 53), a portable space heater was on the floor in the middle of the room. Resident 17 stated a Certified Nursing Assistant (CNA) brought it to her room about a week ago because she was cold. During an interview on 12/2/25 at 9:59 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she was aware the portable space heater was on the floor in the middle of the room.During an interview on 12/3/25 at 3:16 p.m. with the Administrator (ADM), the ADM stated it was facility's policy for residents not to have space heaters because of fire hazard. The ADM stated it was his expectation for staff to inform him if they see a space heater, so they can offer other interventions.During a review on the facility policy titled Electrical Appliances dated 1/2019, the policy indicated .Portable space heaters are not allowed in resident areas .2. During a concurrent observation and interview on 12/2/25 at 2:49 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 53's room, Resident 53 was observed lying in bed. There was a floor pad stored in an upright position next to Resident 53's nightstand. CNA 1 stated the floor pad should have been placed on the floor next to the bed to protect Resident 53 in the event of a fall. During a concurrent observation and interview on 12/3/25 at 9:51 a.m. with CNA 2, in Resident 53's room, Resident 53 was observed lying in bed. There was a floor pad stored in an upright position next to Resident 53's nightstand. CNA 2 stated Resident 53 was a fall risk and the floor pad should have been placed on the floor next to her bed. During a concurrent interview and record review on 12/3/25 at 3:50 p.m. with the Director of Nursing (DON), Resident 53's physician orders, dated 7/27/24, were reviewed. The physician order indicated, .Floor Pad at bedside: Ensure proper placement every shift for fall risk . The DON stated it was nursing staff's responsibility to ensure the floor pad was placed on the floor to prevent injury if a fall were to occur. During a review of the facility policy titled Fall and Fall risk, Managing, dated 3/2018, the policy indicated .The staff .will implement a resident-centered fall prevention plan .

Based on observation, interview, and record review, the facility failed to ensure 1 of 30 sampled residents (Resident 8) care plan interventions were implemented when Resident 8's indwelling urinary catheter (a flexible tube that drains urine from the bladder) collection bag was not positioned below the bladder. This failure placed Resident 8 at risk for urinary tract infections. Findings:During a concurrent observation and interview on 12/1/25 at 3:34 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 8's room, Resident 8's catheter collection bag was positioned above the bladder. LVN 2 stated the catheter collection bag was not positioned correctly to allow urine to drain into the collection bag. LVN 2 stated the catheter collection bag should have been positioned below Resident 8's bladder.During a review of Resident 8's care plan, dated 1/30/25, the care plan indicated, .position catheter bag and tubing below the level of the bladder .During an interview on 12/3/25 at 3:48 p.m. with the Director of Nursing (DON), the DON stated the urinary catheter collection bag should be placed below the level of bladder to prevent back flow which can lead to infection.During a review of the policy and procedure titled, Catheter Care, Urinary, dated 8/2022, indicated, .Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder .

Based on observation, interview, and record review, the facility failed to provide a safe environment when one sharps container (a specially made box used to safely discard sharp items) was overfilled in Unit 2, Shower Room A.This failure had the potential to cause harm to residents and staff.Findings:During a concurrent observation and interview on 12/1/25 at 4:42 p.m. in Unit 2, Shower Room A with Licensed Vocational Nurse (LVN) 1, there was an overfilled sharps container that had razors sticking out of the opening. LVN 1 stated that housekeeping and nursing staff were responsible for emptying the sharps container.During a review of the facility's policy and procedure (P&P) titled, Sharps Disposal, dated January 2012, the P&P indicated, Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container.

Based on interview and record review, the facility failed to initiate effective interventions and supervision to keep one of three sampled residents (Resident 1) safe, when: 1) Resident 1 was admitted to the facility at high risk for falls, and no high fall risk interventions, nor supervision, were initiated to keep her free from falls at the facility. This caused Resident 1 to suffer a fall with injury hours after she was admitted , and; 2) After Resident 1's fall at the facility, she started to exhibit symptoms of decline, and although these symptoms were observed by the Licensed Nurse A, assigned to her care, he failed to notify the physician immediately. The physician was notified only after Resident 1 became unresponsive. As a result of these failures, Resident 1 passed away, one day after she was admitted in stable condition to the facility, from a subdural hematoma (A buildup of blood on the surface of the brain) caused by the fall suffered at the facility. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE], with medical diagnoses including Unspecified Fall and [CONDITION(S)] (A condition in which the [CONDITION(S)] does not produce enough of certain crucial hormones), according to the facility Face Sheet (Facility Demographic). Record review of a document titled, HOSPITALIST HISTORY AND PHYSICAL, dated [DATE] at 1:26 p.m., from the General Acute Care Hospital (GACH) which discharged Resident 1 to the facility on [DATE], indicated, [Resident 1] is a [AGE] year old female .who presents from home today with a mechanical fall while walking with her walker. Record review of a nursing note titled, Admit/Readmit, entered on [DATE] at 5:19 p.m., by Licensed Staff B, indicated, admitted a [AGE] year old female resident from [GACH] around 350pm (3:50 p.m.) via [Transportation agency] transportation in gurney accompanied by 2 paramedics. Resident admitted with Dx (Diagnosis): Weakness with a fall .Resident is FULL code (A term that means, if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive), alert and oriented x 4 (Alerted to place, person, time and situation), awake, verbally responsive when she arrived upon admission. During an interview on [DATE] at 2:35 p.m., Licensed Nurse B, who documented the nursing note titled, Admit/Readmit, on [DATE] at 5:19 p.m., stated she performed the initial assessment on Resident 1 upon admission to the facility, to help Licensed Nurse A, who was Resident 1's assigned nurse. Licensed Nurse A stated she did not remember being aware Resident 1 had recently fallen at home and initiated the standard interventions to prevent falls that were used for all residents, including placing the call light within reach, ensuring the floor was free of clutter and putting the bed in low position. Licensed Nurse B stated a resident with a recent fall before admission to the facility, was considered at high risk for falls. Record review of a fall risk assessment, conducted on [DATE] at 5:49 p.m., indicated Resident 1's fall risk score was 21, which indicated she was at high risk for falls. This was confirmed by the Administrator, by e-mail, on [DATE] at 4:55 p.m. Facility Fall: Record review of a Nursing Note, dated [DATE] at 6:25 p.m., indicated, Resident was found on the floor by the sink in her room lying on L (Left) side. She stated she was trying to close the door, and she had lost balance and fell .Primary Care Provide Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send out 911. This note was documented by Licensed Nurse A. During an interview with Licensed Nurse A on [DATE] at 3:05 p.m., he stated he was in the nursing station the evening on [DATE], when a staff told him Resident 1 had fallen in her room. According to Licensed Nurse A, Resident 1 was found on the floor, on her left side, and told him she was trying to close the door of her room. Licensed Nurse A stated he helped Resident 1 get back to bed with the assistance of a Certified Nursing Assistant (Unlicensed Staff C) and noticed Resident 1 was limping from the left leg. Licensed Nurse stated that at the time, Resident 1 was alert and oriented, and he offered her pain medication but she refused. According to Licensed Nurse A, he noticed Resident 1 had a bump on the head, so he applied ice packs and initiated neurological checks (An evaluation of a person's nervous system to determine if it is impaired). During an interview with Licensed Nurse A on [DATE] at 3:10 p.m., he confirmed being the assigned License Nurse for Resident 1 on [DATE], for evening shift. Licensed Nurse A stated not being aware Resident 1 was at high risk for falls prior to Resident 1's fall at the facility. Licensed Nurse A stated he only saw Resident 1 once before the fall, and he was only passing by when he saw her, but he noticed she was alert and oriented. Licensed Nurse A stated he did not know Resident 1's medical diagnoses or the reason she was admitted to the facility prior to the fall and had not had a chance to review the discharging GACH's documents or history. Licensed Nurse A stated he did not remember performing visual checks (Visual inspection of the resident for safety purposes) on Resident 1 prior to the fall or if there were any care plans in place for her. Licensed Nurse A stated, if he had known Resident 1 was at high risk for falls, he would have placed bed alarms, floor pads, and performed additional visual checks on her. During an interview with Licensed Nurse A on [DATE] at 3:32 p.m., he confirmed documenting calling the physician in his note, dated [DATE] at 6:25 p.m., which indicated, Resident was found on the floor by the sink in her room lying on L (Left) side .Primary Care Provide Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send out 911, however, Licensed Nurse A stated during the interview that the physician was not notified of Resident 1's fall until she became unresponsive, which was at around 8 p.m., the evening of [DATE]. Licensed Nurse A confirmed, at the time when he documented the note, on [DATE] at 6:25 p.m., the physician had not been called yet. When asked the reason for having documented the physician notification of the fall with the physician's recommendation, before this was carried out, Licensed Nurse A stated he did not know why. Licensed Nurse A confirmed the physician was called only once, after the fall, and this was after Resident 1 became unresponsive. Licensed Nurse A stated Resident 1 fell right after 6 p.m., the evening of [DATE]. During a phone interview with Unlicensed Staff C on [DATE] at 11:20 a.m., he stated Resident 1 arrived to the facility sometime between 2:30 p.m. and 3 p.m., on [DATE]. Unlicensed Staff C stated he only saw Resident 1 once before the fall on [DATE], and this encounter was to take vital signs (Clinical measurements of the body's essential body functions) on her. Unlicensed Staff C stated he did not know Resident 1 was at high risk for falls because nobody had informed him, therefore, he was not performing visual checks on her. Unlicensed Staff C stated he saw Resident 1 right after the fall on the floor, under the sink in her room, with a large lump on her forehead which was not there before the fall. Record review of a facility document titled, Weights and Vitals Summary, indicated Resident 1's blood pressure before the fall, on [DATE] at 3:50 p.m., was ,d+[DATE]. Resident 1's blood pressure after the fall, on [DATE] at 6:25 p.m., was documented as ,d+[DATE], which was an increase of 22 points in systolic (The pressure in the arteries when the heart beats) blood pressure and 19 points in diastolic (The pressure in the arteries when the heart rests between beats) blood pressure. This document also indicated Resident 1's pulse before the fall, on [DATE], at 3:50 p.m., was 97 beats per minute. At 6:25 p.m., after the fall, her pulse was recorded as 109, an increase of 12 points. During a phone interview with Licensed Staff A on [DATE] at 1:30 p.m., he stated that right after the fall, he noticed Resident 1's left hand was weaker than the right, and in addition, Resident 1 was complaining of pain on the left leg, but he did not check strength on that leg. Licensed Staff A stated Resident 1's left hand continued getting weaker as time progressed, and the bump on Resident 1's forehead, discovered after the fall, kept getting bigger. Licensed Staff A stated he also noticed Resident 1's blood pressure was high. When asked the reason for not calling the physician after having identified those symptoms, Licensed Staff A stated he thought about it but did not do it, because Resident 1 was alert, and talking to her husband. When asked the reason he did not document Resident 1's weakness on the left hand, and the increase in size of the bump in Resident 1's forehead, Licensed Staff A stated, Honestly, I don't know. I did not document properly. Record review of a facility document titled, NEUROLOGICAL ASSESSMENT FLOWSHEET, dated, ,d+[DATE], with no year, for Resident 1, indicated blood pressure, motor functions (function that involves specific movements of the body's muscles to perform a certain task), and level of consciousness were checked on seven occasions from 6:25 p.m. to 8:10 p.m. This form indicated hand grasps were equal. At 8:10 p.m., this document indicated Resident 1 was alert and had an appropriate pain response. Record review of a nursing note documented by Licensed Staff A dated [DATE] at 9:30 p.m., indicated, Resident was found unresponsive at 2000 (8:00 p.m.). Vital signs assessed. Resident was breathing and unable to wake up .Physician notified and received order out to send resident to hospital .Resident was taken to [Name of GACH] at 2030 (8:30 p.m.). During an interview with Unlicensed Staff C on [DATE] at 11:32 a.m., he stated that when Resident 1 initially fell on [DATE], he saw a lump on her forehead, and by the time Resident 1 was found unresponsive, around 8 p.m., the lump on the forehead was bigger and violet in color. During an interview with the Director of Nursing (DON) on [DATE] at 4:45 p.m., she stated residents at high risk for falls needed to be checked often, approximately every 15 minutes, and placed in a room close to the nursing station for close supervision. The DON also stated Licensed Nurses assigned to newly-admitted residents, needed to review the residents' history from the GACH they were discharged from (if discharged from GACHs). The DON was asked if the assigned physician needed to be notified of a resident's fall resulting in a bump to the forehead, and how soon was the physician required to be notified. The DON responded the physician was required to be notified as soon as possible. During an interview with Licensed Nurse A on [DATE] at 3:42 p.m., he stated the last time he saw Resident 1 before she became unresponsive was sometime between 7:30 p.m., and 7:40 p.m., and the reason he went to see her was because Resident 1's husband called and wanted a nurse to check on her. Licensed Nurse A stated Resident 1 became unresponsive sometime between 7:55 p.m. and 8 p.m., on [DATE]. During a phone interview with Physician D, assigned to Resident 1, on [DATE] at 4 p.m., she stated she was unaware Resident 1 had fallen at the facility, until after Resident 1 became unresponsive. Physician D stated she gave orders to call 911 and send Resident 1 out to a GACH. Physician D stated the following day she found out Resident 1 had a severe brain injury. Physician D stated she liked to be notified of residents' falls as soon as possible after they occurred because she needed to know what happened. Physician D also stated that if she had known Resident 1 fell and developed a bump on the forehead, she would have recommended staff to call 911 and transferred her out immediately to a GACH. When Physician D was asked whether a resident with a bump on the forehead from a fall and starting to exhibit left-handed weakness, could that be a sign of neurological decline, Physician D responded, Yes, it's possible. Physician D stated a resident with a bump from a fall, and left-sided weakness, needed to be immediately transferred to GACH. Record review of Physician Progress Notes (from the GACH Resident 1 was transferred to, the evening of [DATE], after becoming unresponsive at the Skilled Nursing Facility), dated [DATE] at 6:44 a.m., indicated, This is an [AGE] year-old female .who presented completely unresponsive from her nursing facility at 2000 hours .became unresponsive around 2000 hours after a ground level fall. She was found to have a large subdural hematoma (A type of bleeding in the surface of the brain) with midline shift (Pressure that is pushing the brain off the center) that is inoperable .She has been since extubated (The removal of a tube that helps a person breathe) to comfort care .The patient is currently having agonal breathing (the medical term for the gasping that people do when they are struggling to breathe), and family is at bedside. Record review of the GACH's Discharge Summary (Where Resident 1 was transferred to, the evening of [DATE], after becoming unresponsive at the Skilled Nursing Facility), dated [DATE] at 6:11 p.m., indicated, She [Resident 1] was found unresponsive in her bed .She had been found down earlier the evening of this admission .Contrast head CT (A medical imaging tool) showed large acute (Conditions that are severe and sudden in onset) left holohemispheric (Referring to a brain hemisphere) subdural hematoma .She expired this morning. Record review of the facility policy titled, Falls-Clinical Protocol, last revised in March of 2018, indicated, The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days) .In addition, the nurse shall assess and document/report the following: g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls, and to address the risks of clinically significant consequences of falling. The facility did not document pertinent interventions on fall prevention for Resident 1, until [DATE], when Resident 1 was no longer at the facility, and had already fallen. Record review of the facility policy titled, Change in a Resident's Condition or Status, last revised in February of 2021, indicated, The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident. The facility policy titled, Charting and Documentation, last revised in July of 2017, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident's medical record: a. Objective observations .d. Changes in the resident's condition .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The facility policy titled, Neurological Assessment, last revised in October of 2010, indicated, Neurological assessments are indicated: b. Following an unwitnessed fall .Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately.

Based on observation, interview and record review, the facility failed to identify and manage the pain of one of 27 sampled residents (Resident 76), in accordance with his tolerable level of pain, monitor if pain intervention was effective, and communicate with the providing physician when pain management intervention was not effective. This failure resulted in Resident 76 suffering through severe and debilitating pain, thus making him miserable and irritable. Findings: During observation in Resident 76's room and concurrent interview on 05/04/21 at 9:14 AM, Resident 76 was seated on his bed hunched over and grimacing in pain. He slowly and agonizingly stated, in a low faint voice, he had pain on his whole right side of the body. He stated he had a regular pain medication and another that he asked his nurse for when needed. He had a patch for pain before, but he did not know if it had been stopped as he no longer received it. He stated his pain medication was not given until he went to see the nurse and asked for it. During follow-up observation at Resident 76's room at 11:48 AM, Resident 76 was still grimacing in pain. He stated that he had just had his pain medication. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . His medications included [MEDICATION(S)] 100 mg/5 ml (mg: abbreviation of milligram - is a unit of measurement of mass in the metric system equal to a thousandths of a gram) and (ml: abbreviation for milliliter - is a unit of volume in the metric system equal to one thousandths of a liter) to be given 0.3 ml by mouth every one hour, as needed for moderate Pain (4-5) (based on a pain rating scale from 0 to 10, with 0 equal to no pain and 10 the highest level of pain); 0.5 ml by mouth every one hour, as needed for Severe Pain (7-8); and 1 ml by mouth every one hour, as needed for Severe Pain (9-10). He also had orders, dated 4/10/21, for [MEDICATION(S)] 100 mg/5 ml, to be given 1 ml three times a day for moderate to severe pain and [MEDICATION(S)] 10 mg/ml, 0.5 ml every 12 hours for moderate to severe pain. During observation and concurrent interview on 05/05/21 at 10:59 AM, Resident 76 was seated in his wheelchair in the hallway by the Activity Room. He was hunched over, silently waiting. When asked how he was, he responded irritably, and stated he was waiting for the lady who would accompany him outside to the smoking area. He said that he did not feel well and was in pain. He said he was given his pain medication maybe within an hour ago. He was still in pain at 9/10. He did not think he received his medication, as scheduled. The Administrator, who was walking the hall, also spoke with Resident 76. Resident 76 was heard to respond he was not feeling well and was in pain, and he received his medication a while ago. The Administrator left and spoke with Nurse J, then went back to Resident 76 to inform him his medication was discontinued. The Administrator asked Resident 76 if he wanted the medication to be resumed. The Administrator then spoke with Nurse J and went back to Resident 76, and told him that Nurse J would call the prescribing physician to resume his medication. At 05/05/21, on continued observation at 11:19 AM, Nurse J was not seen to approach Resident 76 to check his level of pain to determine the effectiveness of medication administration. At 11:36 AM, on continued observation, Nurse J still had not gone back to Resident 76 to check the effectiveness of the intervention. Resident 76 appeared irritated, looked more hunched over with both shoulders drawn inward and stated in a half growling/groaning tone he should not be suffering through this persistent severe pain. At 11:43 AM, Resident 76 was assisted to the smoking area by an Activity staff. During a telephone interview on 5/6/21 at 11:46 AM, Nurse J was asked what time she gave Resident 76 his pain medication on the morning of 5/5/21. Nurse J stated it was already after 9 AM. When asked if she followed-up and checked his pain level after medication administration, she responded she did after he returned from his smoke break before he was supposed to have his pain medication at 1 PM. When Nurse J was asked if she is aware she should have checked Resident 76's pain level after she gave him his pain medication, she responded, Yes. When asked if she followed-up to check the effectiveness of the pain medication she gave, she responded she should have. She also confirmed she was aware Resident 76 had a pain medication she could have given, as needed, had she checked his pain level and confirmed he was still in pain. On 05/06/21 at 3:03 PM, a review of Resident 76's pain medication orders, pain assessment records and care plans were done with the Director of Nursing (DON). Reviewed records showed there were no changes in the physician orders. Pain assessments prior to scheduled pain medication administration were documented, but no pain assessments after medication administration of scheduled and as needed pain medications were documented. The Progress Notes of Nurse J were reviewed. No documentation of pain assessments in her shift report could be found. There was also no mention of calling the ordering physician to request resumption of a discontinued medication, as was mentioned by the Administrator on 5/5/21. The DON could not find any other documentation of pain assessment after pain medication administration. In addition, Resident 76's Care Plan on Pain management also indicated his acceptable pain level or goal was not identified. It only indicated, ensure patient's comfort level. When asked why the specific acceptable or tolerable pain level was not documented, the DON stated they did not specifically state an acceptable level of pain. During interview with Resident 76 on 5/7/21 at 10:51 AM, he was asked what an acceptable or tolerable pain level was for him, and responded probably, a 4/10. His pain could just go up any second. He was just aching all over the right side of his body, and the pain could just came anytime. He stated he did not know what else could be done further, was at a loss for words and just grimacing and rocking back and forth in his bed.

Based on interview and record review, the facility failed to implement interventions to prevent pressure ulcers for one of two residents (Resident 54) at risk for pressure ulcers. This failure resulted in Resident 54 developing a Stage 2 Pressure Ulcer on her coccyx. Findings: A review of Resident 54's Admission Record indicated she was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 54's Admission Record did not indicate a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review on Resident 54's record indicated, on 12/8/20, the day after admission, the facility assessed Resident 54's risk for pressure ulcers using the Braden Scale (a standardized tool for predicting a patient's risk for developing pressure ulcers). A review of Resident 54's Braden Scale, dated 12/8/20, indicated a score of 15 and indicating Resident 54 was, AT RISK, for developing pressure ulcers. Resident 54's Braden Scale assessment indicated Resident 54's mobility was, very limited. meaning Resident 54, makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. A review of Resident 54's care plans indicated no care plan was created on 12/8/20, with interventions to prevent pressure ulcers, after the facility determined Resident 54 was at risk for pressure ulcers. A review of Resident 54's Progress Notes indicated the first progress note documented in Resident 54's chart was dated 12/9/20, at 3:56 p.m., and was titled, Weekly Summary Note. A review of this note indicated a skin assessment was done which did not list any pressure ulcers. A review of Resident 54's record indicated document titled, SBAR Communication Form, dated 12/13/20, at 2 p.m., indicating, Resident noted with open pressure/incontinence wound on coccyx 1x1CM [Centimeters]. Under, Recommendations of Primary Clinicians, the document indicated, Cleanse with wound cleanser and cover with foam dressing on coccyx. A review of Resident 54's Progress Notes indicated a, Change in Condition, note dated 12/13/20, at 3:10 p.m., which documented the detection of an, open pressure/incontinence wound on coccyx [sacrum area] 1x1 CM [centimeters]. According to the National Pressure Injury Advisory Panel (NPIAP), a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. (https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf) The NPIAP divided pressure injuries/ulcers into four stages: Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis . Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present . Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer (https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf) A review of Resident 54 Care Plans indicated, on 12/13/20, the date the facility detected Resident 54's sacrum pressure ulcer, the facility created the first care plan for treatment and prevention of pressure ulcers. The care plan titled, Resident has . open wound on coccyx R/T [related to] pressure/incontinent, was initiated on 12/13/20, and had the goal of, No Pressure Sores X90days, and listed seven interventions to achieve the goal of no pressure ulcers: [1] Dietician consult as needed .[2] High Protein Supplement .[3] Keep clean and dry .[4] Moisturizing barrier cream to perineal and buttocks areas . [5] Pressure relieving devices in bed and chair . [6] Skin check with daily care .and [7] Turning/repositioning Q 2 hrs. A review of Resident 54's admission records, care plans, progress notes, medication administration records and treatment administration records revealed no documentation of interventions to prevent pressure ulcers from her admission on 12/7/20, until the development of the coccyx pressure ulcer on 12/13/20. A review of a Nurse Practitioner progress note, dated 12/16/20, at 3:49 p.m., indicated Resident 54's coccyx wound measured 1.5 x 1 centimeters and was a Stage 2 Pressure Ulcer which, appears to be a combination of both pressure and moisture related. The Nurse Practitioner recommended, prompt brief change after incontinence and, turn and reposition Q 2 hours. A review of Resident 54's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/6/21, at 10:05 a.m., Resident 54's Case Manager RN stated she was familiar with Resident 54, and stated Resident 54 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and record review on 5/6/21, at 11:30 a.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) reviewed Resident 54's record. They confirmed Resident 54 was admitted on [DATE], without pressure ulcers. They confirmed on 12/8/20, Resident 54 was assessed for risk of pressure ulcers using the Braden Scale, and the facility determined she was at risk for developing pressure ulcers. They confirmed on 12/13/20, Resident 54 developed a Stage 2 pressure ulcer on her coccyx. They confirmed the first care plan for prevention of pressure ulcers for Resident 54 was developed on 12/13/20, seven days after admission and on the same day, Resident 54 developed the pressure ulcer. The DON and ADON were asked if there was any documented evidence in Resident 54's clinical record indicating the facility implemented pressure ulcer prevention interventions for Resident 54, such as frequent turning and repositioning, from admission on 12/7/20, until the development of the coccyx pressure ulcer on 12/13/20. The DON and ADON reviewed Resident 54's clinical record, and stated they could not find any documentation of pressure ulcer prevention interventions during the period of 12/7/20 to 12/13/20, for Resident 54. They stated Resident 54 was non-compliant with care, and it was the facility's policy and practice to implement pressure prevention interventions for all residents at risk of developing pressure ulcers. A review of facility policy titled, Prevention of Pressure Injuries, Revised April 2020, indicated at least 19 interventions for prevention of pressure ulcers: Skin Care: (1) keep the skin clean and hydrated. (2) clean promptly after episodes of incontinence. (3) avoid alkaline soaps and cleansers. (4) Use a barrier product to protect skin from moisture. (5) Use incontinence products with high absorbency. (6) Do not rub or otherwise cause friction on skin that is at risk of pressure injuries, (7) Use facility-approved protective dressings for at risk individuals. Nutrition: (1) conduct nutritional screening for residents at risk. (2) conduct a comprehensive nutritional assessment for any resident at risk of pressure injury who is screened to be at risk for malnutrition, and for all adult residents with a pressure ulcer. (3) Establish and implement a nutrition care plan for any resident with or at risk for a pressure injury who is malnourished or at risk for malnutrition. (4) Provide optimal hydration, nutrient, protein and calories requirements as established by current practice guidelines. (5) Monitor the resident for weight loss and intake of food and fluids. (6) Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. Mobility/Repositioning: (1) Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. (2) Choose a frequency for repositioning based on a resident's risk factors and current clinical practice guidelines. (3) Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Support surfaces and pressure redistribution: (1) Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice . Monitoring: (1) Evaluate, report and document potential changes in the skin. (2) Review the interventions and strategies for effectiveness on an ongoing basis.

Based on observation, interview and record review, the facility failed to ensure resident safety when: 1) Staff did not evaluate, develop, and/or implement adequate individualized care plan interventions for 8 of 24 sampled residents (Resident 1, 3, 11, 12, 14, 15, 17, 19) to prevent multiple falls. This failure contributed to: A. Resident 1 fell 5 times in a 6-month period from 5/27/16 to 12/3/16. B. Resident 3 fell 8 times in a 12-month period from 1/15/16 to 2/16/17. The fall on 2/9/16 resulted in a 2.5 x 0.2 centimeter (cm) laceration above Resident 3's left eyebrow. Resident 3 sustained a right elbow abrasion in a fall on 10/6/16. C. Resident 11 fell 12 times in a 12-month period from 1/15/16 to 2/16/17. The fall on 3/15/16 resulted in a laceration on Resident 11's forehead and a pain of 10 out of 10. The fall on 6/22/16 resulted in a 2 x 3 cm bump on Resident 11's right forehead. The fall on 7/6/16 resulted in a laceration on 7/6/16 with a laceration on her forehead and right knee abrasion. Falls, dated 10/22/16, 12/1/16, and 1/28/17 indicated Resident 11 sustained a lacerations on her forehead and was transferred by ambulance to the emergency room (ER) for sutures. D. Resident 12 fell 3 times in a 6-month period from 6/24/16-1/8/17. E. Resident 14 fell 17 times in a 12-month period from 2/3/16 to 1/26/17. The fall (#14) on 12/15/16 resulted in an abrasion under Resident 14's left eye, chin, and left nostril and a 2.5 cm x 2 cm cut on Resident 14's left bottom lip. Resident 14 had lost consciousness for less then 2 minutes. Resident 14 was sent to an acute care facility's ER to be evaluated post fall on 12/15/16. F. Resident 15 fell 2 times in a 12-month period from 1/15/16 to 2/16/17. Resident 15 sustained 3 cm abrasions to her left hand and left elbow, and pain of 3 out of 10. The second fall, 2/14/17, resulted in Resident 15 fracturing her left-hip fracture, with pain level 8 out of 10, and hospitalized with surgery. G. Resident 17 fell 3 times in a 4-month period from 9/30/16 to 2/16/17. The fall (#2) on 10/9/16 resulted in lots of bruising at left shoulder/arm/elbow and an X-ray showed possible small fracture (Fx) at left elbow; sling was recommended, and a left femur Fx, which required surgery (left internal fixation) from fall on 10/9/16. The fall (#3) on 12/3/16 resulted in Resident 17 sustaining a left temporal (region of the head) bump with cut and was complaining of back and left hip pain. Resident 17 went to an acute care facility's ER to be evaluated; returned to facility same day. H. Resident 19 fell 10 times in a 12-month period from 1/15/17 to 2/16/17. The fall on 3/6/16 resulted in a lump on Resident 19's left scalp, with a pain of 2 out of 10. The fall on 5/19/16 resulted in a bump on Resident 19's right temple, and right wrist pain of 6 out of 10. The fall on 2/6/17 resulted in a pain level of 5 out of 16, when Resident 19 fell on her right side. 2) Toilet paper dispenser in residents' bathroom located in hallway next to Shower B was broken causing toilet paper to be stored on toilet tank lid and on top of paper towel dispenser. This caused residents to have to reach or get up for toilet paper causing residents to be at risk for falls. Findings: 1) A. Review of Sampled Resident 1's admission record, dated 2/2/12, and Resident 1's Physician order [REDACTED]. Resident 1's Fall Risk Assessment, dated 4/26/16, indicated Resident 1 had a score of 15 (a score of ten or greater represented high fall risk). Resident 1's quarterly MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 4/20/16, indicated Resident 1's BIM (Brief Interview of Mental Status) of 10 (moderately cognitively impaired). First Fall The Post Fall Assessment and Nursing Notes, dated 5/27/16 at 4:15 p.m., indicated Resident 1 had an unwitnessed fall. Resident 1 was found lying on her left side by the TV (television) room. Resident 1 stated she was walking toward the TV room when she lost her balance and fell to the floor. Review of Resident 1's Resident Interdisciplinary Care Plan for falls, dated 4/26/16, indicated fall risk interventions included frequent visual checks/supervise intermittently, assist with transfer and walking if needed, Wander Guard bracelet, encourage rest periods when tired, and provide reminders to ask for assist with transfer. Resident 1's fall risk care plan did not specify: 1. How the facility would provided reminders so Resident 1 would remember to ask for assistance with transferring, and; 2. How often the facility would do visual checks/supervision. Resident 1's Interdisciplinary Care Plan for falls, dated 5/27/16, indicated one additional intervention included offer to ask resident to chair/bed when tired. This intervention was already specified. Resident 1's fall risk care plan did not specify interventions as to how the facility would monitor and anticipate Resident 1's needs. Fall 2 The Post Fall Assessment and Nursing Notes, dated 10/8/16 at 2:00/2:10 p.m., indicated Resident 1 had an unwitnessed fall. Resident 1 had been walking out on Unit 1's patio and was found on the floor in a sitting position. Resident 1 stated she was walking and thinks she tripped and fell on her buttocks. Resident 1's Fall Risk Assessment, dated 7/27/16, indicated Resident 1 had a score of 17 (a score of ten or greater represented high fall risk). Resident 1's Interdisciplinary Care Plan for falls, dated 10/9/16, indicated one new intervention included remind resident to ask for assistance as needed when walking or transferring. Resident 1's fall risk care plan did not specify: 1. How the facility would provided supervision to prevent Resident 1 from further falls, and; 2. How the facility would provide reminders so Resident 1 would remember to ask for assistance with transferring or walking. Fall 3 The Post Fall Assessment and Nursing Notes, dated 11/3/16 at 1:50 p.m., indicated Resident 1 had an unwitnessed fall out on patio. Resident 1 had been sitting out on patio by herself and when she stood up Resident 1 told staff she had lost her balance and fell on her buttocks. Resident 1's Interdisciplinary Care Plan for falls, dated 11/3/16, indicated one new intervention included increase supervision and offer assistance. Resident 1's fall risk care plan did not specify how the facility was going to provide and monitor for supervision. Resident 1 continued to be unsupervised. Resident 1's Quarterly MDS dated 10/18/16, indicated Resident 1 needed supervision when walking in corridor on unit. Fall 4 The Post Fall Assessment and Nursing Notes, dated 11/29/16 at 12:05 p.m., indicated Resident 1 was walking by herself in hallway when she lost her balance and fell on her buttocks; got up on own. Resident 1's Interdisciplinary Care Plan for falls, dated 11/29/16, indicated one additional intervention included continue supervision and anticipate needs. The facility did not specify how they would monitor and anticipate Resident 1's needs. Resident 1's Fall Risk Assessment, dated 10/24/16, indicated Resident 1 had a score of 16. Fall 5 The Post Fall Assessment and Nursing Notes, dated 12/3/16 at 2:00 p.m., indicated Resident 1 had walked out on Unit 2's patio on own when she fell . Resident 1 was assisted up to a chair and then to her room. Resident 1's Interdisciplinary Care Plan for falls, dated 12/3/16, indicated one new intervention included have family buy Resident 1 better shoes. Resident 1's fall risk care plan did not specify additional monitoring interventions specific to Resident 1's known behavior of self transferring and walking without supervision, how the facility was going to provide supervision, and how the facility was going to monitor and anticipate Resident 1's needs. During observations on 2/14/17 8:25 a.m. and 12:30 a.m. and 2/15/17 at 6:05 p.m., staff did not supervise Resident 1 when she walked in the hallway, sat on the side of the bed eating her lunch, and sat on the coach in the TV room. B. Review of Sampled Resident 3's admission record, dated 10/6/12, and Resident 3's Physician order [REDACTED]. Her primary language was Spanish. The Fall Risk Assessment, dated 1/18/17, indicated a high fall risk, with a score of 18. A review of Sampled Resident 3's MDS, dated [DATE], 10/10/16, and 1/10/17, indicated Resident 3 was continent and required extensive, one-person toileting assistance. During an interview at Unit 1's nursing station, on 2/15/17 at 10:25 a.m., Licensed Staff O stated Resident 3 used whatever bathroom she wanted, and toileted independently, without staff assistance, saying the resident preferred to use a public bathroom down the hall, next to shower rooms (Unit 1). An interview with Restorative Nursing Assistant AA, on 2/17/17 at 3:20 p.m., indicated Resident 3 needed two-person assistance, and was unable to toilet herself independently. A review of Sampled Resident 3's Post Fall Assessment, on 12/17/17 at 11:45 a.m., indicated the resident had 8 falls since 1/15/16. Falls were as follows: First Fall, on 2/9/16 at 10 a.m., staff found the resident lying on her side in her bedroom, saying she had leaned down from her wheelchair and tried to pick something off the floor; Fall two, on 3/25/16 at 10 a.m., the resident fell in another resident's bathroom; Fall three, on 4/2/16 at 1 p.m., the resident fell in a hall way bathroom as she tried to independently toilet herself; Fall four, on 6/15/16 at 1:45 p.m., the resident fell attempting to independently toilet herself; Fall five, on 10/6/16 at 9:40 a.m., the resident fell in Unit 1's hallway, saying she had stood up to rearrange her skirt; Fall six, on 10/10/16 at 1 p.m., the resident fell attempting to independently toilet herself; Fall seven, on 12/25/16 at 7:30 p.m., the resident fell attempting to toilet herself; Fall eight, on 1/17/17 at 8:40 a.m., the resident fell attempting to toilet herself. A review of Post Fall Assessment outcomes, indicated the following: 1. The fall on 2/9/16 resulted in a 2.5 x 0.2 centimeter (cm) laceration above Resident 3's left eyebrow. 2. The fall on 10/6/16 resulted in a 1 x 1 cm abrasion on her right elbow. 3. The fall on 1/6/16 resulted in a right elbow abrasion. A review of Resident 3's Post Fall Assessment(s), from 1/15/16 to present, 2/17/17, indicated 6 of 8 falls, had been due to Resident 3 attempting to toilet herself, independently (1/17/17 at 8:40 a.m.; 12/15/16 at 7:30 p.m.; 10/10/16 at 1 p.m.; 6/15/16 at 1:45 p.m.; 4/2/16 at 1 p.m.; 3/25/16 at 10 a.m.). A review of posted mealtimes for Unit 1 indicated breakfast was served at 6:45 a.m., lunch at 11:36 p.m., and dinner 4:45 p.m. Mealtime observations on 2/13/17, 2/14/17, and 2/15/17, indicated Resident 3 was through eating 45 minutes to an hour after being served. Resident 3's Resident Interdisciplinary Care Plan, dated 1/18/16, and 1/17/17, did not indicate an individualized toileting routine, and; the Interdisciplinary Team notes did not indicate the facility had discussed connections between falls and toileting. An interview with Resident 3's family member, on 2/15/17 at 1:04 p.m., indicated Resident 3 told her sibling she was depressed and unhappy because it was difficult for her to communicate with staff, and to get timely assistance toileting. A review of Resident 3's Physician Orders, on 2/15/17 at 10:10 a.m., indicated the physician ordered the following treatment on 10/6/15: wedge pillow in wheelchair for proper sitting position. Resident 3's Resident Interdisciplinary Care Plan included a wedge or pommel cushion in the resident's wheelchair for improved posture, repositioning in chair as needed, and increased supervision with toileting and attempts to offer help toileting. During the following observations, Resident 3 had no wedge, or pommel cushion, on her wheelchair: 2/14 /17 at 12:20 p.m., dining 2/15/17 at 10:45 a.m., in wheelchair outside Unit 1's nursing station. 2/16/17 at 8:50 a.m., in wheelchair near Unit 1's nursing station. During a concurrent observation and interview on 2/17/17 at 10:10 a.m., Resident 3 had a cushion on her wheelchair. When asked whether she liked having the cushion, Resident 3 indicated she was more comfortable in the wheelchair with it. When asked whether staff usually provided it for her, Resident 3 denied staff provided the cushion daily. When asked why she had not waited for staff to assist her to the bathroom when she had her falls, Resident 3 stated staff had not been around to help, so she had attempted to transfer herself. During an interview on 2/17/17 at 3:50 p.m., Director of Nursing stated Resident 3 required toileting assistance. When asked to explain various fall interventions, Director of Nursing explained using a wedge or pommel cushion was one type of intervention. When asked whether she expected CNAs to follow the care plan and physician treatment orders, Director of Nursing stated CNAs were expected to document they were following care plans in a special book, refreshed weekly, in which treatment plans, including using wedge cushions, were identified and recorded. When asked whether the interdisciplinary team had identified any one time of day when falls occurred, Director of Nursing stated Resident 3's falls were inconsistent. C. Review of Sampled Resident 11's admission record, dated 8/16/12, and Resident 11's Physician order [REDACTED]. The Fall Risk Assessment, dated 2/15/17, indicated Resident 11 had a high fall risk, with a score of 16. Sampled Resident 11's MDS, dated [DATE], indicated she was [AGE] years-old with severe cognitive impairment, continent of bladder, and requiring assistance with toileting. A review of Sampled Resident 11's Post Fall Assessment, on 12/17/17 at 11:45 a.m., indicated the resident had 12 falls since 1/15/16. Falls were as follows: First fall, on 3/9/16 at 8 a.m., the resident was found sitting on the floor next to her bed; Fall two, on 3/15/16 at unknown time, the resident was found lying on her right side in her bedroom, facing the bathroom; Fall three, on 6/22/16 at 11:45 a.m., the resident was sleeping in her wheelchair at the nursing station, and fell out before staff could catch her; Fall four, on 6/28/16 at unknown time, the resident had an unwitnessed fall, and was found by staff witting on the bathroom floor (hallway public bathroom); Fall five, on 7/6/16 at 3 p.m., the resident stood up from her wheelchair at the activity room, and fell to the floor; Fall six, on 7/10/16 at 6 a.m., staff responded to an alarm and found the resident sitting on the floor of her bedroom; Fall seven, on 8/6/16 at 6:30 p.m., staff found the resident sitting on her bathroom floor; Fall eight, on 10/22/16 at 1:50 a.m., staff found the resident next to her bed, sitting on the floor, saying she wanted to catch a taxi home; Fall nine, on 11/18/16 at 5:30 a.m., staff responded to an alarm and found the resident sitting on her bedroom floor, saying she needed to go to the bathroom; Fall ten, on 12/1/16 at 2:10 p.m., staff found the resident sitting on her bathroom floor; Fall eleven, on 12/23/16 at 8:30 a.m., the resident got out of her bed to go to the bathroom and fell ; Fall twelve, on 1/28/17 at 2 p.m., the resident walked to her bathroom and fell . A review of Post Fall Assessment outcomes, and Interfacility Transfer Report, dated 10/22/16 and 12/1/16, indicated the following: 1. The fall on 3/15/16 resulted in a laceration on Resident 11's forehead and a pain of 10 out of 10. 2. The fall on 6/22/16 resulted in a 2 x 3 cm bump on Resident 11's right forehead. 3. The fall on 7/6/16 resulted in a laceration on the resident's forehead and an abrasion on her right knee 4. The falls, dated 10/22/16, 12/1/16, and 1/28/17 indicated Resident 11 sustained lacerations on her forehead and was transferred by ambulance to the emergency room for treatment, including sutures. A review of Sampled Resident 11's Post Fall Assessment(s), from 1/15/16 to present, 2/16/17, indicated seven of 12 falls were near, or in a bathroom, when the resident attempted to toilet herself (1/28/17 at 2 p.m.; 12/23/16 at 8:30 a.m.; 12/1/16 at 2:10 p.m.; 11/18/16 at 5:30 a.m.; 8/6/16 at 6:30 p.m.; 6/28/16 in a hallway bathroom, time not given; 3/15/16 after breakfast). Mealtime observations on 2/13/17, 2/14/17, and 2/15/17, indicated Resident 11 was through eating 45 minutes to an hour after being served. The Resident Interdisciplinary Care Plan, dated 2/16/17, indicated Resident 11 ambulated in her room with supervisory assistance, needed assistance for all mobility, and had a history of [REDACTED]. The care plan further indicated Resident 11 ambulated to the bathroom, and needed reminders to use her call light for safety and assistance. The care plan did not indicate an individualized toileting routine after meals. D. Review of Resident 12's admission record, dated 6/13/16 (admitted ), revealed Resident 12's [DIAGNOSES REDACTED]. Resident 12's Fall Risk Assessment, dated 6/13/16 (prior to any fall at the facility), indicated Resident 12 had a high fall risk, with a score of 12. Resident 12's admission MDS dated [DATE], included the following assessments: Resident 12's vision was moderately impaired; she had moderate difficulty with hearing, and she was able to make self-understood sometimes and able to understand others sometimes; Resident 12 was unable to complete the BIM; Resident 12 was always incontinent of urine and frequently incontinent of bowel; Resident 12 was a one-person physical assist and transfer, and; Resident 12's assessment for walking in her room did not occur. First Fall: The Post Fall Assessment, dated 6/24/16 at 6:00 p.m., indicated Resident 12's tab alarm (alerts staff to a potential fall when a resident attempts to get out of bed or up from a chair) went off and a CNA (certified nursing assistant) found Resident 12 sitting on floor next to bed. Resident 12 was attempting to get out of bed and slipped down onto the floor. Recommendations to prevent further falls were to continue alarms and offer toileting assistance. Resident 12's Interdisciplinary Care Plan for falls dated 6/29/16 (none prior), indicated Resident 12 had a history of [REDACTED]. Fall risk interventions included staff should place the resident's call light within reach, do frequent visual checks, assist with transfers and ambulation, increase toileting offers, and place an alarm on the resident's bed and wheelchair for safety. Resident 12's fall risk care plan did not specify how often the facility would do visual checks and offer toileting. Fall 2 The Post Fall Assessment, dated 7/27/16 at 2:50 a.m., indicated Resident 12 was lying in bed prior to fall. Resident 12 was found on floor, her head/face facing toward the floor. Resident 12 told staff she had rolled off her bed and hit her head/face on the floor. Recommendations to prevent further falls were to continue alarms and increase supervision. Resident 12's Interdisciplinary Care Plan for falls, dated 7/5/16, indicated one new intervention included switching tab alarm to pressure alarm (alerts staff to a potential fall when a resident attempts to get out of bed or up from a chair) due to Resident 12 was able to remove alarm. Resident 12's Interdisciplinary Care Plan for falls, dated 7/27/16, indicated one new intervention included increased room supervision. The care plan for falls did not specify how the facility would provide increased room supervision and how often. Fall 3 The Post Fall Assessment, dated 1/8/17 at 4:00 p.m., indicated Resident 12's alarm went off and was found on floor next to her wheelchair shaking with excess sweating; blood sugar was 39 (normal blood sugar between 70 and 130 mg/dL (milligram/deciliter) before meals). Resident 12 was given glucagon (emergency medicine used to treat severe [DIAGNOSES REDACTED] (low blood sugar) and placed back in bed. Resident 12's Fall Risk Assessment, dated 12/27/16, indicated Resident 12 had a score of 16 (a score of ten or greater represented high fall risk). Resident 12's Interdisciplinary Care Plan, dated 1/8/17, indicated one new intervention included increased monitoring while Resident 12 was up in wheelchair and offer rest periods when tired. The facility did not specify how they would monitor Resident 12 while she was up in wheelchair alone and how often. Resident 12's quarterly MDS, date 12/20/16, indicated Resident 12 was a one person physical assist and assessment for walking in room did not occur. Resident 12's balance was not steady, only able to stabilize with staff, Resident 12's vision was moderately impaired, she had moderate difficulty with hearing, and she was able to make self-understood sometimes and able to understand others sometimes. During concurrent observation and interview on 2/15/17 at 5:45 p.m., Resident 12 was in her room and sitting up in wheelchair eating her dinner alone. Resident 12's call light was on the bed and not in close range. When Resident 12 was asked if she could reach the call light, Resident 12 had to look for the call light, which was placed near the head of the bed, and then had difficulty reaching it. During an interview on 2/17/17 at 10:10 a.m., Licensed Staff O stated Resident 12 stood up on her own, but staff should assist her for safety because she was a fall risk. Licensed Staff O stated Resident 12 had an alarm on and if it went off a staff member needed to tend to Resident 12 right away because she would try to get up and walk to the bathroom on her own. Licensed Staff O stated Resident 12 needed to be watched because she would not wait for assistance. E. Review of Resident 14's admission record, dated 5/8/13, and Resident 14's Physician order [REDACTED]. Resident 14's Fall Risk Assessment, dated 11/10/15, indicated a high fall risk, with a score of 14. Resident 14's Resident Interdisciplinary Care Plan for falls, dated 5/19/15, indicated Resident 14 primary language was Spanish and she could speak and understand limited English. First Fall The Post Fall Assessment, dated 2/3/16 at 11:00 a.m., indicated Resident 14 was on his way to the resident hallway bathroom (no bathroom in bedroom) near his room, and was found sitting in front of the hallway bathroom. Resident 14 had an urgency to go to the bathroom caused by diarrhea (loose stool). Resident 14 had already had 3 loose stools. Resident 1 walked with a cane. Review of Resident 14's Resident Interdisciplinary Care Plan for falls, dated 11/10/15, included the following fall risk interventions: Staff should do frequent visual checks, position the resident's call light within reach, assist with transfers and walking as needed, continue to remind resident to take time when getting out of bed, remind resident to take rest periods when tired, and remind resident to hold onto rail or other support when standing up. The care plan for falls did not specify how often the facility would do visual checks. Fall 2 The Post Fall Assessment, dated 4/16/16 at 8:30 p.m., indicated Resident 14 was trying to get up and put on his shoes when he lost his balance. Resident 11 bruised his right shoulder. Resident 14's Fall Risk Assessment, dated 2/11/16, indicated Resident 14 had a high fall risk, with a score of 16. Resident 14's Interdisciplinary Care Plan for falls, dated 4/16/16, indicated one new intervention, staff should increase room supervision. The care plan for falls did not specify how the facility would provide increased room supervision and how often. Fall 3 The Post Fall Assessment, dated 6/14/16 at 12:00 p.m., indicated Resident 14 had an unwitnessed fall in his room. Resident 14 was found by certified nursing assistant (CNA) sitting on floor. The Post Fall Assessment indicated Resident 14 could walk independent with cane. Resident 14's annual MDS dated [DATE], indicated Resident 14 had a BIMs of 4 (severely cognitively impaired), needed supervision with walking in room and corridor, one person physical assist with toileting, impaired lower extremity (functional limitation with range of motion), and Resident 14's vision was impaired. Resident 14's Fall Risk Assessment, dated 5/14/16, indicated Resident 14 had a high fall risk, with a score of 19. Resident 14's Interdisciplinary Care Plan, dated 5/17/16, included the following problems: Resident 14's vision was poor; Resident 14 was unable to identify objects in central vision, could see peripheral objects better, and; Resident 14 had a right metatarsal amputation (had no toes). The care plan had no approaches to vision problem indicated on care plan. Resident 14's care plan for falls indicated a few new interventions: intermittent supervision and provide supervision often with transfers and walking. There was one new intervention after Resident 14's fall on 6/14/16, which was to ask physician for physical therapy (PT) evaluation for mobility. Resident 14's care plan for falls did not specify Resident 14 needed supervision with walking in room, corridor, with toileting, etc. at all times although Resident 14's MDS specified Resident 14 needed supervision when walking and with toileting. Fall 4 The Post Fall Assessment, dated 6/16/16 at 4:45 p.m., indicated Resident 14 fell while independently using a public bathroom in the hallway, crosswise from his bedroom. Staff found Resident 14 on his back in the bathroom. Resident 14's Interdisciplinary Care Plan for falls, dated 6//16/16, indicated one new intervention included staff should remind the resident to ask for assistance with toileting. Resident 14's care plan for falls did not did not specify how the facility was going to convey to Resident 14, who had a BIM of 4 (severely cognitively impaired), and whose primary language was Spanish, to remember to ask for assistance with toileting. Resident 14's fall risk care plan did not specify Resident 14 needed supervision when walking and with toileting at all times. Fall 5 The Post Fall Assessment, dated 7/6/16 at 3:50 a.m., indicated staff found Resident 14 lying on the floor in his bedroom. Resident 14 stated he fell out of bed when he turned himself. Resident 14's Interdisciplinary Care Plan for falls, dated 7/6/16, indicated one new intervention included increased supervision to reposition resident in bed. Resident 14's fall risk care plan did not specify how the facility was going to provide increased supervision and how often. Fall 6 The Post Fall Assessment, dated 7/21/16 at 1:45 p.m., indicated Resident 14 was walking with walker to room when he lost his balanced and fell on to floor; it was a witnessed fall. Resident 14's Interdisciplinary Care Plan for fall dated, 7/21/16, indicated one new intervention included ask physician for medication review. Resident 14's fall risk care plan still did not specify Resident 14 needed supervision when walking and with toileting consistently. Fall 7 The Post Fall Assessment, dated 7/30/16 at 12:00 a.m., indicated Resident 14 was found sitting on the floor, next to the toilet, in the resident hallway bathroom crosswise to his room. Resident 14 had been walking unsupervised with the support of a walker, and without staff supervision. Resident 14's Interdisciplinary Care Plan for falls, dated 7/30/16, indicated one new intervention included staff should offer the resident increased toileting opportunities. Resident 14's care plan for falls did not specify how facility was going to provide increased toileting and how often. There were no additional measures identified to monitor Resident 14 to prevent further falls, such as supervision when walking and toileting consistently. Fall 8 The Post Fall Assessment, dated 9/21/16 at 12:00 p.m., indicated resident 14 had an unwitnessed fall on the hallway floor outside his room. Resident 14 had walked unsupervised with the support of a walker. Resident 14 told staff member he had lost his balance and had fallen backwards onto his buttocks. Resident 14's Fall Risk Assessment, dated 8/16/16, indicated Resident 14 had a high fall risk, with a score of 24. Resident 14's Interdisciplinary Care Plan for falls, dated 9/21/16, indicated one new intervention included remind resident to walk slowly with walker and to ask for assistance when feeling tired. There were no additional measures identified to monitor Resident 14 to prevent further falls, such as making sure Resident 14 was supervised when walking with his walker. Resident 14's quarterly MDS dated [DATE], indicated Resident 14 was unable to complete the interview to evaluate BIM, Resident 14's cognitive skills for daily decision making were moderately impaired, he needed supervision with transfer, walking in room and corridor, one person physical assist with toileting, and vision was moderately impaired. Resident 14's MDS indicated he need assistance with walking and toileting. Resident 14's fall risk care plan indicated Resident 14 needed supervision intermittently and to provide assistance with transfers and assistance. Resident 14's fall risk care plan did not specify any new measures for how the facility was going to monitor Resident 14 who was continuously getting up on own without supervision and having unwitnessed falls. Fall 9 The Post Fall Assessment, dated 10/15/16 at 7:30 a.m., indicated Resident 14 had an unwitnessed fall. Resident 14 did not use call light to call for assistance and got out of bed on own. Resident 14 was found sitting on floor. Resident 14's Interdisciplinary Care Plan for falls dated 10/15/16, indicated two additional interventions included remind resident to use call light for assistance with transfer and increase offer for toileting assistance. Neither intervention was new. Resident 14's care plan on fall intervention did not specify how the facility was going to remind Resident 14 to remember to use the call light whose cognitive skills for daily decision making were moderately impaired, or how the facility provided increased toileting, and how often. There were no additional measures identified to monitor Resident 14 to prevent further falls, such as making sure Resident 14 was supervised when walking with walker. Fall 10 The Post Fall Assessment, dated 10/25/16 at 8:15 a.m., indicated Resident 14 had an unwitnessed fall. Resident 14 attempted to walk on own to resident hallway