Every finding on record at Mesa Glen Care Center

Based on interview and record review the facility failed to provide necessary care and services for activities of daily living (ADLs- activities performed daily such as bathing, dressing, and toileting) for one of three sampled residents (Resident 2) when the facility failed to bathe Resident 2, who required substantial to maximal assistance (helper does more than half the effort) with bathing, two times per week.This deficient practice resulted in Resident 2 feeling itchy and uncomfortable and had the potential to result in the development of infections (the invasion and growth of germs in the body) to Resident 2 and affect Resident 2's psychosocial (the emotional and social requirements that individuals need to feel safe, supported, and capable of functioning well in their environment) well-being.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility originally admitted Resident 2 on 6/15/2026 with diagnoses including encounter for orthopedic aftercare (a medical visit where a patient is being seen to monitor healing, manage recovery, or address follow up needs) following surgical amputation (surgical removal of a limb or part of a limb), and lack of coordination (difficulty in moving smoothly or controlling body movements).During a review of Resident 2's History and Physical (H&P), dated 6/17/2026, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 6/19/2026, the MDS indicated Resident 2's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 2 required substantial/maximal assistance with showering and bathing and was dependent (helper does all the effort) on tub and shower transfers (the ability to get in and out of a tub/shower).During an interview on 8/25/26 at 12:10 PM with Resident 2, Resident 2 stated Resident 2 had been bathed three times since Resident 2 was admitted on [DATE]. Resident 2 stated Resident 2 had asked facility staff many times for a bath but was either told it was not Resident 2's bath day or the staff member just did not give Resident 2 a bath. Resident 2 stated Resident 2 had been using personal hygiene wipes to clean Resident 2 but Resident 2 was unable to reach Resident 2's back. Resident 2 stated Resident 2 felt itchy and uncomfortable.During an interview on 8/25/2026 at 1 PM with Certified Nursing Assistant (CNA) 2, CNA 2 stated it was the policy of the facility to bathe residents (in general) two times a week. CNA 2 stated if a resident asked to be bathed on a day that was not the resident's scheduled bathing day, then it was the right of the resident to receive the bath as requested. CNA 2 stated the bath, shower, or refusal of a bath or shower were recorded in the facility's Skin Check and Shower Binder (SCSB). During a concurrent interview and record review on 8/25/2026 at 1:13 PM with the Director of Staffing Development (DSD), the facility's SCSB, dated August 2026 and the Daily CNA Observation Report, dated 8/14/2026, were reviewed. The report indicated Resident 2 was last offered and received a shower or bed bath on 8/14/2026. The DSD stated Resident 2 should be offered a bath or shower two times a week. The DSD stated CNAs should document showers/baths or refusal of showers/baths in the resident's medical record. The DSD stated since Resident 2's scheduled bath days were Wednesdays and Saturdays Resident 2 should have been offered a bath on 8/19/2026 and 8/22/2026. The DSD stated the SCSB did not indicate Resident 2 was offered or given a bath on those days. The DSD stated if Resident 2 asked for a shower on a day that was not Resident 2's scheduled bath day Resident 2 had the right to receive a bath. The DSD states it is important to bathe Resident 2 to keep Resident 2 clean and to prevent Resident 2 from getting infections.During a review of the facility's undated Policy and Procedure (P&P) titled, Quality of Care Shower/Bathing Care, the P&P's policy indicated, It is the policy of this facility to provide residents with bathing assistance based on their individual needs, preferences, and plan of care while maintaining safety, privacy, dignity, hygiene, and skin integrity. The P&P's procedures indicated, Residents will be assisted with showers, baths, or other appropriate bathing methods according to their needs, preferences, and plan of care.Bathing care and applicable observations will be documented according to facility practice.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation for resident needs and preferences for two of three sampled residents (Residents 1 and Resident 3) when:Resident 1 had to wait 90 minutes to be assisted out of bed.Resident 3's call light was observed to be on for 20 minutes without being answered.These failures resulted in Resident 1 feeling frustrated due to Resident 1 not being assisted out of bed and Resident 3 feeling angry due to Resident 3's need not being met. This deficient practice also had the potential to result in psychosocial (the emotional and social needs individuals require to feel safe, supported, and to be able to function well in their environment) harm to Residents 1 and 3.Findings:1. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 6/9/2026 with diagnoses including paraplegia (the loss of the ability to move the legs and lower body) and lack of coordination (the ability of the body to work together to perform movements or actions).During a review of Resident 1's History and Physical (H&P), dated 6/10/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Care Plan (CP), initiated 6/10/2026, the CP's focus indicated Resident 1 had impaired mobility, had decreased strength and endurance decrease, balance and coordination, and joint mobility limitation positioning issues.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/15/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (makes poor decisions requiring cues or supervision). The MDS indicated Resident 1 was dependent (helper does all of the effort) on bed to chair transfers (the ability to transfer to and from a bed to a wheelchair).During an interview and observation on 8/25/2026 at 12 PM with Resident 1, Resident 1 was observed sitting in a wheelchair. Resident 1 stated it took facility staff two hours to answer Resident 1's call light this morning. Resident 1 stated Resident 1 needed help getting out of bed and into Resident 1's wheelchair. Resident 1 stated Resident 1 felt frustrated when Resident 1 had to wait in bed for two hours before getting up.During an interview on 8/25/2026 at 3:17 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had pushed Resident 1's call light at 10 AM to request assistance with getting out of bed and into Resident 1's wheelchair. CNA 1 stated Resident 1 required 2 CNAs (in general) to assist Resident 1 into a wheelchair. CNA 1 stated it took CNA 1 90 minutes to find another staff member to assist Resident 1 into Resident 1's wheelchair.2. During a review of Resident 3's AR, the AR indicated the facility originally admitted Resident 3 on 2/27/2026 with diagnoses including hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue damage) affecting the left non-dominant side, lack of coordination, polyneuropathy (a condition where the nerves outside of the brain and spinal cord are damaged or diseased), and need for assistance with personal care.During a review of Resident 3's CP, initiated 3/3/2026, the CP's focus indicated Resident 3 had Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) self-care performance deficit related to hemiplegia, limited mobility, and polyneuropathy. The CP's interventions indicated to, encourage the resident to use bell to call for assistance.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene.During a review of Resident 3's H&P, dated 8/20/2026, the H&P indicated Resident 3 had the capacity to make medical decisions.During a concurrent observation and interview on 8/25/2026 at 3:10 PM with Resident 3, Resident 3's call light was observed to be on. Resident 3 stated Resident 3 had been waiting since 1 PM for Resident 3's call light to be answered. Resident 3 stated Resident 3 had a bowel movement and needed help with a brief change.During a concurrent observation and interview on 8/25/2026 at 3:30 PM with Resident 3, Resident 3's call light was observed to be on. Resident 3 stated Resident 3's call light had not been answered yet. Resident 3 stated this made Resident 3 feel angry.During an interview on 8/25/2026 at 4:17 PM with the Director of Nursing (DON), the DON stated it was the policy of the facility to answer residents' (in general) call lights right away. The DON stated 90 minutes was not an acceptable time for Resident 1 to have to wait to get out of bed. The DON stated 20 minutes was not an acceptable time for Resident 3 to wait to have Resident 3's call light answered. The DON stated it was important to answer call lights in a timely manner and respond to residents' (in general) needs to ensure the facility provides for the residents' needs and safety.During a review of the facility's undated Policy and Procedure (P&P) titled, Routine Procedures-Call Light/Bell, the P&P's policy indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff. The P&P's procedures indicated, Answer the light/bell within a reasonable time, listen to the resident's request/need, [and] respond to the request.

Based on interview and record review, the facility failed to provide one of three resident's (Resident 6's) medical records within two working days after receiving a valid medical request from the law firm representing Resident 6's legal representative (RP 1). This failure violated Resident 6's rights and resulted in RP 1 not receiving Resident 6's medical records within the required timeframe.During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 10/24/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 6's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 10/27/2025, the H&P indicated Resident 6 could make needs known but could not make medical decisions.During a review of a request for medical records (RMR) from the law firm representing RP 1, dated 5/15/2026, the RMR indicated the RMR was sent to the facility via fax on 5/15/2026.During a review of Resident 6's Authorization for the Release of Medical Information (ARMI), dated 5/15/2026, the ARMI indicated RP 1 gave the facility authorization to send Resident 6's medical records to the law firm representing RP 1. During a concurrent interview and record review on 5/28/2026 at 2:00 p.m. with the Medical Record Director (MRD), the ARMI, dated 5/15/2026, was reviewed. The MRD stated the medical record request from the law firm was received by the facility on 5/15/2026 and the MRD had until 5/30/2026 to send Resident 6's medical records to the law firm in accordance with the facility's policy and procedure (P&P). The MRD stated the facility's P&P indicated record request should be inspected within five (5) working days after a written request was received and copies must be transmitted within 15 days.During a concurrent interview and record review on 5/28/2026 at 3:00 p.m. with the Administrator (ADM), the facility's P&P, Chapter IV Privacy and Security 4025 Resident Access to Records, dated 12/14/2020, was reviewed. The P&P indicated, Request for Copies of the Record: Send requested copies of the record by mail with return receipt requested within 48 hours (excluding weekend and holidays) of the receipt of a valid written request. The ADM stated the facility had 15 days to send medical records to law firms upon receipt of a valid medical records request from the law firm.

Based on observation, interview, and record review, the facility failed to keep the dumpster area free from litter and securely cover four of four large facility trash bins, as indicated in the facility's Policy and Procedure (P&P) on garbage and rubbish disposal. These deficient practices had the potential to attract vermin (animals that are harmful and carry diseases) and pests (any living thing that has a negative effect on humans) that could potentially enter the facility, affect the resident care areas, and expose the residents and staff to diseases. Findings: During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (mental health condition with persistent, excessive, and uncontrollable fear or worry that interferes with daily functioning), and major depressive disorder (a mental disorder with persistent, severe low mood, sadness, or a loss of interest in activities). During a review of Resident 23's History and Physical (H&P) dated 3/5/26, the H&P indicated Resident 23 had the capacity to understand and make decisions. During a facility tour on 5/5/2026 at 1:00 PM, one of four large trash bins had open lid and there was trash on the floor surrounding the trash bin area. During an observation and interview inside Resident 23's room on 5/6/2026 at 9:59 AM, there was one dead cockroach on top of Resident 23's bathroom door. Resident 23 stated, I don't like them. I don't like bugs. During an interview with Certified Nursing Assistant 3 (CNA3) on 5/6/2026 at 10:01 AM, CNA 3 stated there was a dead cockroach on the top part of Resident 23's door. CNA 3 stated there should not have bugs or cockroaches inside a resident's room because it was not sanitary and an infection control issue. During an interview with the Housekeeper (HKP) on 5/6/2026 at 10:03 AM, the HKP stated bugs could get in through the bottom of the door since there was no weather strip (seals gaps around movable building components like doors and windows) to block them from getting in. The HKP stated bugs should not be inside the facility because it was not sanitary. During an observation of the facility's driveway and parking lot area on 5/7/2026 at 7:38 AM, there was one used/dirty blue face mask and used/dirty white gloves on the ground, outside the entrance area. During the same observation, another pair of dirty blue gloves was observed on the ground outside the facility's entrance driveway. Also, there was an empty blue bag of chips and an empty cup container that had been discarded on the ground of the parking lot area. During an interview with the Maintenance Supervisor (MS) on 5/7/2026 at 8:07 AM, the MS stated MS was responsible for maintaining the facility clean, safe and sanitary. The MS stated the MS was made aware of a bug that was inside of one of the residents' rooms. The MS stated, I think it was from the rain. I was not sure how it got in. It's not ok to have bugs/cockroaches inside the residents' rooms because it was an infection control issue and could make the residents sick. During a concurrent tour of the facility's parking lot area with the MS on 5/7/2026 at 8:11 AM, four large trash dumpsters located outside the kitchen area in the parking lot were overfilled with bags of trash preventing the lids from closing. The MS stated the trash dumpster lids should be closed and the bins should not be overfilled with bags of trash. The MS stated it was unacceptable to have overfilled trash bins and trash on the floor/ground in the surrounding areas of the facility even if it was in the parking lot area. The MS stated this was an infection control issue since this could bring rodents or bugs to the facility. During an interview with the Infection Control Nurse (IPN) on 5/8/2026 at 7:39 AM, the IPN stated it was not acceptable to have the trash dumpsters overfilled with trash bags. The IPN also stated the trash dumpster's lids needed to be completely closed to prevent trash falling over onto the ground. The IPN stated if there was trash on the ground or the trash dumpsters lids were not securely closed, it could attract rodents or bugs. During a review of the facility's undated P&P titled Garbage and Rubbish Disposal, the P&P indicated, It is the policy of the facility that garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area. During a review of the facility's undated P&P titled Maintenance Department, the P&P indicated it is the policy of the facility to maintain a clean and safe facility and grounds. During a review of the facility's undated P&P titled Physical Environment, the P&P indicated, It is the policy of the facility to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public through monthly environmental rounds. During a review of the facility's undated P&P titled Homelike Environment, the P&P indicated to provide a homelike environment for the residents. During a review of the facility's undated P&P titled Housekeeping, the P&P indicated the facility will maintain a clean, safe, sanitary, and comfortable environment.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of one facility kitchen, by failing to: a. Discard a plate of chopped fresh fruit dated 4/28/2026 in the kitchen Refrigerator 1. b. Discard a plate of chopped fresh fruit dated 5/1/2026 in the kitchen Refrigerator 1. c. Discard an open loaf of white bread beyond its use-by-date (the last date the food was considered safe to eat) of 5/2/2026 in the kitchen bread storage area. d. Label two bags of frozen pie shells with the received date and expiration or discard date in the kitchen Freezer 1. e. Discard two unlabeled bags of frozen pie shells in the kitchen Freezer 1. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.Findings: a. During an observation with the presence of the Dietary Supervisor (DS) on 5/5/2026 at 8:24 AM of the kitchen Refrigerator 1, there was a plate of chopped fresh fruit dated 4/28/2026. b. During a concurrent observation and interview with the Dietary Supervisor (DS) on 5/5/2026 at 8:24 AM of the kitchen Refrigerator 1, there was a plate of chopped fresh fruit dated 5/1/2026. The DS stated the facility stored the chopped fresh fruit in the refrigerator for up to three days. The DS stated the kitchen staff should discard any chopped fresh fruit three days after the labeled date. The DS stated the fruit plate could have bacterial growth and placed the resident at risk of infection. The DS stated it was infection control to discard the fruit plate after three days of refrigeration to prevent the spread of bacteria and germs and avoid food-borne illness. c. During a concurrent observation and interview with the DS on 5/5/2026 at 8:39 AM in the kitchen bread storage area, there was one open loaf of white bread beyond its use-by-date of 5/2/2026. The DS stated the kitchen staff should discard the bread because it was beyond the use-by-date of 5/2/2026 and should not be kept in the kitchen. The DS stated that the bread that was beyond the use-by-date had the potential to cause infection/ food-borne illness. The DS stated the DS should discard any food items beyond the use-by-date during daily checking in kitchen. d. and e. During a concurrent observation and interview with the DS on 5/5/2026 at 8:47 AM in kitchen Freezer 1, there were two undated bags of frozen pie shells. The DS stated the DS did not see any dates labeled on the two bags of frozen pie shells. The DS stated the kitchen staff should label the two bags of frozen pie shells with received and opened dates. The DS stated labelling food with dates helped track when it was received and opened, ensure proper freezer storage and support infection control. During an interview with the Director of Nursing (DON) on 5/8/2026 at 8:41 AM, the DON stated food beyond the used-by date should not be stored in the facility kitchen because the food should not be consumed to prevent infection and food-borne illness. During a review of the facility's undated Policy and Procedure (P&P) titled, Food Labeling, the P&P indicated the facility would properly label all food items stored, prepared, or served to promote food safety, prevent contamination, and support resident health. The P&P indicated the facility should label all refrigerated and stored food items with the received date and expiration or discard date. The P&P indicated the facility should discard expired, unlabeled, or improperly labeled food items. The P&P further indicated that food labeling practices would follow safe food handling and infection prevention standards.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents with indwelling catheter (including suprapubic catheter and nephrostomy tube, a flexible tube inserted into the body, usually the bladder through the urethra or through a small abdominal incision that remains in place for continuous, long-term urine drainage) for two of three sampled residents (Residents 50 and 104) by failing to:a. Ensure Resident 50's suprapubic catheter tubing was connected to a securement device on Resident 50's thigh.b. Ensure Resident 104's left and right nephrostomy catheter bags were positioned lower than the level of the bladder. These failures placed Residents 50 and 104 at risk for infection and injury related to the use of indwelling catheter. Findings: a. During a review of Resident 50's admission Record (AR), the AR indicated the facility initially admitted Resident 50 on 10/19/2018 and readmitted on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation of the legs), neuromuscular dysfunction of the bladder (occurs when brain, spinal cord, or nerve damage disrupts the signals required to store and empty urine), and presence of urogenital implants (surgically placed medical devices designed to restore or manage the function of the urinary and reproductive systems). During a review of Resident 50's untitled Care Plan (CP) initiated on 9/27/2024, the CP indicated Resident 50 had a suprapubic catheter. The CP goal was for Resident 50 not to show signs and symptoms of infection. During a review of Resident 50's Minimum data Set (MDS, a resident assessment tool) dated 4/15/2026, the MDS indicated Resident 50 had intact cognition (ability to understand and process information). The MDS indicated Resident 50 was dependent (helper did all the effort) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a concurrent observation inside Resident 50's room and interview on 5/5/2026 at 9:18 am with Certified Nurse Assistant 1 (CNA 1), Resident 50 was in bed with suprapubic catheter bag hanging on the right side of the bed. The suprapubic catheter was half-way full of urine. CNA 1 stated the suprapubic catheter tubing was not attached to Resident 50's thigh with a securement device or strap. b. During a review of Resident's 104's AR, the AR indicated the facility admitted Resident 104 on 4/23/2026 with diagnoses including malignant neoplasm (cancerous tumor) of the colon, artificial openings of urinary tract, and colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body). During a review of Resident 104's MDS dated [DATE], the MDS indicated Resident 104 had intact cognition. The MDS indicated Resident 104 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene and substantial/maximal assistance (helper did more than half the effort) with toileting, upper/lower body dressing and personal hygiene. During a concurrent observation inside Resident 104's room and interview on 5/5/2026 at 9:25 am with CNA 1, Resident 104 was in bed with left and right nephrostomy bags on top of the foot part of the bed. The foot/leg section of the bed was elevated. The left and right nephrostomy bags were placed higher than the level of Resident 104's bladder. CNA 1 stated both left and right nephrostomy bags were full. During an interview on 5/5/2026 at 9:31 am with the Treatment Nurse (TN), the TN stated the suprapubic catheter tubing should be connected to the resident's thigh to prevent pulling and dislodgement during bed mobility. The TN stated indwelling catheter bags should be placed lower than the level of the resident's bladder to prevent backflow of the urine and cause urinary tract infection (UTI, an infection in the bladder/urinary tract) to the resident. During an interview on 5/6/2026 at 3:05 pm with the Director of Nursing (DON), the DON stated indwelling catheter tubing should be attached to a securement device or strap on the resident's thigh to prevent pulling and cause trauma or injury to the resident. The DON stated indwelling catheter bags should be placed lower than the level of the resident's bladder and catheter bags should be emptied when half-full, every shift and as needed to prevent backflow of the urine and cause infection to the resident. During a review of the facility's undated Policy and Procedure (P&P) titled, Catheter Care, Foley, the P&P indicated, Each resident with an indwelling catheter will receive catheter care daily and PRN (as needed) for soiling. To avoid tension of the catheter and in and out movement of the catheter, it will be secured with a catheter strap.

Based on observation, interview, and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans (CP) to meet the residents' needs for three of three sampled residents (Residents 1, 85, and 91) by failing to: a. Develop an individualized CP to address the use of namenda (medication to improve memory, awareness, and daily functioning) for Resident 91. b. Follow the CP to maintain the appropriate setting for Resident 1's low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers/injuries [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]). c. Follow the CP for Resident 85's pressure ulcer treatment and LALM. These failures resulted in the residents not receiving individualized care to maintain the residents' highest practicable physical, mental, and psychosocial well-being. a. During a review of Resident 91's admission Record (AR), the AR indicated the facility admitted Resident 91 on 6/26/2025 with diagnoses including amnesia (sudden, loss of memory) and anxiety disorder (mental health condition characterized by persistent, excessive, and uncontrollable fear or worry). During a review of Resident 91's History and Physical (H&P) dated 11/5/2025, the H&P indicated Resident 91 had the capacity to understand and make decisions. During a review of Resident 91's Minimum Data Set (MDS, a resident assessment tool) dated 3/27/2026, the MDS indicated Resident 91 had intact cognition (ability to understand and process information). The MDS indicated Resident 91 required setup assistance from staff with eating and oral hygiene. The MDS indicated Resident 91 required supervision from staff with toileting hygiene and showering/ bathing. The MDS indicated Resident 91 required moderate assistance (helper did less than half the effort) from staff with personal hygiene. The MDS indicated Resident 91 required maximal assistance (helper did more than half the effort) from staff with bed-to-chair transferring. During a review of Resident 91's Physician Order (PO) dated 4/9/2026, the PO indicated Resident 91 had an active order of namenda 5 milligrams (mg- unit of measurement) twice a day for dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a concurrent record review and interview with the Director of Nursing (DON) on 5/8/2026 at 8:41 AM, Resident 91's entire care plans were reviewed. The DON stated there was no CP developed to address Resident 91's use of namenda. The DON stated the licensed nurse who received the namenda order should have developed the specific CP for Namenda for Resident 91. The DON stated the CP needed to be specific and resident-centered to address the specific diagnosis and medications. During a review of the facility's undated Policy and Procedure (P&P) titled, Care Planning, the P&P indicated the facility should develop a comprehensive care plan for each resident within seven days of completion of the resident's MDS. During a review of the facility's P&P titled, Minimum Data Set (MDS) Coordinator Policy & Procedure, dated 1/1/2026, the P&P indicated that the MDS Coordinator was responsible for ensuring all care plans reflect the resident's current clinical status. b. During a review of Resident 1's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including but not limited to cerebral infarction (stroke, loss of blood flow to a part of the brain), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and cognitive communication deficit (communication difficulty caused by impaired thinking skills). During a review of Resident 1's progress note, dated 4/26/2026, the progress note indicated Resident 1 has the capacity to make needs known. During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 1 has moderate impairment of thinking and memory. The MDS indicated Resident 1 has one-sided impairment to upper and lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). The MDS also indicated Resident 1 is at risk for developing PUs. During a review of Resident 1's weight log, dated 5/7/2026, the weight log indicated Resident 1's most recent weight, taken on 4/5/2026, was 119 pounds. During an observation on 5/5/2026 at 9:33 AM in Resident 1's room, Resident 1 was lying in her bed asleep. Resident 1 had a LALM in place that was turned on. The setting on the LALM control panel was set to 210 pounds. During an interview on 5/5/2026 at 10:21 AM with Treatment Nurse (TN) 1, TN 1 stated Resident 1's LALM should not be set at 210 pounds. The correct setting should be the resident's most recent weight, which is 119 pounds. During a concurrent interview and record review on 5/7/2026 at 10:00 AM with TN 1, Resident 1's physician's order, dated 4/13/2026, was reviewed. The physician's order indicated Resident 1 may have a LALM for wound management and to check for the placement, function, and setting of the LALM every shift. TN 1 stated it is the TN's responsibility to do rounds every morning to make sure the LALM is at the correct setting. If the LALM is left at the incorrect setting, it could lead to wound decline, delayed healing, or the development of a new PU. The order to monitor the LALM was not followed for Resident 1 because her LALM was at the incorrect setting. During a concurrent interview and record review on 5/7/2026 at 10:01 AM with TN 1, Resident 1's care plan titled, The Resident is at Risk for Further Skin Breakdown., last revised on 4/17/2026, was reviewed. The care plan indicated Resident 1 may have a LALM for wound management. The LALM should be monitored for placement, function, and setting. TN 1 stated the care plan was not followed because Resident 1's LALM was not at the correct setting. TN 1 further stated care plans outline the steps nursing must take to help residents improve. If not followed, the resident's wounds may deteriorate. During an interview on 5/7/2026 at 9:26 AM with the Minimum Data Set Coordinator (MDSC), the MDSC stated care plans help take care of the patient effectively. Care plans guide the care of the residents. If they are not followed, it could lead to the resident being hospitalized . During an interview on 5/7/2026 at 3:01 PM with the Director of Nursing (DON), the DON stated it is important to have LALMs be at the correct setting to ensure that they treat wounds and promote their healing or prevent new wounds from being formed. If the LALM is not at the appropriate setting, it could create a new wound or make the existing wound worsen. The DON further stated it is important to ensure care plans are followed because they tell nursing staff what they are supposed to and guide the care of the residents. During a review of the facility's LALM operator manual titled, Med-Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System, undated, the manual indicated the LALM setting should be set at the patient's weight. During a review of the facility's policy and procedure (P&P) titled, Alternating Pressure Pad or Mattress, undated, the P&P indicated the facility may use specialized mattresses to prevent skin breakdown and to treat PUs of residents. During a review of the facility's policy and procedure (P&P) titled, Care Plan and Care Plan Update, undated, the P&P indicated the facility must ensure each resident receives the care and services to attain and maintain their highest practicable wellbeing. The care plan will be initiated upon identification of a resident need that requires intervention or monitoring. c. During a review of Resident 85's face sheet, dated 5/7/2026, the face sheet indicated Resident 85 was admitted to the facility on [DATE] with diagnoses including but not limited to malnutrition (a condition of imbalance between the nutrients the body needs to function and the nutrition it gets), dementia (a progressive state of decline in mental abilities), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 85's history and physical (H&P), dated 3/5/2026, the H&P indicated Resident 85 does not have the capacity to understand and make decisions. During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85 has severe problems with thinking or memory. The MDS indicated Resident 85 has one-sided impairment to upper and lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). The MDS also indicated Resident 85 is at risk for developing PUs and currently has PUs. During a review of Resident 85's physician's orders, dated 5/1/2026 at 4:41 PM, the order indicated treatment instructions for Resident 85's right hip stage 3 PU (full-thickness loss of skin; dead and black tissue may be visible). The instructions were to cleanse the wound, pat dry, apply antiseptic (a substance applied to skin or tissue to destroy germs), then cover with a dressing every day and as needed for soiled or dislodged dressings. During a review of Resident 85's physician's orders, dated 4/29/2026 at 5:32 PM, the order indicated treatment instructions for Resident 85's left fourth-finger stage 4 PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). The instructions were to cleanse the wound, apply ointment, then cover with a dressing every day and as needed for soiled or dislodged dressings. During a review of Resident 85's care plan titled, The Resident is at Risk for Further Skin Breakdown., last revised on 4/13/2026, the care plan indicated Resident 85 may have a LALM for wound management. The LALM should be monitored for placement, function, and setting. During a review of Resident 85's care plan titled, Resident has an Actual Pressure Ulcer Stage 3 on Right Hip, revised on 4/19/2026, the care plan indicated to keep the wound covered with a dressing and administer treatments as ordered. During a review of Resident 85's care plan titled, Resident has an Actual Stage 4 Pressure Ulcer on Left 4th Finger, revised on 5/1/2026, the care plan indicated to keep the wound covered with a dressing and administer treatments as ordered. During a review of Resident 85's weight log, dated 5/7/2026, the weight log indicated Resident 85's most recent weight, taken on 4/5/2026, was 102 pounds. During an observation on 5/5/2026 at 9:26 AM in Resident 85's room, Resident 85 was lying in his bed asleep. Resident 85 had a LALM in place that was turned on. The setting on the LALM control panel was set to 200 pounds. During an interview on 5/5/2026 at 10:21 AM with TN 1, TN 1 stated Resident 85's LALM should not be set at 200 pounds. The correct setting should be the resident's most recent weight, which is 102 pounds. During a concurrent observation and interview on 5/6/2026 at 3:11 PM with TN 1 and TN 2 in Resident 85's room, Resident 85's treatment was being performed for the right hip stage 3 PU. There was no dressing in place on the wound. The right hip stage 3 PU was red and had some scabs starting to form. TN 2 stated there was no dressing in place on the wound before starting the treatment. TN 1 stated there is a physician's order to keep the wound covered with a dressing and this physician's order was not carried out. During a concurrent observation and interview on 5/6/2026 at 3:14 PM with TN 1 and TN 2 in Resident 85's room, Resident 85's treatment was being performed for the left fourth-finger stage 4 PU. There was no dressing in place on the wound. The left fourth-finger stage 4 PU was red and open. TN 2 stated there was no dressing in place on the wound before starting the treatment. TN 1 stated there is a physician's order to keep the wound covered with a dressing and this physician's order was not carried out. During a concurrent interview and record review on 5/7/2026 at 10:05 AM with TN 1, Resident 85's physician's order, dated 4/13/2026, was reviewed. The physician's order indicated Resident 85 may have a LALM for wound management and to check for the placement, function, and setting of the LALM every shift. TN 1 stated it the treatment nurse's responsibility to do rounds every morning to make sure the LALM is at the correct setting. If the LALM is left at the incorrect setting, it could lead to wound decline, delayed healing, or the development of a new PU. The order to monitor the LALM was not followed for Resident 85 because his LALM was at the incorrect setting. During an interview on 5/7/2026 at 10:06 AM with TN 1, TN 1 stated the physician's orders for two of Resident 85's PUs were not carried out. For Resident 85's right hip stage 3 PU and left fourth-finger stage 4 PU, the physician's orders were not carried out because the two wounds initially did not have dressings in place before starting their treatments. To follow the orders, the two wounds should be always covered with dressings. If these orders are not followed, Resident 85 is at risk for further skin breakdown and wound decline. During an interview on 5/7/2026 at 10:07 AM with TN 1, TN 1 stated that the care plans regarding Resident 85's LALM, right hip stage 3 PU, and left fourth-finger stage 4 PU were not carried out. The LALM was at the incorrect setting, and the two wounds did not have dressings. It is important to follow care plans because they guide nursing on what interventions to perform. During an interview on 5/7/2026 at 3:01 PM with the DON, the DON stated it is important to have LALMs be at the correct setting to ensure that they treat wounds and promote their healing or prevent new wounds from being formed. If the LALM is not at the appropriate setting, it could create a new wound or make the existing wound worsen. The DON further stated wounds with treatment orders to have dressings should have dressings in place to prevent infection. It is important to ensure care plans are followed because they tell nursing staff what they are supposed to and guide the care of the residents. During a review of the facility's LALM operator manual titled, Med-Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System, undated, the manual indicated the LALM setting should be set at the patient's weight. During a review of the facility's policy and procedure (P&P) titled, Alternating Pressure Pad or Mattress, undated, the P&P indicated the facility may use specialized mattresses to prevent skin breakdown and to treat PUs of residents. During a review of the facility's policy and procedure (P&P) titled, Care Plan and Care Plan Update, undated, the P&P indicated the facility must ensure each resident receives the care and services to attain and maintain their highest practicable wellbeing. The care plan will be initiated upon identification of a resident need that requires intervention or monitoring. During a review of the facility's policy and procedure (P&P) titled, Skin Management System, undated, the P&P indicated a plan of care will be initiated to address areas of actual skin breakdown.

Based on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 91 and 98) Minimum Data Set (MDS, a resident assessment tool) reflected an accurate assessment by failing to: a. Ensure Resident 91's diagnosis of anxiety disorder (mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry) was coded in MDS assessment dated [DATE]. b. Ensure Resident 98, who was discharged to home under the care of home health (wide range of health care services that could be given at home for an illness or injury) service was coded in the MDS assessment dated [DATE], accurately. These deficient practices resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and work with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Residents 91 and 98 not receiving interventions to address specific care concerns.Findings: a. During a review of Resident 91's admission Record (AR), the AR indicated the facility admitted Resident 91 on 6/26/2025 with diagnoses including amnesia (sudden loss of memory) and anxiety disorder (mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry). During a review of Resident 91's History and Physical (H&P) dated 11/5/2025, the H&P indicated Resident 91 had the capacity to understand and make decisions. During a review of Resident 91's Psychiatric Progress Note (PPN) dated 3/23/2026, the PPN indicated Resident 91 had a diagnosis of anxiety disorder. During a review of Resident 91's Physician Order (PO) dated 3/23/2026, the PO indicated Resident 91 had an active order of buspirone HCL (medication for anxiety disorder) twice a day. During a review of Resident 91's MDS dated [DATE], the MDS indicated Resident 91 had intact cognition (ability to understand and process information). The MDS indicated Resident 91 required setup assistance from staff with eating and oral hygiene. The MDS indicated Resident 91 required supervision from staff with toileting hygiene and showering/ bathing. The MDS indicated Resident 91 required moderate assistance (helper did less than half the effort) from staff with personal hygiene. The MDS indicated Resident 91 required maximal assistance (helper did more than half the effort) from staff with bed-to-chair transferring. During a concurrent record review and interview with MDS Nurse 1 (MDSN 1) on 5/8/2026 at 9:50 AM, Resident 91's Medication Administration Record (MAR) for March 2026 was reviewed. MDSN 1 stated the MAR indicated Resident 91 received buspirone HCL for anxiety disorder starting on 3/23/2026. During a concurrent record review and interview with MDSN 1 on 5/8/2026 at 9:50 AM, Resident 91's MDS dated [DATE] was reviewed. MDSN 1 stated the MDS dated [DATE] did not indicate Resident 91 had a diagnosis of anxiety disorder. MDSN 1 stated anxiety disorder should have been coded in Resident 91's MDS because Resident 91 was taking buspirone HCL for anxiety starting on 3/23/2026. MDSN 1 stated that the MDS should be modified and resubmitted to CMS. b. During a review of Resident 98's AR, the AR indicated the facility admitted Resident 98 on 2/15/2026 with diagnoses including sepsis (a life-threatening blood infection) and hypertension (high blood pressure). During a review of Resident 98's H&P dated 2/16/2026, the H&P indicated Resident 98 had the capacity to understand and make decisions. During a review of Resident 98's PO dated 3/3/2026, the PO indicated to discharge Resident 98 to home with home health for wound follow up. During a review of Resident 98's MDS dated [DATE], the MDS indicated Resident 98 had intact cognition. The MDS indicated Resident 98 required setup assistance from staff with eating and oral hygiene. The MDS indicated Resident 98 required moderate assistance from staff with toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. During a review of Resident 98's Physician's Discharge Summary (PDS) dated 3/9/2026, the PDS indicated the facility discharged Resident 98 home with home health because Resident 98 no longer needed the services provided by the facility. During a concurrent record review and interview with MDS Coordinator (MDSC) on 5/7/2026 at 9:17 AM, Resident 98's MDS dated [DATE] was reviewed. The MDSC stated the MDS indicated Resident 98 was discharged to home/community instead of discharged home under care of organized home health service organization. The MDSC stated Resident 98's MDS was not an accurate assessment. The MDSC stated the facility transcribed the resident's assessment to CMS. The MDSC stated it was important to have an accurate MDS assessment because the MDS assessment was a reflection of the overall residents' care and the services provided to the residents. The MDSC stated the MDSC certified the assessment accuracy by signing the MDS assessment. The MDSC stated an inaccurate MDS assessment did not provide the correct residents' information to CMS. During an interview on 5/8/2026 at 8:41 AM with the Director of Nursing (DON), the DON stated it was important to have an accurate MDS assessment because the facility needed to provide accurate information to CMS. The DON stated the MDS assessment should indicate resident's diagnoses and discharge destination accurately. During a review of the facility's Policy and Procedure (P&P) titled, Minimum Data Set (MDS) Coordinator Policy & Procedure, dated 1/1/2026, the P&P indicated the facility should complete all MDS assessments accurately in compliance with federal and California state regulations. The P&P indicated the MDSC was responsible for ensuring all assessments reflect the resident's current clinical status. The P&P indicated that the MDSC was responsible for ensuring the accuracy of coding through chart review and correcting errors promptly. The P&P further indicated that the DON was responsible for reviewing MDS accuracy.

Based on observation, interview, and record review, the facility failed to provide care and services to promote healing for residents with pressure ulcer/injury (PU/PI, localized damage to the skin and/or underlying tissue usually over a bony prominence) and skin maintenance for five of seven sampled residents (Residents 1, 85, 3, 50 and 58 ) by failing to:a. Ensure Resident 1's Low Air Loss Mattress (LAL, a specialized medical support surface designed to prevent and treat skin ulcers by combining alternating pressure with a steady low-volume airflow) was set consistent with Resident 1's weight.b. Ensure Resident 85's LAL mattress pressure was set consistent with Resident 85's weight and treatment for Resident 85's PU was provided in accordance with physician's order.c. Ensure Resident 3's LAL mattress was set on alternating pressure (a system of interconnected air cells that inflate and deflate in cycles to continuously shift support and relieve pressure over bony prominence) and not on static.d. Ensure Resident 50's LAL mattress pressure was set consistent with Resident 50's weight.e. Ensure Resident 58's LAL mattress pressure was set consistent with Resident 58's weight. These failures had the potential to result in worsening of PU/PI or development of skin breakdown for Residents 1, 85, 3, 50 and 58. Findings: a. During a review of Resident 1's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis including but not limited to cerebral infarction (stroke, loss of blood flow to a part of the brain), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and cognitive communication deficit (communication difficulty caused by impaired thinking skills). During a review of Resident 1's progress note, dated 4/26/2026, the progress note indicated Resident 1 has the capacity to make needs known. During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 1/28/2026, the MDS indicated Resident 1 has moderate impairment of thinking and memory. The MDS indicated Resident 1 has one-sided impairment to upper and lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). The MDS also indicated Resident 1 is at risk for developing PUs. During a review of Resident 1's weight log, dated 5/7/2026, the weight log indicated Resident 1's most recent weight, taken on 4/5/2026, was 119 pounds. During an observation on 5/5/2026 at 9:33 AM in Resident 1's room, Resident 1 was lying in her bed asleep. Resident 1 had a LAL in place that was turned on. The setting on the LAL control panel was set to 210 pounds. During an interview on 5/5/2026 at 10:21 AM with Treatment Nurse (TN) 1, TN 1 stated Resident 1's LAL should not be set at 210 pounds. The LAL should be set to the resident's most recent weight. TN 1 stated the correct setting should be 119 pounds. During a concurrent interview and record review on 5/7/2026 at 10:00 AM with TN 1, Resident 1's physician's order, dated 4/13/2026, was reviewed. The physician's order indicated Resident 1 may have a LAL for wound management and to check for the placement, function, and setting of the LAL every shift. TN 1 stated it is the TN's responsibility to do rounds every morning to make sure the LAL is at the correct setting. If the LAL is left at the incorrect setting, it could lead to wound decline, delayed healing, or the development of a new PU. The order to monitor the LAL was not followed for Resident 1 because her LAL was at the incorrect setting. b. During a review of Resident 85's face sheet, dated 5/7/2026, the face sheet indicated Resident 85 was admitted to the facility on [DATE] with diagnoses including but not limited to malnutrition (a condition of imbalance between the nutrients the body needs to function and the nutrition it gets), dementia (a progressive state of decline in mental abilities), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 85's history and physical (H&P), dated 3/5/2026, the H&P indicated Resident 85 does not have the capacity to understand and make decisions. During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85 has severe problems with thinking or memory. The MDS indicated Resident 85 has one-sided impairment to upper and lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). The MDS also indicated Resident 85 is at risk for developing PUs and currently has PUs. During a review of Resident 85's weight log, dated 5/7/2026, the weight log indicated Resident 85's most recent weight, taken on 4/5/2026, was 102 pounds. During a review of Resident 85's physician's orders, dated 5/1/2026, the order indicated treatment instructions for Resident 85's right hip stage 3 PU (full-thickness loss of skin; dead and black tissue may be visible). The instructions were to cleanse the wound, pat dry, apply antiseptic (a substance applied to skin or tissue to destroy germs), then cover with a dressing every day and as needed for soiled or dislodged dressings. During a review of Resident 85's physician's orders, dated 4/29/2026, the order indicated treatment instructions for Resident 85's left fourth-finger stage 4 PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). The instructions were to cleanse the wound, apply ointment, then cover with a dressing every day and as needed for soiled or dislodged dressings. During an observation on 5/5/2026 at 9:26 AM in Resident 85's room, Resident 85 was lying in his bed asleep. Resident 85 had a LAL in place that was turned on. The setting on the LAL control panel was set to 200 pounds. During an interview on 5/5/2026 at 10:21 AM with TN 1, TN 1 stated Resident 85's LAL should not be set at 200 pounds. The LAL should be set to the resident's most recent weight. TN 1 stated the correct setting should be 102 pounds. During a concurrent observation and interview on 5/6/2026 at 3:11 PM with TN 1 and TN 2 in Resident 85's room, Resident 85's treatment was being performed for the right hip stage 3 PU. There was no dressing in place on the wound. The right hip stage 3 PU was red and had some scabs starting to form. TN 2 stated there was no dressing in place on the wound before starting the treatment. TN 1 stated there is a physician's order to keep the wound covered with a dressing and this physician's order was not carried out. During a concurrent observation and interview on 5/6/2026 at 3:14 PM with TN 1 and TN 2 in Resident 85's room, Resident 85's treatment was being performed for the left fourth-finger stage 4 PU. There was no dressing in place on the wound. The left fourth-finger stage 4 PU was red and open. TN 2 stated there was no dressing in place on the wound before starting the treatment. TN 1 stated there is a physician's order to keep the wound covered with a dressing and this physician's order was not carried out. During a concurrent interview and record review on 5/7/2026 at 10:05 AM with TN 1, Resident 85's physician's order, dated 4/13/2026, was reviewed. The physician's order indicated Resident 85 may have a LAL for wound management and to check for the placement, function, and setting of the LAL every shift. TN 1 stated it the treatment nurse's responsibility to do rounds every morning to make sure the LAL is at the correct setting. If the LAL is left at the incorrect setting, it could lead to wound decline, delayed healing, or the development of a new PU. The order to monitor the LAL was not followed for Resident 85 because his LAL was at the incorrect setting. During an interview on 5/7/2026 at 10:06 AM with TN 1, TN 1 stated the physician's orders for two of Resident 85's PUs were not carried out. For Resident 85's right hip stage 3 PU and left fourth-finger stage 4 PU, the physician's orders were not carried out because the two wounds initially did not have dressings in place before starting their treatments. To follow the orders, the two wounds should always be covered with dressings. If these orders are not followed, Resident 85 is at risk for further skin breakdown and wound decline. During an interview on 5/7/2026 at 3:01 PM with the Director of Nursing (DON), the DON stated it is important to have LALs be at the correct setting to ensure that they treat wounds and promote their healing or prevent new wounds from being formed. If the LAL is not at the appropriate setting, it could create a new wound or make the existing wound worsen. The DON further stated wounds with treatment orders to have dressings should have dressings in place to prevent infection. During a review of the facility's LAL operator manual titled, Med-Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System, undated, the operator manual indicated the LAL setting should be set at the patient's weight. During a review of the facility's policy and procedure (P&P) titled, Alternating Pressure Pad or Mattress, undated, the P&P indicated the facility may use specialized mattresses to prevent skin breakdown and to treat PUs of residents. During a review of the facility's policy and procedure (P&P) titled, Skin Management System, undated, the P&P indicated it is the policy of the facility to ensure residents will have appropriate preventative measures taken to ensure residents do not develop PUs. The healthcare team will collaborate to support wound healing, pressure reduction, and prevention strategies. c. During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 1/7/2026 with diagnoses including stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral region, stage 4 pressure ulcer of the right buttock, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 4/10/2026, the MDS indicated Resident 3 had intact cognition (ability to understand and process information), The MDS indicated Resident 3 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene and upper body dressing. The MDS indicated Resident 3 required substantial/maximal assistance (helper did more than half the effort) with toileting, shower, lower body dressing and personal hygiene. During a review of Resident 3's Order Summary Report (OSR) dated 4/12/2026, the OSR indicated Resident 3 had an order to have LAL mattress for wound management and for staff to check placement, function, and setting every shift. During a review of Resident 3's Skin Issues (SI) dated 5/7/2026, the SI indicated Resident 3 had one or more unhealed pressure ulcers/injuries. During a concurrent observation inside Resident 3's room and interview on 5/5/2026 at 9:45 am with Certified Nurse Assistant 1 (CNA 1), Resident 3 was in bed sleeping. Resident 3 was using LAL mattress. CNA 1 stated the LAL mattress pressure was set at 120 and static. CNA 1 stated the number on the yellow sticker on the LAL pressure control unit was the most current weight of the resident. CNA 1 stated the resident's weight written on the yellow sticker was 159 pounds. d. During a review of Resident 50's AR, the AR indicated the facility initially admitted Resident 50 on 10/19/2018 and readmitted on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation of the legs), neuromuscular dysfunction of the bladder (occurs when brain, spinal cord, or nerve damage disrupts the signals required to store and empty urine), and presence of urogenital implants (surgically placed medical devices designed to restore or manage the function of the urinary and reproductive systems). During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 had intact cognition. The MDS indicated Resident 50 was dependent (helper did all the effort, resident did none) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a review of Resident 50's OSR dated 4/22/2026, the OSR indicated Resident 50 had an order to have LAL mattress for wound management and for staff to check placement, function, and setting every shift. During a concurrent observation inside Resident 50's room and interview on 5/5/2026 at 9:18 am with CNA 1, Resident 50 was in bed. Resident 50 was using LAL mattress. CNA 1 stated the LAL mattress pressure was set at 200. CNA 1 stated the number on the yellow sticker on the LAL pressure control unit was the most current weight of the resident. CNA 1 stated the resident's weight written on the yellow sticker was 168 pounds. During an interview on 5/7/2025 at 11:47 am with the Treatment Nurse (TN), the TN stated the LAL mattress was used for residents with pressure ulcer/injury and those at risk for developing or re-developing skin pressure ulcer/injury. The TN stated LAL mattress pressure should be set up according to the weight of the resident. The TN stated the LAL mattress should be set in static pressure (constant unchanging level of continuous air support that maintains the patient's body weight across the mattress surface) during care and back to alternating pressure after the care to relieve pressure on bony prominences and to help with healing and prevent developing new skin breakdowns. During an interview on 5/8/2026 at 8:59 am with the Director of Nursing (DON), the DON stated LAL mattress pressure should be set according to the resident's weight and on alternating pressure (not on static) to prevent worsening of existing pressure ulcers/injuries and prevent developing new skin breakdowns. During a review of the facility's undated LAL Mattress Operation Manual (OM), the OM indicated, This digital control unit includes intuitive controls for adjusting the air pressure based on the patient's weight and comfort levels. Static button is available to discontinue alternation therapy for patient transfers, caregiving, comfort, and preference. During a review of the facility's undated Policy and Procedures (P&P) titled, Stage II, Stage III and Stage IV, the P&P indicated, Pressure relief devices as, as indicated, based on nursing & therapy assessments. e. During a review of Resident 58's AR, the AR indicated the facility initially admitted Resident 58 on 1/31/2022 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM2, a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine) with foot ulcer (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) and morbid obesity (excessive body fats). During a review of Resident 58's MDS dated [DATE], the MDS indicated Resident 58 had intact cognition. The MDS indicated Resident 58 required maximum assistance (helper does more than half of the effort) from staff for toileting hygiene, lower body dressing, putting on/off footwear and personal hygiene. During a review of Resident 58's Monthly Weight and Vitals Summary (MWVS) dated 4/5/2026, the MWVS indicated Resident 58 weighed 283.4 pounds (lbs. unit of measurement). During a review of Resident 58's OSR dated 4/12/2026, the OSR indicated to use bariatric LAL mattress on Resident 58 for wound management. The OSR indicated for staff to check placement, function and setting every shift. During a review of Resident 58's untitled Care Plan (CP) revised on 4/17/2026, the CP indicated Resident 58 had a potential to develop pressure ulcer related to incontinence, bed bound, DM2 and obesity. The CP interventions indicated for nursing staff to place the LAL mattress, administer treatment as ordered and monitor for effectiveness. During an observation inside Resident 58's room and concurrent interview on 5/5/2026 at 9:27 am, with Licensed Vocational Nurse 4 (LVN 4), Resident 58 was awake and lying on LAL mattress. LVN 4 stated Resident 58's LAL setting was set at 400 lbs. During an interview and record review on 5/6/2026 at 1:57 pm with Treatment Nurse 1 (TN 1) of Resident 58's medical records (PointClickCare - PCC, a cloud-based software) was reviewed. TN 1 stated Resident 58 weighed 283.4 lbs. on 4/5/2026. TN 1 stated Resident 58 was on LAL due to history of bilateral pressure injury on the buttocks. TN 1 stated Resident 58's LAL mattress setting needed to be based on Resident 58's actual weight. TN 1 stated Resident 58 would be at risk of developing pressure ulcer if the LAL mattress was not set based on the resident's actual weight. During an interview on 5/6/2026 at 3:05 pm with the facility's Director of Nursing (DON), the DON stated, Resident 58's LAL mattress needed to be set up based on the resident's actual weight to prevent Resident 58 from developing pressure ulcer. During a review of the facility's undated user manual titled, Med-Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System, the manual indicated, Weight settings range from less than or equal to 250 to 1,000 lbs. and can be used to adjust the pressure of inflated cells based on the patients weight and comfort level.

Based on observation, interview, and record review, the facility failed to ensure that the call light (a device used by residents to call for assistance from staff) was within reach (an arm's length) for two of two sampled residents (Residents 5 and 69). These deficient practices had the potential to result in delayed provision of care and services and placed the residents at risk for falls/injury.Findings: a. During a review of Resident 69's admission Record (AR), the AR indicated Resident 69 was admitted to the facility on [DATE] with a diagnoses including dementia (a decline in mental abilities, including memory, thinking, language, and reasoning severe enough to interfere with daily life), Alzheimer's disease (a progressive, irreversible brain disorder leading to severe memory loss, and personality changes) and anxiety disorder (excessive fear or worry about a specific situation). During a review of Resident 69's History and Physical (H&P) dated 9/25/2025, the H&P indicated Resident 69 could make needs known but could not make medical decisions. During a review of Resident 69's Minimum Data Set (MDS- standardized assessment tool) dated 4/1/2026, the MDS indicated Resident 69 required supervision or touching assistance (helper provides verbal cues ad or touching steadying and or contact guard assistance as resident competes activity) for toileting hygiene, shower/bathe self, upper body dressing putting on/taking off footwear and personal hygiene. During a review of Resident 69's Fall Risk Evaluation (FRE) dated 4/9/2026, the FRE indicated Resident 26 was high risk for falls. During initial observation inside Resident 69's room on 5/5/2026 at 9:12 AM, Resident 69 was in bed, resting on the right side and the call light was not within reach. The call light was hanging on the wall behind Resident 69's bed. During a concurrent observation and interview inside Resident 69's room on 5/5/2026 at 12:36 pm, Resident 69 was sitting up on the right side of the bed eating lunch. Resident 69's call light was not within reach. The call light was still hanging on the wall behind Resident 69's bed. Resident 69 stated, I don't know where my call light is, I don't see it anywhere. If I need help, I'll just have to scream until someone comes. During a concurrent observation and interview inside Resident 69's room on 5/6/2026 at 10:52 AM, Certified Nursing Assistant 3 (CNA 3) stated Resident 69's call light was not within Resident 69's reach. CNA 3 stated the call light should always be placed next to the resident's hands so the resident could call when they needed to be cleaned or if they needed to go to the bathroom. CNA 3 stated the resident could suffer a fall if the call light was not within reach and the resident could not call for help. During an interview with the Director of Nursing (DON) on 5/6/2026 at 10:41 AM, the DON stated the resident's call light should be within arm's reach. The DON stated if the call light was not within reach, then the resident won't be able to call for assistance. The DON stated if the resident could not call for assistance, the resident could suffer a fall/ accident or injury. During a review of the facility's undated Policy and Procedure (P&P) titled, Call Light/Bell, the P&P indicated Place the call device within resident's reach before leaving the room. b. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 3/21/2026 and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (GT, tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) status. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/26/2026, the MDS indicated, Resident 5 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 needed maximum assistance (helper does more than half the effort) from staff for oral hygiene, toileting hygiene, shower, upper/lower body dressing and putting on/taking off footwear. During a review of Resident 5's untitled Care Plan (CP) revised on 4/7/2026, the CP indicated Resident 5 was at risk for falls related to confusion and being unaware of safety needs. The CP intervention indicated for nursing staff to ensure Resident 5's call light was within reach and encouraged Resident 5 to use it for assistance as needed. The CP intervention indicated Resident 5 needed prompt response to all requests for assistance. During an observation inside Resident 5's room on 5/5/2026 at 8:47 am, Resident 5 was awake, lying in bed. Resident 5's call light was hanging on the right side of the bed rail touching the floor. During a concurrent observation inside Resident 5's room and interview on 5/5/2026 at 8:49 am with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, Resident 5's call light was on the floor and Resident 5 was unable to reach it. LVN 2 stated Resident 5's call light needed to be accessible at all times for Resident 5's safety and for staff to be able to provide care when Resident 5 needed help. During an interview on 5/6/2026 at 3:04 pm with the Director of Nursing (DON), the DON stated the residents' call light needed to be accessible and within reach by the residents at all times for them to ask help from the staff for assistance or in case of an emergency. During a review of the facility's undated Policy and Procedure (P&P) titled, Call Light/Bell, the P&P indicated Place the call device within resident's reach before leaving room.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving respiratory therapy (a specialized healthcare field focused on assessing, treating, and managing patients with breathing or cardiopulmonary disorders) and oxygen therapy (a treatment that provides extra oxygen to breathe in) in accordance with professional standards of practice for two of four sampled residents (Residents 9 and 11) by failing to: a. Ensure Resident 9's nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was not touching the floor, the NC tubing was connected to the portable oxygen concentrator (POC, provides patients with a continuous or pulse-dose supply of supplemental oxygen) and the NC prongs (two small, curved tubes on a nasal cannula that rest directly inside the nostrils) were placed inside Resident 9's nostril. b. Ensure Resident 11's use of bilevel positive airway pressure (BIPAP, a non-invasive ventilator used to assist breathing) had a physician's order and the BIPAP mask was stored appropriately when not in use. These failures placed Residents 9 and 11 at risk for complications related to the use of oxygen, shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) and the risk of infection which could lead to respiratory complications.Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated the facility initially admitted Resident 9 on 1/25/2021 and readmitted on [DATE] with diagnoses including epilepsy (recurrent, unprovoked seizures) and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 9's untitled Care Plan (CP) initiated on 8/12/2024, the CP indicated Resident 9 was on oxygen therapy related to COPD. The CP goal indicated Resident 9 would not have signs and symptoms of poor oxygen absorption. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 3/2/2026, the MDS indicated Resident 9 had intact cognition (ability to understand and process information). The MDS indicated Resident 9 required set up or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene. The MDS indicated Resident 9 required substantial/maximal assistance (helper did more than half the effort) with shower, lower body dressing and personal hygiene. The MDS indicated Resident 9 was on oxygen therapy. During a review of Resident 9's Order Summary Report (OSR) dated 4/12/2026, the OSR indicated Resident 9 had an order for oxygen at 2 liters (L)/minute (min) via nasal cannula every shift for COPD. During a concurrent observation inside Resident 9's room and interview on 5/5/2026 at 9:09 am with Licensed Vocational Nurse 1 (LVN 1), Resident 9 was in bed with NC. LVN 1 stated Resident 9's NC tubing was touching the floor, the NC tubing was not connected on the portable oxygen concentrator and the NC prongs were on Resident 9's left cheek. LVN 1 stated the NC tubing should not touch the floor to prevent contamination and infection. LVN 1 stated the NC tubing should be connected to the portable oxygen concentrator. LVN 1 stated the NC prongs needed to be placed inside Resident 9's nostrils to ensure Resident 9 received enough oxygen to prevent shortness of breath.b. During a review of Resident 11's AR, the AR indicated the facility admitted Resident 11 on 4/11/2026 with diagnoses including pneumonia (an infection/inflammation of the lungs), COPD, and morbid obesity (dangerous level of excess body fat). During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had intact cognition. The MDS indicated Resident 11 required set up or clean-up assistance with eating and supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral and personal hygiene. The MDS indicated Resident 11 required substantial/maximal assistance with toileting, shower, and lower body dressing. The MDS indicated Resident 11 was on oxygen therapy. During a concurrent observation inside Resident 11's room and interview on 5/5/2026 at 9:05 am with Certified Nurse Assistant 1 (CNA 1), Resident 11 was in bed. Resident 11's BIPAP mask was on top of the BIPAP machine. CNA 1 stated Resident 11 used the BIPAP machine during the night. During a concurrent interview and record review on 5/6/2026 at 9:56 am with Licensed Vocational Nurse 2 (LVN 2), Resident 11's Order Summary Report (OSR), with active orders as of 5/5/2026 were reviewed. LVN 1 stated Resident 11 did not have an order for the use of BIPAP machine at night. LVN 2 stated Resident 11 should have an order from the physician for the use of BIPAP machine to ensure Resident 11 had the correct setting and set up to manage Resident 11's health concerns. During an interview on 5/6/2026 at 3:11 pm with the Director of Nursing (DON), the DON stated staff should ensure all residents on oxygen therapy had the nasal cannula prongs placed properly in the resident's nostrils and connected to the portable oxygen concentrator to prevent oxygen desaturation (drop in blood oxygen levels below normal) and shortness of breath. The DON stated the NC tubing should not be touching the floor to prevent contamination and spread of infection. The DON stated the use of BIPAP required a doctor's order and prescription to ensure the setting was correct for the resident's condition. The DON stated BIPAP mask, nebulizer mask and nasal cannula should be stored inside the transparent bag intended for respiratory supplies when not in use to prevent infection. During a review of facility's undated Policy and Procedure (P&P) titled, Respiratory Supply, the P&P indicated, Respiratory supplies and equipment will be stored, maintained, and handled safely and in accordance with manufacturer's guidelines, infection prevention standards, CMS regulations, and California Title 22 requirements. During a review of facility's undated P&P titled, CPAP/BiPAP Support, the P&P indicated, Review the physician's order to determine the oxygen concentration and flow, and the PPE pressure for the machine. Set mode, CPAP, IPAP, and EPAP settings on the machine, as prescribed.

Based on observation, interview, and record review, the facility failed to post the actual nurse staffing information at the beginning of the shift in a prominent location, readily accessible to residents, visitors, and staff for viewing for one of four recertification survey days (5/5/2026). This failure had the potential to mislead the residents, visitors, and staff of the actual staffing in the facility that could affect the quality of nursing care provided to the residents. Findings: During an observation in the facility's lobby, hallways, reception area and North Nursing Station on 5/5/2026 at 12:50 pm, there was no daily nurse staffing information posted. During a concurrent observation in the South Nurse Station and interview on 5/5/2026 at 12:54 pm, with Infection Prevention Nurse (IPN), the IPN stated the IPN did not know where the staffing information was posted. The IPN stated there was no staffing information posted in North Nursing Station, lobby and in the facility's hallway. During a concurrent observation and interview on 5/5/2026 at 12:55 pm, with the Assistant Director of Staff and Development (ADSD), the ADSD stated the ADSD was responsible in posting the staffing information and the ADSD did not post the staffing information. During a concurrent interview with the Director of Nursing (DON) on 5/5/2026 at 1:52 pm, and record review of the facility's Policy and Procedure (P&P) titled Posting Direct Care Daily Staffing Numbers, the DON stated, the facility needed to post on a daily basis each shift, the nurse staffing data directly responsible for resident care and should be available in a prominent location accessible to residents and visitors. The DON stated staffing information should be easily seen and read by residents, staff, and visitors. The DON stated the nurse staffing information was inside a binder in the North Station. The DON stated the nurse staffing information was not readily accessible to staff, residents and visitors if it was inside a binder. During a concurrent observation in the South Nurse Station and interview on 5/5/2026 at 2:05 pm with the DON, the DON stated there was no staffing information posted in the South Nurse Station. The DON stated staff needed to bring the residents or visitors into the dining room if they wanted to see the staffing information. The DON stated the purpose of posting the staffing information was for the residents, visitors and staff to determine the facility had sufficient staff to take care of the residents. The DON stated the facility should post the staffing information in a prominent area where the residents, visitors and staff could access and view the form. During an interview on 5/7/2026 at 9:08 am with the facility's Administrator (ADM), the ADM stated the facility did not post the staffing information in the lobby or in the stations. The ADM stated the staffing information was placed inside a binder in the North Nurse Station. During an interview on 5/7/2026 at 11:10 am with Resident 23 inside Resident 23's room, Resident 23 stated it was far for Resident 23 to walk to the North Nurse Station to look for the staffing information and Resident 23 could not walk far. Resident 23 stated Resident 23 would like to view the staffing information posted in the South Nurse Station because the other station (North Nurse Station) was too far for Resident 23. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted Resident 23 on 3/3/2026 with diagnoses including other symptoms and signs involving the musculoskeletal system and dysphagia (difficulty swallowing). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/9/2026, the MDS indicated Resident 23 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). During a review of the facility's undated Policy and Procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, the P&P indicated the facility will post on a daily basis each shift the nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care should be available in a prominent location (accessible to residents and visitors) and in a clear and readable format. The charge nurse or designee completes the form and posts the staffing information in the location(s) designated by the administrator.

Based on observation, interview, and record review, the facility failed to maintain the integrity and proper labeling of peripherally inserted central catheter (PICC, a long, flexible tube inserted into a vein in the upper arm and guided into a large vein near the heart) line in accordance with professional standards of practice for two of five sampled residents (Resident 75 and Resident 106). These failures had the potential to result in infection and accidental PICC line dislodgement for Residents 75 and Resident 106.Findings: a. During a review of Resident 75's admission Record (AR), the AR indicated the facility admitted Resident 75 on 3/31/2026 with diagnoses including abscess of liver (a pus-filled mass that develops within the liver due to an infection or injury), bacteremia (the presence of bacteria in the blood stream), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 75's untitled Care Plan (CP) initiated on 4/2/2026, the CP indicated Resident 75 was at risk for infection related to presence of PICC line on the right upper arm. The CP interventions included changing the dressing per facility policy. The CP goal included monitoring Resident 75 for any signs and symptoms of pain or discomfort at the site. During a review of Resident 75's Order Summary Report (OSR) dated 4/2/2026, the OSR indicated Resident 75 had an order for licensed staff to monitor the right upper arm PICC line site for signs and symptoms of infection and complications. During a review of Resident 75's Minimum Data set (MDS, a resident assessment tool) dated 4/3/2026, the MDS indicated Resident 75 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 74 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral and personal hygiene. The MDS indicated Resident 75 required partial/moderate assistance (helper did less than half the effort) with toileting and upper body dressing and substantial/maximal assistance (helper did more than half the effort) with shower and lower body dressing. The MDS indicated Resident 75 had an IV (within a vein) medication. During a concurrent observation inside Resident 75's room and interview on 5/5/2026 at 10:06 am with Licensed Vocational Nurse 1 (LVN 1), Resident 75 was sitting in a wheelchair with right upper arm PICC line. LVN 1 stated Resident 75's PICC line transparent dressing was loose and coming out. LVN 1 stated the PICC line dressing was not labeled with a date and LVN 1 did not know the last time the PICC line dressing was changed. LVN 1 stated the PICC line site should be maintained clean to prevent infection. b. During a review of Resident 106's AR, the AR indicated the facility admitted Resident 106 on 5/4/2026 with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract), extended spectrum beta lactamase (ESBL, refers to a type of enzyme produced by certain bacteria that makes them highly resistant to many common antibiotics) resistant, and DM. During a review of Resident 106's OSR dated 5/4/2026, the OSR indicated Resident 106 was on IV antibiotics therapy (use of specific medications to treat, manage, or prevent bacterial infections) for ESBL and UTI. During a review of Resident 106's untitled CP initiated on 5/5/2026, the CP indicated Resident 106 was at risk for infection related to presence of left upper arm PICC line site. The CP interventions included changing the dressings per facility policy and monitoring Resident 106 for any signs and symptoms of infection. During a concurrent observation inside Resident 106's room and interview on 5/5/2026 at 9:52 am with Registered Nurse 1 (RN 1), Resident 106 was in bed with a PICC line on Resident 106's left upper arm. Resident 106's PICC line had two (2) lumens. One of the lumens was not covered. RN 1 stated all PICC line lumens should be capped and covered when not in use for infection control. During an interview on 5/7/2026 at 10:47 am with RN 1, RN 1 stated PICC line dressing should be changed every seven (7) days and as needed to prevent getting contaminated and infected. During a review of Resident 106's MDS dated [DATE], the MDS indicated Resident 106 had intact cognition. The MDS indicated Resident 106 required partial/moderate assistance with oral hygiene and upper body dressing and substantial/maximal assistance with toileting, shower and lower body dressing. The MDS indicated Resident 106 was dependent (helper did all the effort, resident did none) with personal hygiene. The MDS indicated Resident 106 was on IV antibiotic medications. During an interview on 5/8/2026 at 8:48 am with the Director of Nursing (DON), the DON stated PICC line site should be kept clean and the dressing changed every 7 days or as needed when dressing was loose and not clean to prevent infection and skin irritation. During a review of facility's undated Policy and Procedure (P&P) titled, Intravenous Site Crea, the P&P indicated, The facility will provide safe monitoring and care of intravenous and central lines sites in accordance with physician orders and infection prevention practices to reduce the risk of complications and infection. Dressing will be changed according to physician orders, facility protocol, and infection prevention guidelines. Tubing, caps, and supplies will be maintained and changed per facility protocol and/or manufacturer's recommendations.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 46) was free from restraints. Resident 46 had a Wanderguard (a wearable security device used to manage and monitor residents prone to wandering or at risk of leaving the facility) without a physician's order. This failure placed Resident 46 at risk for psychological distress (an experience of emotional, mental, suffering that occurs when individuals are overwhelmed) related to the use of the Wanderguard alarm.Findings: During a review of Resident 46's admission Record (AR), the AR indicated Resident 46 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a type of stroke that happens when blood, which carries oxygen, gets blocked from reaching a part of the brain), schizophrenia (mental illness) and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 46's Minimum Data Sheet (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 46 had moderately impaired cognition (ability to understand) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral and personal hygiene and upper body dressing and partial/moderate assistance (helper did less than half the effort) with toileting, shower, lower body dressing and putting on/taking off footwear. During a review of Resident 46's Assessment Outcomes (AO- elopement evaluation) dated [DATE], the AO indicated Resident 46 was at risk for elopement. During a review of Resident 46's untitled Care Plan Report (CPR) with a revision date of [DATE], the CPR indicated Resident 46 had Wanderguard in place due to Resident 46's risk for wandering/elopement. During a review of Resident 46's Resident Informed Consent Physical Restraint or Medical Device (ICPR or MD) dated [DATE], the ICPR or MD indicated an informed consent from Resident 46's responsible party (RP) was obtained via phone for Resident 46's use of a Wanderguard During a review of Resident 46's Order Summary Report (OSR), the OSR indicated an active order for staff to check Wanderguard placement on Resident 46's left wrist functionality every shift, ordered on [DATE]. The OSR also indicated Resident 46 had an active order for staff to monitor Resident 46's skin integrity to the left wrist with wander guard for signs and symptoms of skin breakdown, ordered on [DATE]. The OSR did not indicate an order and reason for the use of Wanderguard for Resident 46. During an observation on [DATE] at 11:38 AM, at the South Nursing Station, Resident 46 was observed ambulating in the hallway near the nursing station with Wanderguard alarm bracelet on the right wrist. During an observation and interview inside Resident 46's room with Certified Nursing Assistant 3 (CNA3) on [DATE] at 12:50 PM, Resident 46 was resting in bed. CNA3 stated Resident 46 had a Wanderguard applied to the right wrist. CNA3 stated CNA3 checked Resident 46's skin every day to ensure Resident 46 had no cuts, rashes or bruises from the Wanderguard. During an interview and record review with License Vocational Nurse 3 (LVN 3) on [DATE] at 12:56 PM, LVN 3 stated based on the active/current orders for Resident 46, there was no physician's order for the use of a Wanderguard. LVN 3 stated while reviewing the discontinued orders, Wanderguard for Resident 46 was discontinued since [DATE]. LVN3 stated Resident 46 should not be wearing a Wanderguard if there was no active physician's order. LVN 3 stated a physician's order was needed since the Wanderguard was a restraint. During a concurrent observation and interview with LVN 3 inside Resident 46's room on [DATE] at 1:00 PM, Resident 46 was resting in bed. LVN 3 stated Resident 46 was wearing a Wanderguard on the right wrist. LVN 3 stated staff were monitoring for the Wanderguard placement but there was no actual physician's order for Resident 46 to use a Wanderguard. LVN 3 stated it was important to have a physician's order for a Wanderguard because it was considered a restraint device and Resident 46's Responsible Party (RP) needed to sign the consent for Resident 46 to have a Wanderguard. During an interview and record review with Treatment Nurse 2 (TN2) on [DATE] at 1:55 PM, TN 2 stated the Wanderguard was considered a type of restraint because it restricted the resident from going out and prevented the resident from leaving the facility. TN 2 stated there was an order for Wanderguard monitoring, placement assessment and skin check but there was no actual physician's order for the Wanderguard to be placed on Resident 46. TN 2 stated it was not acceptable to place a Wanderguard on Resident 46 without a physician's order. During an interview with the Infection Prevention Nurse (IPN) on [DATE] at 7:49 AM, the IPN stated the Wanderguard was a security system device to alert staff when a resident who was at risk of elopement tried to leave the building. IPN stated that in order to use a Wanderguard, a physician's order was needed. IPN stated, in order for a resident to have a Wanderguard, an elopement assessment should be completed, a consent must be signed, and a physician's order needed to be in place. During an interview with the Director of Nursing (DON) on [DATE] at 8:32 AM, the DON stated the Wanderguard was used on a resident when the resident was at risk for elopement. The DON stated the purpose of a Wanderguard was to alert the staff if a resident attempted to exit the facility. The DON stated the Wanderguard was considered a restraint and should have a physician's order and consent before it could be placed on Resident 46. During a review of the facility's Policy & Procedure (P&P) titled, Use of Restraints, revised [DATE], the P&P indicated, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it.that device is considered a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). During a review of the facility's undated P&P titled Devices, the P&P indicated, The facility will utilize monitoring devices (e.g. wander guard, alarm, etc.) for residents assessed at risk, to promote safety.

Based on observation, interview, and record review, the facility failed to ensure the resident's bathroom sink was repaired for one of four sampled residents (Resident 23) when Resident 23's bathroom sink did not produce freely flowing hot water.This failure had the potential to increase Resident 23's risk of physical and emotional discomfort and distress due to a lack of access to hot water. Findings: During a review of Resident 23's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including but not limited to cervical disc disorder (the breakdown of the cushion-like pads separating the bones in the neck), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that causes intense and constant feelings of worry and fear). During a review of Resident 23's History and Physical (H&P), dated 3/5/2026, the H&P indicated Resident 23 has the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 23 has no impairment to upper or lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). The MDS also indicated Resident 23 requires partial assistance with toileting hygiene and personal hygiene. During an interview on 5/5/2026 at 9:06 AM with Resident 23, Resident 23 stated the sink in her bathroom never works properly. She stated she can get cold water easily, but the hot water does not run. When she turns on the hot-water faucet handle, water barely trickles out and the water never gets hot. She has told staff before, but it has never been fixed. She further stated she wishes the hot water worked in her sink because it is more comfortable when washing hands.During an observation on 5/5/2026 at 9:10 AM in Resident 23's bathroom, the cold-water faucet handle was turned on. Water flowed freely from the sink and the water was cold. Then the hot-water faucet handle was turned on. Water slowly trickled out of the sink in drops and at a significantly slower rate than when the cold-water faucet handle was turned on. The temperature of the water was also cold. The hot-water faucet handle was left on to allow time to observe the temperature of the water. During an observation on 5/5/2026 at 9:15 AM in Resident 23's bathroom, the hot-water faucet handle was still turned on, and water was slowly trickling out of the sink. The temperature of the water coming out of the sink was still cold after being let run for five minutes continuously. During a concurrent observation and interview on 5/6/2026 at 10:38 AM with the Maintenance Supervisor (MS) in Resident 23's bathroom, the function of the bathroom sink was tested. When the cold-water faucet handle was turned on, water flowed freely and the temperature of the water was cold. When the hot-water faucet handle was turned on, water slowly trickled out and the temperature of the water was cold. MS stated the water from the sink is not getting warm. Hot water should flow freely from the sink when the hot-water faucet handle is turned on and the temperature should immediately start warming up. MS stated the sink is not working as it should, and it is important that the residents have access to hot water in their bathroom sinks to honor their preferences. During an interview on 5/7/2026 at 3:02 PM with the Director of Nursing (DON), the DON stated it is important for residents to have working bathroom sinks because it ensures their environment is homelike. Equipment should not be broken, and they should have access to running hot water in their bathrooms. During a review of the facility's policy and procedure (P&P) titled, Physical Environment, undated, the P&P indicated the facility must provide a functional and comfortable environment for residents. Resident rooms must be equipped for the comfort of residents.

Based on interview and record review, the facility failed to revise the care plan for one of three sampled residents (Resident 64) when her care plan indicated to provide her with two conflicting diets (meals that meet daily and special dietary needs of each resident).This failure had the potential to result in Resident 64 not receiving the appropriate diet, leading to malnutrition (a condition where the body does not get the right balance of nutrients to function correctly). Findings: During a review of Resident 64's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 64 was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (stroke, loss of blood flow to a part of the brain), and hypertensive chronic kidney disease (a condition where long-term high blood pressure damages the blood vessels of the kidneys). During a review of Resident 64's History and Physical (H&P), dated 8/14/2025, the H&P indicated Resident 64 has the capacity to make her needs known. During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 64 is capable of normal cognition and memory. During a concurrent interview and record review on 5/6/2026 at 2:50 PM with the Director of Nursing (DON), Resident 64's nutrition assessment, dated 10/29/2025, was reviewed. The nutritional assessment indicated Resident 64's diet order was a fortified diet (a diet that adds extra vitamins and minerals to boost their nutritional value). The DON stated Resident's 64's prescribed diet is a fortified diet.During a concurrent interview and record review on 5/7/2026 at 9:31 AM with the Minimum Data Set Coordinator (MDSC), Resident 64's physician's order, dated 10/9/2026, was reviewed. The order indicated Resident 64 should have a fortified diet with regular texture. MDSC stated that is the only active diet order for Resident 64. During a concurrent interview and record review on 5/7/2026 at 9:32 AM with the MDSC, Resident 64's care plans were reviewed. The care plan titled, The Resident has Potential Nutritional Problem Related to Fortified Diet., last revised on 12/11/2025, indicated to serve the fortified diet as ordered. The care plan titled, Resident is at Risk of Altered Nutrition/Hydration., last revised on 8/28/2024, indicated Resident 64 is on a Consistent Controlled Carbohydrate (CCHO - a diet that manages blood sugar by eating a balanced amount of carbohydrates at the same time each day) No Added Salt (NAS - a diet that limits salt intake by excluding added salt in food) diet and to serve the diet as ordered. MDSC stated the care plans are confusing because there are two different care plans with two different diet orders. MDSC stated the care plan should be revised to identify the correct diet. It is important for care plans to be revised so they may clearly guide staff on how to care for the residents. During an interview on 5/7/2026 at 3:01 PM with the DON, the DON stated it is important to keep care plans up to date because they guide how the residents should be cared for. Updated care plans show nursing staff what interventions they should do. During a review of the facility's policy and procedure (P&P) titled, Care Plan and Care Plan Update, undated, the P&P indicated care plans must be reviewed and revised with significant changes in condition and as needed based on resident progress or decline. Care plans may be resolved or discontinued when the intervention is no longer applicable.

Based on observation, interview, and record review, the facility failed to ensure non-English speaking (refers to individuals who cannot speak or understand or have difficulty speaking or understanding the English language) residents were provided with a communication device in a language that the resident understood for one of one sampled resident (Resident 105). This failure had the potential to affect Resident 105's communication with staff and had the potential for delay in the provision of care, treatment and service to the resident.Findings: During a review of Resident 105's admission Record (AR), the AR indicated the facility admitted Resident 105 on 5/1/2026 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), and anxiety (a feeling of fear, dread, or unease). During a concurrent observation inside Resident 105's room and interview on 5/5/2026 at 9:47 am with Licensed Vocational Nurse 1 (LVN 1), Resident 105 was in bed. Resident 105 smiled when greeted and did not answer when asked. LVN 1 stated Resident 105 did not speak or understand English. LVN 1 stated Resident 105 did not have a communication board in the room. LVN 1 stated all residents in which English was not the residents' primary language (language an individual uses most frequently and proficient) should have a communication board with pictures and descriptions of their spoken language in the room for the resident to communicate basic needs and for the staff to understand the residents better and ensure the needs of the residents were met. During a review of Resident 105's Minimum Data Set (MDS, a resident assessment tool) dated 5/8/2026, the MDS indicated Resident 105's preferred language was Korean. The MDS indicated Resident 105 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 105 required set up or clean-up assistance (helper sets up or cleans up; resident completes the activity) with eating and oral hygiene. The MDS indicated Resident 105 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting, shower, upper/lower body dressing and personal hygiene. During an interview on 5/8/2026 at 9:11 am with the Director of Nursing (DON), the DON stated all non-verbal, but alert and oriented residents and non-English speaking residents should have a communication board in the room to express their needs and staff be able to address the resident's needs appropriately. During a review of the facility's undated Policy and Procedures (P&P) titled, Communication Board, the P&P indicated, The facility will make reasonable effort to communicate effectively with residents who do not speak or understand English. The facility may utilize: Communication board, Translation services, Picture boards, and interpreter assistance.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 64) was provided with bilateral quarter side rails on her bed for mobility and repositioning as ordered.This failure had the potential to cause a decline in Resident 64's mobility and independence.Findings: During a review of Resident 64's admission Record (face sheet), dated 5/7/2026, the face sheet indicated Resident 64 was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (stroke, loss of blood flow to a part of the brain), and hypertensive chronic kidney disease (a condition where long-term high blood pressure damages the blood vessels of the kidneys). During a review of Resident 64's History and Physical (H&P), dated 8/14/2025, the H&P indicated Resident 64 has the capacity to make her needs known. During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 64 is capable of normal cognition and memory. The MDS also indicated Resident 64 has no impairment to the upper extremities (shoulder, elbow, wrist, hand) and one-sided impairment to the lower extremities (hip, knee, ankle, foot). The MDS indicated Resident 64 requires moderate assistance with rolling from left to right side when lying in bed. During a review of Resident 64's care plan titled, The Resident Uses Quarter Side Rails for Mobility and Repositioning, created on 11/4/2024, the care plan indicated Resident 64 should remain free of complications, including contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion). The care plan also indicated to monitor for decreases in Resident 64's self-performance of activities of daily living. During a concurrent observation and interview on 5/5/2026 at 11:48 AM with Resident 64 in Resident 64's room, Resident 64 was lying in her bed that was not equipped with side rails. Resident 64 stated she is upset the facility removed the side rails from her bed. She stated previously when she did have side rails, she would use her right arm to grab onto the side rails so she could turn her body from side to side. She further stated because her side rails have been gone for weeks, she has not been able to turn herself. She does not know why they removed them. During a concurrent interview and record review on 5/7/2026 at 10:20 AM with Licensed Vocational Nurse (LVN) 3, Resident 64's physician's order, dated 11/4/2024, was reviewed. The physician's order indicated Resident 64 may have bilateral quarter side rails on her bed to assist with mobility and repositioning. LVN 3 stated Resident 64 does not currently have side rails attached to her bed, and this order is not currently followed. LVN 3 further stated it is important for Resident 64 to have the bed side rails placed as ordered to help with her mobility so she can turn herself from side to side. During an interview on 5/7/2026 at 3:01 PM with the Director of Nursing (DON), the DON stated it is important for the facility to provide residents with the equipment they need to prevent a decrease in their ROM or mobility. During a review of the facility's policy and procedure (P&P) titled, Restorative Care, undated, the P&P indicated the resident will receive the services needed to attain and maintain the highest possible physical functional status.

Based on interview and record review, the facility failed to address the significant weight loss (the resident lost a large amount of weight in a short time) for one of five sampled residents (Resident 65) who had significant weight loss of 6.52 percentage (%) from 3/20/2026 to 3/29/2026. This deficient practice placed Resident 65 at risk for further weight loss. Findings: During a review of Resident 65's admission Record (AR), the AR indicated the facility admitted Resident 65 on 1/12/2026 and readmitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (the resident suddenly had trouble breathing and did not get enough oxygen) and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). During a review of Resident 65's History and Physical (H&P) dated 3/26/2026, the H&P indicated Resident 65 did not have the capacity to understand and make decisions. During a review of Resident 65's Minimum Data Set (MDS, a resident assessment tool) dated 4/23/2026, the MDS indicated Resident 65 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 65 required setup assistance from staff with eating. The MDS indicated Resident 65 required moderate assistance (helper did less than half the effort) from staff with oral hygiene. The MDS indicated Resident 65 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene, showering/ bathing, and personal hygiene. The MDS indicated Resident 65 was dependent (helper did all the effort) on staff for bed-to-chair transferring. During a review of Resident 65's Weights and Vitals Exceptions (WVE), the WVE indicated Resident 65 weighed 89.2 pounds (lbs.) on 3/5/2026. The WVE indicated Resident 65 weighed 98.2 lbs. on 3/20/2026 (re admission weight). The WVE indicated Resident 65 weighed 91.8 lbs. on 3/29/2026. The WVE indicated that Resident 65 had weight loss of 6.5% from 3/20/2026 to 3/29/2026. The WVE indicated Resident 65 weighed 91 lbs. as of 5/7/2026. During an interview with Registered Nurse 1 (RN 1) on 5/7/2026 at 10:24 AM, RN 1 stated the facility should have addressed Resident 65's 6.52 % weight loss in 3/2026 because it was the professional standard of care. RN 1 stated the licensed nurse should document Resident 65's weight loss in the nurses' progress note (NPP). RN 1 stated the licensed nurse should notify the physician and responsible party, follow up with registered dietitian's recommendation, notify the Director of Nursing (DON) and wound care team, develop care plan, and complete a change of condition assessment. During a concurrent record review and interview with RN 1 on 5/7/2026 at 10:24 AM, Resident 65's entire medical record was reviewed. There was no documentation indicated the facility addressed Resident 65's 6.52 % weight loss in 3/2026. RN 1 stated there was no documentation in Resident 65's NPP indicating the facility notified Resident 65's physician or responsible party regarding the weight loss. RN 1 stated there was no change of condition (COC) assessment, interdisciplinary team (IDT, a team of different staff who worked together to plan and review the resident's care) conference record and care plan initiated to address Resident 65's weight loss. During a concurrent record review and interview with Licensed Vocational Nurse 4 (LVN 4) on 5/7/2026 at 10:43 AM, Resident 65's entire MDS assessments were reviewed. There was no MDS assessment indicating Resident 65's 6.52 % weight loss. During an interview with the Dietary Supervisor (DS) on 5/8/2026 at 8:21 AM, the DS stated Resident 65 was in-and-out of the hospital and the resident's weight was fluctuating, making it hard to maintain a stable weight. The DS stated the facility should have addressed Resident 65's weight loss in 3/2026 to prevent further weight loss. During an interview with the DON on 5/8/2026 at 8:41 AM, the DON stated it was a significant weight loss when Resident 65's weights changed from 98.2 lbs. on 3/20/2026 to 89 lbs. on 3/29/2026. The DON stated the licensed nurse should have completed the COC assessment and MDS significant change assessment, notified the physician and registered dietitian, and developed a weight loss care plan. The DON stated it was important to address Resident 65's significant weight loss to develop interventions to find out the root cause. The DON stated the restorative nurse assistant (RNA) should have notified the licensed nurse when there were weight changes on the residents. The DON stated it was the facility's standard of practice to notify the licensed nurse of weight changes. The DON stated Resident 65 was at risk of further weight loss, malnutrition, and wounds, when the facility did not address Resident 65's significant weight loss on 3/29/2026. During a review of the facility's Policy and Procedure (P&P) titled, Weight Assessment and Intervention, undated, the P&P indicated the facility should monitor the resident with undesirable or unintended weight loss. The P&P indicated the facility should evaluate resident with undesirable weight change, including:a. The resident's calorie, protein, and other nutrient needs compared with the resident's current intake;b. The relationship between current medical condition or clinical situation and recent fluctuations in weight; andc. Whether and to what extent weight stabilization or improvement could be anticipated.The P&P indicated the physician and the IDT should identify conditions and medications that might be causing the weight loss or increasing the risk of weight loss. The P&P further indicated the facility should have individualized care plans to address the identified causes of weight loss with goals and benchmarks for improvement.

Based on observation, interview, and record review, the facility failed to promote and treat one of one sampled resident (Resident 5) with respect, privacy and dignity in accordance with facility's policy titled Dignity and Respect. This deficient practice had the potential to cause psychosocial (mental and emotional well-being) decline and low self-esteem for Resident 5.Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 3/21/2026 and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (GT, tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) status. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/26/2026, the MDS indicated, Resident 5 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 needed maximum assistance (helper does more than half the effort) from staff for oral hygiene, toileting hygiene, shower, upper/lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 5/5/2026 at 8:52 am with Licensed Vocational Nurse 2 (LVN 2) inside Resident 5's room, Resident 5 was awake, lying in bed. LVN 2 pulled up Resident 5's gown and assessed Resident 5's GT site. LVN 2 did not close the privacy curtain of Resident 5 to provide Resident 5's privacy, exposing Resident 5's abdominal area to the roommate and passerby. LVN 2 stated, LVN 2 did not close the privacy curtain and Resident 5's door prior to assessing Resident 5's GT site. LVN 2 stated, privacy curtain and room door needed to be closed prior to providing care and treatment to Resident 5 to provide privacy. During an interview on 5/6/2026 at 3:02 pm with the facility's Director of Nursing (DON), the DON stated the resident's privacy curtain and room door needed to be closed prior to providing care and treatment to Resident 5 to provide privacy, dignity and comfort. During a review of the facility's undated Policy and Procedure (P&P) titled, Dignity and Respect,, the P&P indicated It is the policy of the facility that all residents be treated with kindness, dignity and respect. Residents shall be treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by. Privacy of a Resident's body shall be maintained during toileting, bathing and other activities of personal hygiene, except when staff assistance is needed for the resident's safety.

Based on observation, interview, and record review, Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) failed to ensure one of five sampled residents (Resident 4) was not physically assaulted (attacked or harmed through physical violence) by another resident (Resident 5) on 3/20/2025. This deficient practice resulted in Resident 4 sustaining a closed head injury (type of traumatic brain injury where the skull remains intact) and mildly comminuted (bones break into pieces), minimally displaced (out of place) right nasal (nose) bone fracture (break in the bone) on 3/20/2025. Resident 4 was transferred to General Acute Care Hospital 1 (GACH 1) for evaluation of moderate head pain after a head injury from an assault. Findings: a. During a review of Resident 5's Admission Record (AR), the AR indicated the facility admitted Resident 5 on 2/27/2025 with diagnoses that included paranoid schizophrenia [a type of schizophrenia (a mental illness characterized by disturbances in thinking) associated with feelings of being persecuted or plotted against] and major depressive disorder (persistent feeling of sadness, hopelessness and loss of interest/pleasure in activities). During a review of Resident 5's Progress Note (PN), dated 3/20/2025 and timed at 11:54 pm, the PN indicated Resident 5 sustained scratches on the right side of the face, the forehead and bleeding on top of Resident 5's nose. The PN indicated Resident 5 continued to scream and yell towards staff. During a review of Resident 5's PN dated 3/21/2025 timed at 5:09 pm, the PN indicated, Resident 5 was transferred to GACH 2 on 5150 hold (a 72-hour involuntary hold when an individual was deemed a danger to self or others or gravely disabled due to a mental order) for evaluation. b. During a review of Resident 4's AR, the AR indicated the facility admitted Resident 4 on 2/19/2025 with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember, severe enough to affect a person's daily functioning), schizophrenia, and major depressive order. During a review of Resident 4's Minimum Data Sheet (MDS, a resident assessment tool) dated 2/25/2025, the MDS indicated Resident 4 had moderately impaired cognition (ability to understand and process information). During a review of Resident 4's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) communication form dated 3/20/2025, the SBAR indicated Resident 4 went to Resident 5's (Resident 4's roommate) bed, stood at the end of the bed, held onto the footboard of Resident 5's bed. When Resident 5 got up, Resident 4 grabbed Resident 5's hair. During a review of Resident 4's PN dated 3/20/2025 and timed at 12:55 pm, the PN indicated CNA 1, and LVN 1 heard screaming coming from Resident 4 and 5's room. The PN indicated Resident 4 walked toward Resident 5's bed and started making the bed (the act of preparing/arranging the bed) of Resident 5 while Resident 5 was sleeping in bed. The PN indicated Resident 5 got up from bed and walked towards Resident 4. The PN indicated Resident 5 screamed, hit Resident 4 on the head with Resident 5's fist and scratched Resident 4 on the face with Resident 5's other hand. The PN indicated Resident 4 grabbed the hair of Resident 5. The PN indicated Resident 4 sustained a bump on the forehead, finger scratch marks on the face and bleeding from the right nostril. The PN indicated Resident 4 complained of 5/10 pain on a scale of 0 to 10 (a scale to measure and quantify the intensity of pain; 0 = no pain,10 = worst pain, and 5 = moderate pain) to the face. During a review of Resident 4's Physician's Order (PO) dated 3/20/2025 and timed at 2:36 pm, the PO indicated to transfer Resident 4 to GACH 1 for evaluation. During a review of Resident 4's PN dated 3/20/2025 and timed at 4:04 pm, the PN indicated Resident 4 was transferred to GACH 1. During a review of Resident 4's GACH 1's Emergency Department (ED) records, dated 3/20/2025, the ED records indicated Resident 4 was brought to the ED for evaluation of head pain after a head injury from an assault. The ED records indicated another resident (Resident 5) hit Resident 4 in the facility. The ED records indicated Resident 4 had a Computed Tomography (CT, a medical imaging procedure) of facial bones because of acute (severe and sudden onset) facial pain after an assault. The ED records indicated the CT of Resident 4's facial bones showed mildly comminuted, minimally displaced right nasal bone fracture. The ED records indicated Resident 4 received Tylenol (medication used to relieve mild to moderate pain) 650 milligrams (mg, unit of measurement) by mouth for 6/10 pain (moderate pain) on the face while in the ED. The ED records indicated Resident 4 was discharged back to the facility with a clinical impression (healthcare assessment) of closed head injury and nasal fracture. During a review of Resident 4's PN dated 3/20/2025 and timed at 9:17 pm, the PN indicated Resident 4 returned to the facility from GACH 1. During a concurrent observation inside Resident 4's room and interview with Resident 4 on 3/24/2025 at 10:51 am, Resident 4 was lying in bed. Resident 4 had a small brown discoloration on the right forehead. Resident 4 could not recall the altercation (fight) between Resident 4 and Resident 5 on 3/20/2025. Resident 4 stated Resident 4 had 4/10 (moderate) pain on the nose. During an interview with CNA 1 on 3/24/2025 at 11:20 am, CNA 1 stated CNA 1 was the assigned CNA for Resident 4 on 3/20/2025. CNA 1 stated on 3/20/2025 before 11 am (could not recall exact time), CNA 1 heard yelling coming from Resident 4 and 5's room. CNA 1 stated CNA 1 ran into Resident 4 and 5's room and saw Resident 4 grabbing Resident 5's hair. CNA 1 stated CNA 1 removed and redirected Resident 4 to the dining room. CNA 1 stated CNA 1 saw blood on Resident 4 and 5's faces. CNA 1 stated all residents (in general) with aggressive (likely to attack) behavior should be monitored closely to prevent incidents of physical altercation. During an interview with LVN 1 on 3/24/2025 at 11:47 am, LVN 1 stated on 3/20/2025 at around 11 am (could not recall exact time) LVN 1 heard screaming coming from Resident 4 and 5's room. LVN 1 stated LVN 1 ran into Resident 4 and 5's room and saw Resident 5 stood at the end of Resident 5's bed and Resident 4 grabbed Resident 5's hair. LVN 1 stated LVN 1 separated Residents 4 and 5. LVN 1 stated Resident 4 sustained finger scratch marks on the right side of Resident 4's face, a small bump on the forehead and bleeding from the right nostril. LVN 1 stated Resident 4 complained of 5/10 pain on the face. LVN 1 stated Resident 5 had bleeding on top of Resident 5's nose and scratches on the right side of the face and forehead. LVN 1 stated Resident 4 was transferred to GACH 1 for medical evaluation. LVN 1 stated on 3/20/2025 at 9:17 pm, Resident 4 returned to the facility with a CT scan result indicating Resident 4 sustained a minimally displaced mildly comminuted fracture of the right nasal bone. LVN 1 stated Resident 5 was transferred to GACH 2 on 3/21/2025 on a 5150 hold. LVN 1 stated all facility staff need to work as a team to ensure safety of the residents and to prevent incidents of resident-to-resident altercation or any type of abuse. During an interview with the facility's Administrator (ADM) on 3/24/2025 at 2:30 pm, the ADM stated, the ADM was the abuse coordinator (the person that investigates allegations of abuse) of the facility. The ADM stated, LVN 1 notified the ADM on 3/20/2025 at 11:30 am of the altercation between Residents 4 and 5 that occurred on 3/20/2025 before 11 am. The ADM stated the result of the facility's investigation indicated Residents 4 and 5 had a resident-to-resident altercation that became physical and both residents sustained physical injuries. The ADM stated all staff should be educated and trained on abuse prevention and abuse reporting to ensure safe interactions with residents. During a telephone interview with the facility's Director of Nursing (DON) on 3/26/2025 at 11:42 am, the DON stated all residents had the right to be protected from any kind of physical altercation, assault and abuse while residing in the facility. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, revised 8/2006, the P&P indicated, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.

Based on observation, interview, and record review, the facility failed to provide a safe environment to prevent injuries for two of two sampled residents (Residents 37 and 294) by failing to: a. For Resident 37, the facility failed to: 1. Ensure Licensed Vocational Nurses (LVNs) implemented Resident 37's untitled Care Plan (CP), dated 2/26/2025, to provide interventions such as anticipating Resident 37's needs and providing opportunities for positive interaction/attention to Resident 37 to decrease or eliminate Resident 37's episodes of banging head on the walls/doors. 2. Ensure Certified Nursing Assistants (CNAs) provided hourly monitoring to Resident 37 who was assessed with aggressive behavior (any behavior or act aimed at harming a person or damaging physical property) as ordered by Resident 37's physician (Medical Doctor/MD 1) on 2/2/2025. As a result, Resident 37 sustained a self-inflicted (injury that person causes to themselves) laceration (cut, a wound that is produced by the tearing of soft body tissue) on the scalp (skin on top of the head) which measured one centimeter (cm, unit of measurement), and a head contusion (bruise) on 3/2/2025. Resident 37 was sent to General Acute Care Hospital 2 (GACH 2) where Resident 37 underwent a repair of laceration by application of skin tissue adhesive glue (a glue used to close wounds in the skin as an alternative to sutures [stitches]). In addition, on 3/4/2025 Resident 37 had a physical altercation (fight) with Resident 37's roommate (Resident 196) and Resident 37 was sent to GACH 2 for medical evaluation. Resident 37 sustained a displaced nasal septal fracture (break in the bone that separates the two nostrils), a frontal (front) scalp hematoma (pool of clotted blood) and complained of severe pain (10 out of 10 pain [10/10], on a pain scale from 0 to 10, 0 indicated no pain, and 10 indicated severe pain) on the face from the altercation with Resident 196. b. For Resident 294, the facility failed to ensure staff did not leave Resident 294's lunch tray in Resident 294's room until staff was ready to assist Resident 294 with feeding on 3/5/2024. Resident 294 was assessed with impairment on both upper extremities, severely impaired cognition (the ability to think and process information), and was dependent on staff for eating. As result, Resident 294 reached for his lunch tray on the bedside table by himself and fell on [DATE]. Cross Reference: F656 and F600 Findings: a. 1. During a review of Resident 37's Admission Record (AR), the AR indicated the facility initially admitted Resident 37 on 10/11/2024 and readmitted on [DATE] with diagnoses that included Huntington's Disease (HD, a progressive and genetic [inherited] disorder that affects the brain), and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 37's History and Physical (H&P, formal document of a medical provider's examination of a resident) dated 2/3/2025, the H&P indicated Resident 37 was able to make needs known but cannot make medical decisions. During a review of Resident 37's Minimum Data Set (MDS, a resident assessment and care planning tool) dated 2/7/2025, the MDS indicated Resident 37 had moderately impaired cognition (ability to think, learn, and process information). The MDS indicated Resident 37 required supervision (overseeing or watching someone do something) for toileting, bathing, sitting to standing, and partial/moderate assistance (helper does less than half the effort, helper helps lift, hold, or support trunk or limbs) for walking 10 feet. During a review of Resident 37's untitled CP, dated 2/26/2025, the CP indicated Resident 37 had a behavior problem of banging head on the wall and punching the wall due to dementia. The CP goal indicated to ensure Resident 37 would not have incidence of behavior problem and fewer episodes of banging head on the wall. The CP interventions indicated for nursing staff to anticipate the needs of Resident 37 and provide opportunities for positive interaction and attention. During a review of Resident 37's Progress Notes (PN) dated 3/2/2025 timed at 2:04 PM, the PN indicated Resident 37 was walking in the hallway and suddenly threw a remote control from Resident 37's hand to the floor. The PN indicated Resident 37 turned around and hit the top of Resident 37's head on the door. The PN indicated Resident 37 had angry outburst (a sudden violent expression of strong feeling) for no reason. The PN indicated Treatment Nurse (TN) 1 assessed Resident 37 and Resident 37 had minimal bleeding from the top of the center of Resident 37's head. The PN indicated Resident 37 sustained a laceration on the head which measured 2.5 cm in length by 0.3 cm in width by 0.3 cm in depth. During a review of Resident 37's Change of Condition Evaluation (COCE) dated 3/2/2025 timed at 2:34 PM, the COCE indicated Resident 37 was walking in the hallway and hit Resident 37's head on the door causing bleeding on the top of Resident 37's head. During a review of Resident 37's GACH 2 Emergency Department General (EDG) form dated 3/2/2025 at 3:27 PM, the EDG form indicated Resident 37 was brought in the Emergency Department from the facility by ambulance for evaluation of head injury. The EDG form indicated Resident 37 had head contusion and one cm laceration to the scalp. The EDG form indicated Resident 37 underwent a repair of the scalp laceration with application of skin tissue adhesive glue. During a review of Resident 37's PN dated 3/2/2025 timed at 7:32 PM, the PN indicated Resident 37 returned back to the facility from GACH 2. The PN indicated Resident 37's laceration on the head was glued with skin tissue adhesive glue at GACH 2. During a review of Resident 37's Order Summary Report (OSR) dated 3/4/2025, the OSR indicated for nursing staff to monitor Resident 37's top of the head laceration with surgical glue status post (S/P-after) banging head to the wall for any wound dehiscence (separation of wound edges), bleeding or unusual changes every shift and to report to MD 1 promptly. During a concurrent interview with LVN 3 on 3/6/2025 at 1:39 PM, LVN 3 stated on 3/2/2025 (could not remember exact time) Resident 37 hit Resident 37's head on the shower door in the hallway. LVN 3 stated Resident 37 sustained a laceration on top of Resident 37's head. LVN 3 stated Resident 37 was sent to GACH 2 and received treatment for the laceration (laceration was glued together). LVN 3 stated she did not know Resident 37 had an order to monitor Resident 37 for episodes of hitting head on walls/doors. a. 2. During a review of Resident 37's OSR, dated 2/2/2025, the OSR indicated an order for hourly monitoring of Resident 37 for aggressive behavior every shift. During a review of Resident 37's COCE dated 3/4/2025 timed at 7:13 AM, the COCE indicated Resident 37 had a physical altercation with another resident (Resident 196). The COCE indicated Resident 196 hit Resident 37 on the face and head. The COCE indicated Resident 37 sustained a bloody mouth, a bloody nose, and a small bump on the forehead. During a review of Resident 37's Situation, Background, Assessment, Recommendation Communication (SBARC, communication form used to share information about the condition of a resident), dated 3/4/2025, timed at 7:20 AM, the SBARC indicated Resident 37 sustained a bloody mouth, bloody nose, and a small bump on the forehead. The SBARC form indicated Resident 37 was punched by Resident 37's roommate (Resident 196). During a review of Resident 37's GACH 2 EDG form dated 3/4/2025 timed at 11:50 AM, the EDG form indicated Resident 37 was brought in the Emergency Department from the facility by ambulance due to head and nose pain (pain level was not indicated) after a physical altercation at the facility on 3/4/2025 at 7 AM. The EDG form indicated there was no treatment given for Resident 37 at GACH 2. During a review of Resident 37's GACH 2 Computer Tomography (CT, imaging procedure that produces images of the inside the body) of Resident 37's face, dated 3/4/2025, timed at 11:53 AM, the CT scan result indicated a mildly displaced nasal septal fracture and a frontal scalp hematoma. During an interview with Certified Nursing Assistant 8 (CNA 8) on 3/4/2025 at 4:15 PM, CNA 8 stated Resident 37 returned from GACH 2 on 3/4/2025 (unable to recall time) with a bump on Resident 37's forehead. During a concurrent observation of Resident 37 in Resident 37's room and interview with Resident 37 on 3/4/2025 at 4:17 PM, Resident 37 was calm and had a small bump on the forehead. Resident 37 stated Resident 37 had a 10/10 pain on Resident 37's face as the result of the altercation with Resident 196 on 3/4/2025. During an interview with the facility's Director of Staff Development (DSD) on 3/7/2025 at 12:18 PM, the DSD stated, on 3/4/2025 in the early morning (unable to recall the time) the DSD entered Resident 37's room and saw blood around Resident 37's nose and mouth. The DSD stated Resident 37 told the DSD that Resident 196 punched Resident 37 in the face. The DSD stated the incident was not witnessed by facility staff. During a concurrent interview and record review with CNA 7 on 3/7/2025 at 12:29 PM, Resident 37's OSR dated 2/2/2025 was reviewed. The OSR indicated an order for hourly monitoring to Resident 37 for aggressive behavior every shift. CNA 7 stated there were no Hourly Behavioral Monitoring Sheet (HBMS) created for Resident 37 on 3/2/2025 and 3/3/2025 and the HBMS on 3/4/2025 was created after the physical altercation incident happened between Resident 37 and Resident 196 on 3/4/2025. CNA 7 stated CNA 7 was not aware or informed that Resident 37 required hourly monitoring. CNA 7 stated Resident 37 needed hourly monitoring when the resident was aggressive and had behavior of hurting himself. CNA 7 stated hourly monitoring was a physician's order and needed to be followed. CNA 7 stated CNAs (all CNAs) were responsible for hourly monitoring and documenting the hourly monitoring on the HBMS. CNA 7 stated CNA 7 did not see any HBMS completed for Resident 37 prior to the incidents on 3/2/2025 and 3/4/2025. During a concurrent interview and record review with LVN 3 on 3/7/2025 at 2:21 PM, Resident 37's OSR dated 2/2/2025 was reviewed. The OSR dated 2/2/2025 indicated an order for hourly monitoring of Resident 37 for aggressive behavior every shift. LVN 3 stated hourly monitoring for Resident 37 was not done as ordered by the physician. LVN 3 stated the purpose of monitoring Resident 37 hourly was to ensure Resident 37 was safe. LVN 3 stated prior to the incident on 3/2/2025 and 3/4/2025 nursing staff did not provide hourly monitoring/supervision to Resident 37 as MD 1 ordered. During an interview with the facility's Director of Nursing (DON) on 3/7/2025 at 3:15 PM, the DON stated hourly monitoring for Resident 37 was not done prior to the incidents on 3/2/2025 and 3/4/2025. The DON stated Resident 37 was not supervised/monitored because the physician's order for hourly monitoring was not implemented. The DON stated, The incidents on 3/2/2025 and 3/4/2025 could have been prevented if hourly monitoring was done (on Resident 37). During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated the care team shall target interventions to reduce individual related risks related to hazards in the environment including adequate (enough, acceptable in quality or quantity) supervision and monitoring of residents. 50016 b. During a review of Resident 294's Admission Record (AR), the AR indicated the facility admitted Resident 294 on 2/4/2025, with diagnoses including, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), toxic encephalopathy (brain dysfunction caused by exposure to toxic substances, resulting in symptoms like altered consciousness, memory loss, and cognitive impairment), and lack of coordination. During a review of Resident 47's Fall Risk Evaluation (FRE) and Assessment Outcomes (AO), dated 2/24/2025, timed at 8:36 PM, the FRE and AO indicated Resident 294 was a moderate fall risk. During a review of Resident 294's Multidisciplinary Care Conference (MCC), dated 2/26/2025, timed at 11:11 AM, the MCC indicated Resident 294's cognition was severely impaired. During a review of Resident 294's Functional Abilities and Goals (FAAG), dated 2/26/2025, timed at 5:17 AM, the FAAG indicated Resident 294 was dependent (helper does all of the effort) on staff for activities of daily living (ADL, term used in healthcare that refers to self-care activities) including eating and mobility, and had functional impairment on both sides of his upper extremities. During an observation on 3/5/2025 at 12:15 PM, Resident 294 was lying in bed asking to be fed in frustration. Licensed Vocational Nurse (LVN) 1 approached Resident 294 and took his vital signs (measurements of your body's basic functions, like your heart rate, breathing rate, temperature, and blood pressure). Resident 294 denied pain when asked by LVN 1. During an interview on 3/5/2025 at 12:21 PM, with LVN 1, LVN 1 stated that he had just returned from lunch and was conducting rounds to ensure residents were receiving their lunch trays. LVN 1 stated that (on 3/5/2025) when he entered the south unit, the maintenance supervisor (MS) informed him that there was a resident on the floor in room [ROOM NUMBER]. LVN 1 stated that he immediately went to room [ROOM NUMBER] and found Resident 294 sitting on the floor with his back against the bed and facing the window. LVN 1 stated that Resident 294's food tray had been placed on the bedside table, positioned between the window and the bed. LVN 1 stated that Resident 294 was observed reaching for his lunch tray. LVN 1 stated that Resident 294 was then assisted back into bed and assessed for injuries. LVN 1 stated that Resident 294 denied any injuries, and no physical injuries were noted. LVN 1 stated that Resident 294 was dependent with eating, had been identified as a fall risk, was cognitively impaired, and had episodes of confusion. LVN 1 stated that staff should not have delivered Resident 294's lunch tray until staff were ready to assist with feeding the resident, which could have prevented the fall. LVN 1 stated Resident 294 likely attempted to reach for the tray, which was placed on the bedside table next to the bed and fell . LVN 1 stated that, due to the resident's condition and for his safety, staff should have ensured that the tray was not delivered or placed on the bedside table until they were ready to feed the resident. During an interview on 3/5/2025 at 12:29 PM, with Certified Nursing Assistant (CNA) 4, CNA 4 stated that Resident 294 was confused and dependent on staff for eating. CNA 4 stated that she was notified of Resident 294's fall but did not witness the fall as she was passing out meal trays at the time. CNA 4 stated that Resident 294's meal tray should not be placed on Resident 294's bedside table, given the resident's confusion and fall risk. CNA 4 stated that Resident 294's tray should not be delivered to Resident 294's room until staff were ready to assist Resident 294 with his meal, as this would have helped prevent the fall. During an interview on 3/7/2025 at 11:08 AM, with the Director of Nursing (DON), the DON stated that residents who were cognitively impaired often lacked the awareness of their surroundings or their physical capabilities. The DON stated if the meal tray was within reach and a cognitively impaired resident was not being supervised or assisted, they may attempt to grab it, which could lead to a fall, as the facility unfortunately experienced with Resident 294. The DON stated that Resident 294's confusion and inability to recognize the potential hazard were significant factors in the fall incident. The DON stated that staff should not deliver a meal tray to a confused and dependent resident unless staff were ready to assist with feeding. The DON stated the meal tray should only be placed in the resident's vicinity when staff were present to help the resident with the meal. The DON stated this would ensure that the resident was not left in a vulnerable state where the resident might reach for the tray on his/her own. During a review of the facility's P&P titled, Safety and Supervision of Residents, revise 7/2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated, The facility-oriented approach and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P indicated, The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in resident's condition.

Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of five sampled residents (Residents 3 and 6) when on 7/24/24 Resident 2 hit/punched Resident 3's face and on 7/28/24 Resident 5 hit Resident 6 in the head with a water pitcher. These failures resulted in Resident 3 being subjected to physical abuse by Resident 2 and Resident 6 being subjected to physical abuse by Resident 5 while under the care of the facility. Resident 3 sustained facial fractures (break in bones on the face) and facial contusions (bruises) on Resident 3's right eye. Resident 6 sustained a laceration (a cut or tear in the skin) on the left forehead that required suturing (stitch made to join the open parts of a wound) at General Acute Care Hospital 1 (GACH 1). Findings: 1a. During a review of Resident 2's Admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/29/24 and readmitted Resident 2 on 7/25/24 with diagnoses that included post-traumatic stress disorder (PTSD - difficulty recovering after experiencing or witnessing a terrifying event), anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear) and unspecified psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). During a review of Resident 2's Care Plan (CP) titled, Psychosocial, dated 3/29/24, the CP indicated Resident 2 had episodes of striking out and getting upset when Resident 2 did not get what Resident 2 wanted. The CP interventions included for staff to observe for changes in Resident 2's mood, behavior, and psychosocial well-being (the state of mental, emotional, and social health of an individual). During a review of Resident 2's CP titled, Behavior, dated 3/29/24, the CP indicated Resident 2 had episodes of verbal aggression. The CP interventions included for staff to monitor behavior summary, encourage Resident 2 to participate in activities and when the Resident 2 agitated to leave the resident for a while and come back when calm. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment and care screening tool) dated 7/3/24, the MDS indicated Resident 2 had intact cognition (ability to understand and process thoughts). The MDS indicated Resident 2 had no impairment in the upper or lower extremity range of motion (ROM- full movement potential of a joint [where two bones meet]) and Resident 2 used a wheelchair for ambulation (act of moving about). During a review of Resident 2's History & Physical (H&P) dated 7/24/24, the H&P indicated Resident 2 had the capacity to understand and make decisions. 1b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 4/9/24 and readmitted Resident 3 on 6/17/24 with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions, uncontrollable shaking that is rapid and rhythmic, with the muscles contracting and relaxing repeatedly] over time), depression (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities) and schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had intact cognition. The MDS indicated Resident 3 required supervision or touching assistance to walk for ten feet. During a review of Resident 3's H&P dated 6/18/24, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Situation, Background, Assessment, Recommendation (SBAR- communication tool to provide essential information during crucial situation), dated 7/24/24, at 9:45 p.m., the SBAR indicated Resident 3 sustained a bloody nose, a skin tear to the left 3rd and 4th knuckle, and Resident 3 complained of 6 out of 10 pain (moderately stronger pain) on pain scale of 0 to10 (0 equal no pain and 10 equal the worst pain) on the right side of Resident 3's face as a result from an altercation between Residents 2 and 3. During a review of Resident 3's GACH 1 Computed Tomography (CT, a non-invasive imaging procedure that uses a computer and X-ray machine to create detailed 3D pictures of the inside of the body) Examination Report of the maxillofacial (relating to the jaws and face) dated 7/24/24, GACH 1 CT Examination Report indicated Resident 3 had right zygomaticomaxillary complex fractures (a facial fracture that can occur after a direct blow), right maxillary sinus minimally displaced anterior and posterolateral wall fractures (facial injury that can occur when the maxilla [bone of the jaw] was impacted by force), right orbital floor mild blow-in fracture (break in the inner wall or surrounding bones of the eye socket), and facial contusions. During a review of Resident 3's GACH 1 Emergency Department Report (EDR), dated 7/24/24 at 10:58 p.m., the EDR indicated Resident 3 came to the ED with chief complaint of being punched in the face. The EDR indicated Resident 3 had right zygomaticomaxillary complex fractures, right orbital floor mild blow-in fracture, right maxillary sinus minimally displaced anterior and posterolateral wall fractures, and facial contusions. During a concurrent observation of Resident 4 and the facility's outside patio (the area where Resident 2 hit and punched Resident 3) and interview with Resident 4 on 8/1/24 at 3:47 p.m., there was a light fixture on the eave (lower edge of a roof extending past a building's wall) of the building. Resident 4 stated Resident 4 witnessed the incident on 7/24/24 at 9:30 p.m. between Residents 2 and 3. Resident 4 was alert and coherent. Resident 4 stated (on 7/24/2024 at 9:30 p.m.) Resident 4 sat next to Resident 3, who was seated at a metal table. Resident 4 stated Resident 2 jumped up and placed a dry towel over the light fixture on the eave. Resident 3 then told Resident 2 to stop what Resident 2 was doing because it, (placing a dry towel over the light fixture) would cause a fire. Resident 4 stated Resident 2 and Resident 3 exchanged words and Resident 2 ran over to Resident 3 and pushed the table towards Resident 3. Resident 2 hit and punched Resident 3. Resident 3 grabbed Resident 4's cane to protect himself. Resident 4 stated there was no staff present to stop the altercation. Resident 4 stated Resident 3 had blood all over Resident 3's face when Resident 2 hit Resident 3. Resident 4 stated facility's staff (unable to recall) came to intervene after the altercation occurred. During an observation of Resident 3's face in Resident 3's room and a concurrent interview on 8/1/24, at 4:15 p.m., with Resident 3, Resident 3 stated Resident 2 sucker punched (hit someone with an unexpected punch or blow) Resident 3. Resident 3 stated on 7/24/24 at 9:30 p.m. in the facility's patio, Resident 2 placed a towel over the patio light fixture and Resident 3 told Resident 2 to stop what Resident 2 was doing because it would cause a fire. Resident 3 stated Resident 2 pushed the metal table on Resident 3 and Resident 3 got up and started walking away. Resident 3 stated Resident 2 came up and punched Resident 3's right eye. Resident 3 stated Resident 3 was in pain and complained of a 9 to 10 pain (excruciating pain, on a scale of 0 to 10). Resident 3's face had redness and swelling near Resident 3's right eye. There was a purple-bluish mark near Resident 3's right eye, approximately one inch. Resident 3 stated when Resident 2 punched Resident 3, Resident 3 felt angry and had (excruciating) pain on his face. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 8/2/24 at 3:25 p.m., LVN 3 stated the types of resident abuse included physical abuse, isolation, and neglect. 2a. During review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 2/28/24 and readmitted Resident 5 on 4/29/24 with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and schizophrenia. During a review of Resident 5's CP titled, Behavior, dated 4/29/24, the CP indicated Resident 5 needed behavior management manifested by agitation (nervous excitement or uneasiness) and aggressive behavior (behavior intending to cause physical or mental harm). The CP interventions included for staff to monitor episodes of behavior for Resident 5 every shift. During a review of Resident 5's H&P dated 5/2/24, the H&P indicated Resident 5 had the capacity to make needs known but could not make medical decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition. The MDS indicated Resident 5 required supervision or touching assistance with activities of daily living (ADLs, the basic skills that people need to do every day to care for themselves and maintain their health and safety), and mobility (the ability to move freely). During a review of Resident 5's CP titled, Mood State (a short-term feeling state that may fluctuate within minutes to days), dated 6/5/24, the CP indicated Resident 5's mood was easily altered, and Resident 5 had episodes of unprovoked verbal aggression. The CP interventions included for staff to monitor Resident 5's mood status every shift and provide close monitoring to Resident 5 as needed. During a review of Resident 5's CP titled, Abusive, dated 7/24/24, the CP indicated Resident 5 had episodes of verbally abusive behavior demonstrated by verbalizing aggression. The CP interventions included for staff (in general) to refocus Resident 5's behavior to something positive when Resident 5 exhibiting verbally abusive behavior. 2b. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 7/28/22 and readmitted Resident 6 on 6/12/24 with diagnoses that included epilepsy and persistent mood affective disorder (disturbance in mood affecting emotional state and daily life). During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had moderately impaired cognition. The MDS indicated Resident 6 required patrial/moderate assistance with ADLs. The MDS indicated Resident 6 used a manual wheelchair for ambulation. During a review of Resident 6's H&P, dated 6/25/24, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's SBAR, dated 7/28/24, at 10:15 a.m., the SBAR indicated Resident 6 sustained an approximately three centimeter (cm- unit of measurement in length) long laceration to Resident 6's left forehead. During a review of Resident 6's GACH 2 Discharge Note dated 7/28/24, the note indicated Resident 6 had laceration repair with absorbable sutures. During an observation of Resident 6's forehead in Resident 6's room and a concurrent interview with Resident 6 on 7/31/24, at 2:45 p.m., Resident 6's left forehead had intact stiches (2 stitches). Resident 6 stated Resident 6 had no previous altercation with Resident 5. Resident 6 stated Resident 5 struck Resident 6 on the left side of Resident 6's forehead with an empty water pitcher for about eight times and Resident 6 had to be transferred to General Acute Care Hospital 2 (GACH 2) for suturing of the laceration on Resident 6's left side of the forehead. Resident 6 stated being struck by Resident 5 made Resident 6 feel mad as hell. During an interview with Certified Nurse Assistant 1 (CNA 1) on 7/31/24 at 2:50 p.m., CNA 1 stated resident abuse included physical, verbal, and mental abuse. During an interview on 7/31/24, at 5:35 p.m., with LVN 1, LVN 1 stated she was the Desk Nurse (Nurse who assisted with admissions and work on laboratory findings) on 7/28/24, the day of the incident between Residents 5 and 6. LVN 1 stated, on 7/28/24 at 10:15 a.m., Receptionist 1 (REC 1) called LVN 1 for help. LVN 1 stated according to REC 1 Resident 5 was sitting on a chair in the facility lobby and Resident 6 was sitting in Resident 6's wheelchair and Resident 5 got up from Resident 5's chair, approached Resident 6 and hit Resident 6 in the head with a pitcher. Residents 5 and 6 were separated by LVN 1. LVN 1 stated Certified Nursing Assistants (CNAs) and other facility staff ran out to assist Resident 6 after hearing REC 1 yelled for help. LVN 1 stated Resident 6 did not provoke Resident 5 and there were no words exchanged between Residents 5 and 6 prior to the altercation on 7/28/24. LVN 1 stated Resident 5 carried a pitcher with Resident 5 because Resident 5 liked to drink water. LVN 1 stated Resident 6 sustained a forehead laceration on the left side of Resident 6's forehead. LVN 1 stated Resident 6's laceration and nose were bleeding when Resident 5 used the water pitcher to hit Resident 6's forehead. LVN 1 stated Resident 5 refused to give a statement to LVN 1 when LVN 1 interviewed Resident 5 and Resident 6 was so upset that Resident 6 refused to give a statement regarding the incident (Residents 5 and 6's altercation). LVN 1 stated Resident 6 was transferred to GACH 2 on the same date (7/28/24) for suturing of Resident 6's laceration on the left forehead. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention Program, revised on December 2016, the P&P indicated our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interview and record review, the facility's licensed nurses (Registered Nurse 1 [RN 1], Licensed Vocational Nurse 2 [LVN 2], LVN 3, and LVN 4), failed to identify signs and symptoms of stroke (lack of blood flow and oxygen in the brain due to blood clot or bleeding due to a tear in the blood vessels in the brain) and provide needed care and services to one of three sampled residents (Resident 1), as indicated in the facility's policy and procedure on stroke and Resident 1's stroke care plan. On [DATE] from 7 a.m. to 3:30 p.m., RN 1and LVN 2 observed Resident 1 was non-verbal, lethargic (tired and sleepy), difficult to wake up, and, not eating. At 5 p.m., LVN 3 and LVN 4 observed Resident 1 unresponsive with facial droop (a result due to the damage of the nerve in the brain). LVN 3 called 911 (emergency services) at 5:30 p.m., (ten hours and thirty minutes later) and the resident was transferred to the emergency department of the general acute care hospital for treatment and services. These deficient practices resulted in Resident 1 not receiving emergency medical care in the timely manner, which contributed to the resident being admitted to the General Acute Care Hospital (GACH) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 returned to the facility on [DATE] and expired on [DATE]. Cross Refer to F580 and F760 Findings: 1. A review of Resident 1's Facesheet (an admission record) indicated the facility admitted the resident on [DATE], and readmitted her on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's CVA Care Plan dated [DATE] indicated the resident was at risk for a repeat CVA and the plan was to administer medications as ordered and for the staff to monitor the resident for any signs of CVA every shift such as facial drooping, Altered Level of Consciousness (ALOC), impaired and slurred speech, and monitor for any decline in mobility. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated [DATE], indicated Resident 1 spoke Arabic and needed an interpreter and was usually able to express ideas and wants both in verbal and nonverbal expressions. The MDS indicated the resident required extensive assistance for eating and bed mobility. The MDS indicated Resident 1 did not exhibit behavior of rejection of care or evaluation. A review of Resident 1's Physician's Telephone Order, dated [DATE] and timed at 7 p.m., indicated to admit Resident 1 to the facility under Hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure). A review of Resident 1's Certificate of Death indicated the resident expired at the facility on [DATE] at 7:04 a.m. The Certificate of Death indicated Resident 1's immediate cause of death (final disease or condition resulting in death) was end stage [CONDITION(S)] (stroke). 2. During a telephone interview on [DATE] at 4:48 p.m., LVN 1 stated that on [DATE] at approximately 6:45 a.m. to 7 a.m., she observed Resident 1 non-verbal, difficult to arouse, and was not in her usual self. LVN 1 stated Resident 1 was usually a pleasant lady, able to communicate her needs with simple words or gestures. LVN 1 stated she informed LVN 2 and RN 1 regarding Resident 1's condition the same day ([DATE]). During a telephone interview on [DATE] at 3:15 p.m., LVN 2 stated that on [DATE] between 6:45 a.m., and 7 a.m., LVN 1 reported to monitor Resident 1 who was lethargic (sleepy and tired) but with stable vital signs. LVN 2 stated that on [DATE] at around 7 a.m., she observed Resident 1 as lethargic, when she rubbed her arm, the resident just stared at her and did not respond back as Resident 1 usually did. LVN 2 stated Resident 1 was usually was able to communicate her needs by simple words and gestures. LVN 2 stated that on [DATE] at around 7:30 a.m., she observed RN 1 inside Resident 1's room. During a telephone interview on [DATE] at 3:20p.m., LVN 2 stated she did not recall if she gave the medications (unable to specify which medications) to Resident 1 on [DATE] at 9 a.m., and at 1 p.m. LVN 2 explained Resident 1 remained nonverbal, nonresponsive and with her mouth tightly closed throughout the day until the end of her shift at 3 p.m 3. A review of RN 1's text message to MD 1 dated [DATE], and timed at 12:48 p.m., indicated Resident 1 was non-verbal, refused to eat twice (breakfast and lunch) and she was difficult to wake up but I think she is faking can we get CBC (complete blood count) and UA (urine analysis, a laboratory test of urine) just in case. During an interview with RN 1 on [DATE] at 12:02 p.m., RN 1 stated on [DATE] at around 7 a.m., he observed Resident 1 lying in bed, lethargic but able to move her arm and able to blink her eyes when her name was called. RN 1 stated he did not try to talk to the resident to check her mental status. RN 1 stated he thought Resident 1 was fine but maybe faking. RN 1 stated Resident 1 had history of faking which he described as being nonverbal, nonresponsive even when her family or staff talked to her she would not open her mouth to talk or to eat. RN 1 stated he just heard from other staff that Resident 1 was faking but he had not observed resident faking. Further interview on [DATE] at 12:15 p.m., RN 1 stated he sent a text message to MD 1 on [DATE] morning (no specific time) to inform him that Resident 1 was being nonverbal, refused to eat and difficult to wake up but think she was faking. RN 1 stated at 2 p.m., he continued to observe Resident 1 as nonverbal and unresponsive, but he did not comprehensively assess the residents change in mental status and accurately report the change of condition to the physician. RN 1 stated, as a new nurse, he lacked of skills in assessing of new stroke event or recurrent of stroke, he did not think Resident 1 could be having a stroke because Resident 1 was reported to have normal vital signs. RN 1 further stated, I thought there was no neurological issues, I wish I had sent her out to the hospital, I did not catch it. A review of the facility's policy and procedure, titled Stroke-TIA (Transient Ischemic Attack, a temporary period of having symptoms of stroke)-Clinical Protocol dated ,d+[DATE] with RN 1, the policy indicated: The physician will identify the individuals with or at risk of stroke of TIA. The staff will identify and report individuals that could indicate a current TIA or stroke which included but not limited to: a. sudden onset of confusion. b. difficulty speaking c. sudden numbness or unilateral weakness of the face, arm, and leg. In addition the nurse shall assess and document and report the following to the physician: a. Vital Signs b. neurological abnormalities c. Onset, duration, severity, scope of abnormality The staff should carefully describe signs and symptoms including the resident's current level of consciousness, cognitive level (ability to think and reason), speech, and overall physical function compare to the current condition and usual (baseline) condition. Unilateral (one side) facial and limb weakness or difficulty of speech that is new or represent a decline from previous function may be more specific indicator of acute stroke. After the review of the policy and procedures, on [DATE] at 2:24 p.m., RN 1 stated he failed to comprehensively assess, immediately and accurately report to the physician and document in Resident 1's clinical record the neurological changes of Resident 1. RN 1 stated, he did not assess the resident for the signs and symptoms of stroke such as assess for orientation, ability to eat, swallow, verbally respond, slurred speech and check for movements of the arms and legs, facial droop and monitor the vital sign changes. RN 1 stated he lacked clinical experience and skill set to assess residents with new or recurrent stoke. 4. During an interview on [DATE] at 3:32 p.m., LVN 3 stated on [DATE] at 3 p.m., he received a report to from LVN 2 that Resident 1 was fine. LVN 3 stated at about 5 p.m., he saw Resident 1 unresponsive, with facial droop and She was not the resident as I know her, she was different. LVN 3 was asked if he assessed Resident 1 for the signs and symptoms of stroke, LVN 3 replied Yes. LVN 3 was asked why he did not call the physician or the paramedics to ensure Resident 3 received immediate care, LVN 3 replied he was not sure if Resident 3 was having a stroke which was why he called RN 2 from her home to assist with the assessment and interventions. LVN 3 stated RN 2 arrived at the facility at about 5:30 p.m. and instructed him to call 911. A review of Resident 1's Prehospital Care Report dated [DATE] and timed at 5:49 p.m., indicated the facility called the emergency agency on [DATE] at 5:49 p.m. The report indicated paramedics arrived at the facility at 5:58 p.m., and the Resident 1 was unconscious (the state in which a person is unable to respond to stimuli) in severe distress, nonverbal, and had right sided facial droop. The report indicated the staff reported to paramedics Resident 1 was last known well (LKW) on [DATE] at 6 a.m. The report indicated Resident 1's blood pressure was ,d+[DATE] (high, normal ,d+[DATE]), heart rate 140 (high, normal 60 to 100 beat per minute), and Resident 1 was transferred to GACH at 6:10 p.m. The report indicated Resident 1 had history of left sided deficits (weakness) from previous CVA and now exhibiting right facial droop and not following commands. The report indicated at 6:08 p.m., the report indicated Resident 1 had [CONDITION(S)] with rapid ventricular response (fast irregular heartbeat). A review of Resident 1's GACH Discharge Summary Report dated [DATE], and timed at 12:49 a.m., indicated the resident presented to the GACH as a stroke alert on [DATE] and needed to be monitored in the GACH's Intensive Care Unit (ICU, unit in a hospital providing intensive care for critically ill or injured patients that is staffed by specially trained medical personnel and has equipment that allows for continuous monitoring and life support). The report indicated Resident 1 was discharged to the facility on [DATE] with comfort care (essential part of medical care at the end of life) and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. During an interview on [DATE] at 3:56 p.m., LVN 4 stated she did not receive a report from LVN 3 and RN 1 that Resident 1 had a change of condition. LVN 4 stated at around 5 p.m. she was informed by Certified Nursing Assistant 4 (CNA 4) that Resident 1 did not want to open her mouth to eat. LVN 4 stated she went to the resident's room and observed her with facial droop, unresponsive and her arms were flaccid (lack of strength-limp), she immediately informed LVN 3 who called RN 2 for assistance and she attended to the resident around 5:30 p.m. During a telephone interview on [DATE] at 12:07 p.m., RN 2 stated, at the end shift on [DATE], LVN 1 informed her that Resident 1 was not in her usual self. She asked LVN 1 to check her VS which were within normal limits with blood pressure of ,d+[DATE] and heart rate of ,d+[DATE]. According to RN 2, LVN 1 gave a report to RN 1 at about 7 a.m. and asked if he could monitor Resident 1 and he said, Yes. RN 2 stated she told RN 1 to make sure to monitor and keep an eye on Resident 1 because if she was normal at one day and not normal for whatever reason then that should be reported. RN 2 stated she was supposed to come to work at 7 p.m. but around past 5 p.m., she received a call from LVN 3 in a panic mode and said he needed help, he said something wrong with Resident 1. RN 2 stated she arrived at the facility after 5 p.m., went to Resident 1's room and found her unresponsive. RN 2 stated she had the nurse check BP and it was high. RN 2 stated she did a sternal rub (application of painful stimulus to the chest to someone who is not alert). RN 2 stated she asked the staff to call 911 while she completed the assessment. RN 2 stated she could clearly tell the Resident 1 was having a stroke. During a record review conducted with the DON on [DATE] at 4:49 p.m., the DON stated Resident 1's records had no documented evidence that Resident 1 was comprehensively assessed on the morning shift of [DATE] and there was no record of a change in condition report and a nursing progress notes written by RN 1 or LVN 2. In a concurrent interview, RN 1 stated he did not document a change of condition report or the assessment for Resident 1 on [DATE], because he did not think the resident had a significant change of condition.

Based on interview and record review, the facility failed to promptly (within approximately one-half hour or less) consult with Medical Doctor 1 (MD 1) and notify Responsible Party 1 (RP 1) for one of three sampled residents (Resident 1) as indicated in the facility's Clinical Protocol Acute Condition Changes policy when there was a significant change (a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions) in Resident 1's condition by failing to: 1. Ensure Licensed Vocational Nurse 2 (LVN 2) consulted with MD 1 and notified RP 1 when LVN 2 observed Resident 1 was lethargic (sluggish, tired, and sleepy), would not open her mouth to take her medications, difficult to arouse, nonverbal, and the resident did not eat breakfast and lunch on [DATE] from 7 a.m., to 3 p.m., (total of eight hours). 2. Ensure Registered Nurse 1 (RN 1) consulted with MD 1 and notified RP 1 regarding Resident 1's significant change of condition. RN 1 sent a phone text message to MD 1 on [DATE] at 12:48 p.m., indicating that he (RN 1) thought Resident 1 was faking the change of condition when Resident 1 was nonverbal, refusing to eat two meals, and when the resident was difficult to wake up. 3. Ensure LVN 3 and LVN 4 consulted with MD 1 and notified RP 1 when they both observed Resident 1 on [DATE] at approximately 5 p.m., with left facial droop (not responsive and will not react to activity or stimulation), unresponsive (not responding to stimuli), non-verbal (not talking), mouth tightly closed, with abnormal vital signs (clinical measurements) such as severely high blood pressure (HBP the force of blood flowing through your blood vessels, is consistently too high) that measured ,d+[DATE] (high-normal range systolic 80/diastolic 120), heart rate (HR) of 140 (high-normal range ,d+[DATE] millimeter per mercury), and oxygen saturation at 78% (low-a measure of how much oxygen the blood is carrying blood, normal range ,d+[DATE]%). LVN 3 and LVN 4 waited for RN 2 to arrive at the facility from home to assess Resident 1's change of condition before calling paramedics. The paramedics transferred Resident 1 to a General Acute Care Hospital (GACH) at 6:10 p.m. 4. Ensure Licensed Nurses (in general) report to MD 1 and RP 1 when Resident 1 refused to take medications prescribed to control heart rate, blood pressure, and prevent blood clot formation during [DATE]. These deficient practices resulted in Resident 1 to lose consciousness (state of being awake and awareness of the environment) and received delayed emergency care and services for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was admitted to the Intensive Care Unit (ICU, unit in a hospital providing intensive care for critically ill or injured patients that is staffed by specially trained medical personnel and has equipment that allows for continuous monitoring and life support) for eight days with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross Reference to F684 Findings: 1. A review of Resident 1's Facesheet (an admission record) indicated the facility admitted the resident on [DATE], and readmitted her on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's CVA Care Plan dated [DATE] indicated the resident was at risk for a repeat CVA and the plan was to administer medications as ordered and monitor for any signs of CVA such as facial drooping. A review of Resident 1's Pacemaker (a small device that is placed under the skin in the chest to help control the heartbeat) Care Plan dated [DATE] indicated the resident was at risk for irregular pulse and the plan was to report any irregular pulse to the physician promptly. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated [DATE], indicated Resident 1 spoke Arabic and needed an interpreter and was usually able to express ideas and wants both in verbal and nonverbal expressions. The MDS indicated the resident required extensive assistance for eating and bed mobility. The MDS indicated Resident 1 did not exhibit behavior of rejection of care or evaluation. A review of Resident 1's Physician's Telephone Order, dated [DATE] and timed at 7 p.m., indicated to admit Resident 1 to the facility under Hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure). A review of Resident 1's Certificate of Death indicated the resident expired at the facility on [DATE] at 7:04 a.m The Certificate of Death indicated Resident 1's immediate cause of death (final disease or condition resulting in death) was end stage [CONDITION(S)] (stroke). During a telephone interview on [DATE] at 4:48 p.m., LVN 1 stated that on [DATE] at approximately 6:45 a.m. to 7 a.m., she observed Resident 1 non-verbal, difficult to arouse, and was not in her usual self. LVN 1 stated Resident 1 was usually a pleasant lady, able to communicate her needs with simple words or gestures. LVN 1 stated she informed LVN 2 and RN 1 regarding Resident 1's condition the same day ([DATE]). During a telephone interview on [DATE] at 10 a.m., MD 1 stated he did not recall if the facility informed him or texted him to inform him that the resident refused or did not take her medications on [DATE]. During a telephone interview on [DATE] at 3:15 p.m., LVN 2 stated that on [DATE] between 6:45 a.m., and 7 a.m., LVN 1 reported to monitor Resident 1 who was lethargic (sleepy and tired) but with stable vital signs. LVN 2 stated that on [DATE] at around 7 a.m., she observed Resident 1 as lethargic, when she rubbed her arm, the resident just stared at her and did not respond back as Resident 1 usually did. LVN 2 stated Resident 1 was usually was able to communicate her needs by simple words and gestures. LVN 2 stated that on [DATE] at around 7:30 a.m., she observed RN 1 inside Resident 1's room. LVN 2 stated she did not inform MD 1 and Resident 1's RP 1 for the change in the Resident 1's condition because RN 1 was already aware of the change of condition and the RN supervisors were usually the ones who would text or call the doctors or the responsible party of the change of condition. During a telephone interview on [DATE] at 3:20 p.m , LVN 2 stated she did not recall if she gave the medications (unable to specify which medications) to Resident 1 on [DATE] at 9 a.m., and at 1 p.m. LVN 2 explained Resident 1 remained nonverbal, nonresponsive and with her mouth tightly closed throughout the day until the end of her shift at 3 p.m. LVN 2 stated she did not notify MD 1 that Resident 1 did not take some of her medications (unable to specify which medications) on [DATE] because she thought RN 1 already informed the physician. 2. A review of RN 1's text message to MD 1 dated [DATE], and timed at 12:48 p.m., indicated Resident 1 was non-verbal, refused to eat twice (breakfast and lunch) and she was difficult to wake up but I think she is faking. During an interview on [DATE] at 12:02 p.m., RN 1 stated that on [DATE] at around 7 a.m., he observed Resident 1 in her room and noted she was lethargic but able to move her arm and able to blink when he called out her name. RN 1 stated he did not try to talk to the resident to check her mental status. RN 1 stated he thought Resident 1 was fine. RN 1 stated he thought Resident 1 was faking, because Resident 1 had history of faking, which he described as being non-verbal, non- responsive even when her family tried to talk to her and would not open her mouth to eat. RN 1 stated he just heard from other staff that Resident 1 was faking, but he had not observed resident faking. RN 1 also stated, there was no documentation in Resident 1's clinical record that Resident 1 had history of faking. During an interview on [DATE] at 12:15 p.m., RN 1 stated he sent a text message to MD 1 on [DATE] at 12:48 p.m., to inform him that Resident 1 was being non-verbal, refused to eat, and difficult to wake up and that he (RN 1) thought the resident was faking. RN 1 stated at 2 p.m., he continued to observe Resident 1 as non-verbal and unresponsive but he did not comprehensively assess the resident's change in mental status and accurately report the change of condition to the physician. RN 1 stated as a new nurse, he lacked of skills in the assessment of new stroke event or recurrent stroke. RN 1 stated he did not think Resident 1 could be having a sign and symptoms of stroke because Resident 1 was reported to have normal vital signs. RN explained, I thought there was no neurological issues, I wish I sent her out to the hospital, I did not catch it. During an interview on [DATE] at 2:24 p.m., RN 1 stated he did not inform MD 1 of Resident 1's change of condition on [DATE] even after he observed Resident 1 to be unresponsive and nonverbal at 2 p.m. because he did not think Resident 1 had significant change of condition. RN 1 stated he did not ask any other staff to find the Resident 1's baseline mental status. RN 1 also stated he was uncomfortable to inform MD 1 if he was unsure of the change in Resident 1's change of condition. RN 1 stated he often called the facility's Director of Nursing (DON) if he was in doubt of his assessment skills and stated the DON was not in the facility on [DATE]. RN 1 stated he did not call Resident 1's RP 1 for assistance to talk to Resident 1 in her native language or to determine her baseline mental status. During a concurrent interview on [DATE] at 2:40 p.m., and record review of Resident 1's clinical record that included the Nursing Progress Notes and Care Plans, RN 1 stated Resident 1's medical record did not have documented evidence that Resident 1 had any episodes of faking, as RN 1 described. RN 1 stated he did not document a change of condition report on [DATE], did not comprehensively assess Resident 1, and did not accurately report to MD 1 and Resident 1's RP 1 Resident 1's condition on [DATE]. During an interview on [DATE] at 4:49 p.m., the DON stated the facility's licensed staff (in general) should have informed MD 1 and RP 1 timely or should have called the paramedics when Resident 1 was observed with the change in mental status and elevated BP and HR because the resident could be having a stroke. The DON stated a permanent brain damage could occur if the resident did not receive emergency intervention right away. The DON also stated RN 1 should consult with MD 1 to get directions for necessary interventions. During a telephone interview on [DATE] at 9:42 a.m., MD 1 stated he received a text message on [DATE] at 12:48 p.m., from RN 1 that Resident 1 was nonverbal and refused to eat twice at which he advised RN 1 to monitor the resident. MD 1 stated he was not aware Resident 1 was lethargic and difficult to arouse. MD 1 stated he did not recall if he received a call or text indicating Resident 1 was Faking to be non-verbal, and stated the word Faking, should not be used in the clinical setting. MD 1 stated he was aware that sometimes Resident 1 was not motivated to talk but she was able to communicate her needs. MD 1 stated he did not receive a call or text from the facility that Resident 1 continued to be non-verbal or non-responsive until 6:12 p.m., on [DATE] when Resident 1 was being transferred to the hospital via 911(emergency services) because of left facial droop and signs and symptoms of stroke. During a telephone interview on [DATE] at 10 a.m., MD 1 stated the signs and symptoms of stroke included difficulty to be aroused, different from baseline, facial droop, weak or no movement of the extremities. MD 1 stated if the staff (in general) observed Resident 1 with signs and symptoms of stroke, Resident 1 certainly needed emergency and immediate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD 1 stated he did not receive a text or call from the staff in the morning of [DATE] to notify him Resident 1 had manifested signs and symptoms of stroke. 3. During an interview on [DATE] at 3:32 p.m., LVN 3 stated that on [DATE] at around 5 p.m., LVN 4 informed him Resident 1 was lethargic and showing signs and symptoms of stroke. LVN 3 stated he immediately went to see Resident 1 and observed the resident unresponsive, with facial droop, and hard to wake up. LVN 3 stated he immediately called RN 2 at home who was supposed to work at 7 p.m. for assistance. LVN 3 stated he did not call MD 1 because the RN supervisors are the only one that could call the doctor LVN 3 stated while waiting for RN 2 to arrive at the facility, Resident 1's BP measured ,d+[DATE] (high), HR 140 (high) minute and oxygen saturation to 78% (low). LVN 3 stated when RN 2 arrived at the facility at about 5:30 p.m., he called the paramedics. During an interview on [DATE] at 3:56 p.m., LVN 4 stated that on [DATE] at around 5 p.m., Certified Nursing Assistant 4 (CNA 4) informed her that Resident 1 did not want to open her mouth to eat. LVN 4 stated she went to Resident 1's room and observed the resident with facial droop, nonverbal, unresponsive, and her arms were flaccid (lack of strength-limp), mouth tightly closed, severely high BP and HR. LVN 4 stated she informed LVN 3 and LVN 3 called RN 2 for assistance. LVN 4 stated she did not call MD 1 and RP 1 because RN 2 was supposed to call MD 1. During an interview on [DATE] at 4:49 p.m., DON she received a call from RN 2 on the evening of [DATE] (she does not recall the time) that Resident 1 was having facial droop and unresponsive. DON stated she told RN 2 What are you waiting for call 911. The DON stated if the resident was observed with facial droop and unresponsive, the nurses should have called the doctor right away and then inform the responsible party. A review of Resident 1's Prehospital Care Report dated [DATE] and timed at 5:49 p.m., indicated the facility called the emergency agency on [DATE] at 5:49 p.m. The report indicated paramedics arrived at the facility at 5:58 p.m., and the Resident 1 was unconscious (the state in which a person is unable to respond to stimuli) in severe distress, nonverbal, and had right sided facial droop. The report indicated the staff reported to paramedics Resident 1 was last known well (LKW) on [DATE] at 6 a.m. The report indicated Resident 1's blood pressure was ,d+[DATE] (high), heart rate 140 (high), and Resident 1 was transferred to GACH at 6:10 p.m. A review of Resident 1's GACH Discharge Summary Report dated [DATE], and timed at 12:49 a.m., indicated the resident presented to the GACH as a stroke alert on [DATE] and needed to be monitored in the GACH's Intensive Care Unit (ICU, unit in a hospital providing intensive care for critically ill or injured patients that is staffed by specially trained medical personnel and has equipment that allows for continuous monitoring and life support). The report indicated Resident 1 was discharged to the facility on [DATE] with comfort care (essential part of medical care at the end of life) and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's policy and procedure, titled Clinical Protocol Acute Condition Changes, with a revised date of ,d+[DATE] indicated the physician would identify individuals for having acute changes of condition. The policy indicated the nurses should assess and document and report the following baseline information: vital signs, level of consciousness, cognitive and emotional status onset, duration and severity. The policy indicated the nursing staff would contact the physician based on the urgency of the situation, for emergencies, the staff would call the physician and request prompt request within approximately one half hour or less. 4. During a telephone interview on [DATE] at 10:34 a.m., and review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the licensed nurses should have reported that Resident 1 had been refusing to take medications and to inform MD 1 to prevent complications such as stroke. During a telephone interview on [DATE] at 10:34 a.m., and a review of Resident 1's MAR for [DATE] the DON stated Resident 1 did not receive the following medications on the following dates and times: a. [MEDICATION(S)] (medication to control high blood pressure) 1 tablet 10 milligrams (mg, unit of measurement), refused by resident on [DATE], [DATE], [DATE], and [DATE], at 9 a.m., and on [DATE] and [DATE] at 5 p.m., (6 doses). b. [MEDICATION(S)] (medication to control rapid heart rate) 12 hour (HR) ER 120 mg 1 capsule refused by resident on [DATE], [DATE], [DATE], and on [DATE] at 9 a.m., ( 4 doses). c. [MEDICATION(S)](medication administered to prevent development of blood clot-also known as blood thinner) 5 mg one refused by resident on [DATE], [DATE], and on [DATE] at 9 a.m., and on [DATE] at 5 p.m. DON stated [MEDICATION(S)] tablet was not administered because the medication was unavailable. DON stated (during the concurrent telephone interview) on [DATE] at 5 p.m., [MEDICATION(S)] was not administered. d. [MEDICATION(S)] (medication to control blood pressure) [MEDICATION(S)] 50 mg one tablet on [DATE], [DATE], [DATE], [DATE], and on [DATE] at 9 a.m., and on [DATE] at 5 p.m. (6 doses). e. [MEDICATION(S)] 50 mg tablet (medication to control high blood pressure) on [DATE], [DATE], [DATE], [DATE], and on [DATE] at 9 a.m., [DATE], [DATE], [DATE], and [DATE] at 1 p.m., and on [DATE] at 5 p.m., (10 doses). f. [MEDICATION(S)] (medication to control high blood pressure) tablet 20 mg one tablet on [DATE], [DATE], [DATE], [DATE], and [DATE] at 9 a.m., (5 doses). During a telephone interview on [DATE] at 10 a.m., MD 1 he stated he did not recall if the licensed nurses had informed him Resident 1 had repeatedly refused to take medications. A review of the facility's policy and procedure, titled Change in Resident's Condition and Status, dated ,d+[DATE] indicated the following: l. The nurse would notify the resident's Attending Physician or physician on call when there had been a significant change in the resident's physical/emotional/mental change in condition; refusal of treatment or medications two or more consecutive times, need to transfer the resident to a hospital/treatment center. 2. Prior to notifying the Physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider. 3. Unless otherwise instructed by the resident, a nurse would notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status and the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the facility's policy and procedure, titled Clinical Protocol Acute Clinical Changes, dated ,d+[DATE], indicated the physician would help identify individuals with a significant risk for having acute changes of condition. The policy indicated the nurse should assess and document/report the following baseline information: a. Vital signs; b. Neurological status; d. Level of consciousness; e. Cognitive and emotional status; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, et j. All active diagnoses; and k.All current medications. The policy indicated direct care staff, including nursing assistants would be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. The policy indicated nursing staff would contact the physician based on the urgency of the situation. The policy indicated for emergencies, the staff would call or page the physician and request a prompt response (within approximately one-half hour or less).

Based on observation, interview, and record review the facility failed to establish records of receipt, maintain accurate records of receipt and disposition (disposal), and maintain accurate counts of a medications to prevent [MEDICAL CONDITION] for 2 of 12 sampled residents (Residents 1 and 7), by failing to: a. Assure that the medication [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) was available to meet the needs of the resident. The licensed nurses failed to reorder a routine regularly scheduled medication, [MEDICATION NAME], for a resident who was to receive it twice a day. The investigation confirmed the resident had been without the [MEDICATION NAME] medication for three days, and missed three doses. This failure resulted in the resident complaining he had several [MEDICAL CONDITION]. The onset of the [MEDICAL CONDITION] make the resident feel fearful that by not taking his [MEDICATION NAME] he would have another [MEDICAL CONDITION] and possibly die. b. Ensure the medication count and documentation on the Medication Administration Record for Resident 1, who was to receive 4 medications to control his [MEDICAL CONDITION], ([MEDICATION NAME], Levetiracetam, [MEDICATION NAME] Extended Release, and [MEDICATION NAME]) accurately reflected the amount remaining in the medication bubble packs (packing medications, where each dose of medication is placed in a small plastic bubble and backed by a sheet of foil) were consistent with the licensed nurse's signature who administered the medications. Findings: a. A review of Resident 7's Face Sheet indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's History & Physical dated 5/10/19 indicated the resident has the capacity to understand and make decisions. A review of Resident 7's MDS (standardized assessment and care screening tool) dated 10/01/18, indicated Resident 7's cognition (mental process of acquiring knowledge and understanding) was intact and the resident had no mental impairment (a physical or mental defect). The MDS (a standardized assessment and care-screening tool) indicated Resident 7 required assistance with mobility and transferring. During an interview on 7/10/19 at 11:25 AM, Resident 7 stated his [MEDICAL CONDITION] medication had not been available since 7/9/19 and this was not the first time this has happened. Resident 7 stated he went to an appointment at the Veterans Administration (VA) hospital and was given a 90-day supply of [MEDICATION NAME] (medication used to prevent [MEDICAL CONDITION]) because his medical doctor did not trust the (skilled nursing), facility would provide it to him. Resident 7 stated the facility staff took his 90-day supply of [MEDICATION NAME] and now cannot find the medication. Resident 7 stated he had two [MEDICAL CONDITION] that morning and was accused by a certified nursing assistant (CNA) of throwing himself out of bed. Resident 7 stated the medication nurse told him they did not know when his medication would arrive. Resident 7 stated he feared they would not get the medication and he would continue to have [MEDICAL CONDITION], which could be deadly. A review of the physician's orders [REDACTED]. During an observation on 7/10/19 at 11:45 AM, Licensed Vocational Nurse 3 (LVN 3) opened the medication cart to look for Resident 7's medication. The morning medication drawer only had three resident specific bubble packs (prepackaged medication) of Xarelto (blood thinning medication). The evening medication drawer had no resident specific medication bubble packs and the narcotic drawer had an empty bubble pack of Resident 7's [MEDICATION NAME]. The pharmacy label on Resident 7's [MEDICATION NAME] indicated the pharmacy dispensed 28 tablets of [MEDICATION NAME] 200 milligrams on 6/21/19. The label read, Take one tablet by mouth twice a day. According to the directions, this medication ran out on 7/5/19. A review of Resident 7's Medication Administration Record (MAR) for (MONTH) 2019, indicated Resident 7 did not receive scheduled [MEDICATION NAME] doses on 7/6/19 at 8 AM, 7/9/19 at 5 PM, and 7/10/19 at 8 AM. During a concurrent interview and record review on 7/10/19 at 11:45 AM, LVN 1, a medication nurse, stated Resident 7's [MEDICATION NAME] ran out yesterday and she faxed the refill request to pharmacy on 7/9/19 at 7:50 AM. LVN 1 stated she did not document the refill request in the resident's medical record. LVN 1 stated Resident 7 did not receive his doses of [MEDICATION NAME] as ordered on [DATE] at 8 AM, 7/9/19 at 5 PM, and 7/10/19 at 8 AM. A review of the MAR with an administration time on 7/10/19 at 8 AM for [MEDICATION NAME] documented the dose as refused by the resident. LVN 1 stated she circled her initials on the medication sheet as if the resident refused the [MEDICATION NAME]. LVN 1 added the medication was not available and the resident did not refuse. LVN 1 stated she did not document in notes that medication was not available. LVN 1 also stated another licensed nurse would interpret her documentation as the resident refusing his morning dose of [MEDICATION NAME]. LVN 1 stated Resident 7 informed her that another staff member (unnamed) took the medication, he received from the VA, but no one can locate it. LVN 1 stated the resident needs his [MEDICATION NAME], it is a critical medication, without the medication, the resident could have [MEDICAL CONDITION] which are life threatening. LVN 1 stated the resident report having had a [MEDICAL CONDITION] that morning. During a concurrent interview and record review on 7/10/19 at 11:48 AM, the DON stated Resident 7's [MEDICATION NAME] was missing (date not indicated). The DON stated [MEDICATION NAME] is a narcotic and a critical medication that prevents [MEDICAL CONDITION]. [MEDICATION NAME] has a short half-life (the time it takes the drug in the body will be half of the starting dose) and if the resident does not have it within a certain amount of time, he will begin to have [MEDICAL CONDITION]. During an interview on 7/11/19 at 12:53 PM, the Attending Physician 1 (AP 1) stated he was never notified by the facility or the pharmacy that Resident 7 was in need of [MEDICATION NAME] or that the resident did not receive doses on 7/9/19 at 5 PM or 7/10/19 at 9 AM. AP 1 stated the resident has a history of breakthrough [MEDICAL CONDITION] (suddenly experiences a [MEDICAL CONDITION]) and needs to continue to take his medication regularly. AP 1 stated he never received a call asking for authorization to use [MEDICATION NAME] supplied by the VA and was not even aware the VA gave Resident 7 the [MEDICATION NAME] during his last visit. During an interview on 7/11/19 at 12:56 PM, the DON stated Resident 7's [MEDICATION NAME] arrived last night and the resident received his PM dose on 7/10/19. The DON stated they located the [MEDICATION NAME] bottle from the VA and it is now in the narcotic drawer. The DON stated she did not know who located the bottle of [MEDICATION NAME]. During an interview on 7/11/19 at 12:58 PM, Licensed Vocational Nurse 6 (LVN 6) stated the resident brought in the [MEDICATION NAME] after a VA appointment on 7/1/19. She took the medication from the resident and placed it in the narcotic drawer. LVN 6 stated she did not document the receipt of the medication or create a log. LVN 6 stated she placed the [MEDICATION NAME] bottle in the drawer sealed. She did not know who opened the seal on the bottle of [MEDICATION NAME], but it is as if someone used the medication. LVN 6 stated she did not call the doctor to inform him about the receiving the [MEDICATION NAME] or for an order to use it. During a concurrent interview and record review on 7/11/19 at 1:30 PM, the DON stated she had the Record of Controlled Substance forms placed in MAR today. There was no form completed for the [MEDICATION NAME] and the DON instructed LVN 5 to complete the form. The DON stated the Record of Controlled Substance form was incorrect. There form did not have the signature or date from nurse who received the medication or that Resident 7's medication came from the V[NAME] The DON stated the nurse should have completed the form properly but probably did not know how. The DON stated last night LVN 5 found the bottle of [MEDICATION NAME] during her shift. The DON did not know where the LVN 5 found it. During an interview on 7/12/19 at 8:02 AM, LVN 5 stated Resident 7 told her he had not received some doses of his [MEDICATION NAME]. LVN 5 stated she did not know the VA gave Resident 7 a bottle of [MEDICATION NAME]. LVN 5 stated LVN 6 told her that morning (7/12/19) the bottle of [MEDICATION NAME] was in the back of narcotic drawer. LVN 5 stated when she looked she did not recall seeing the bottle of [MEDICATION NAME] there before. LVN 5 stated the bottle was open, so they did a count and there were 59 pills in it. LVN 5 stated LVN 6 then brought out a Record for Controlled Substances form and they wrote the number 59. LVN 5 stated she had no experience with this sheet and had no idea how to fill it out. She did not know she had to sign it or write the date and time. LVN 5 stated [MEDICATION NAME] is a [MEDICAL CONDITION] medication and it is very important the resident receive it. LVN 5 stated she refills the order when there is less than 3 days left, but did not know the facility's policy. A review of the facility's undated policy titled, Preparation and General Guidelines IIA7: Controlled Medications (undated) indicated reorder the controlled medications when a seven-day supply remains. A review of Record of Controlled Substances form on 7/11/19 indicated 90 [MEDICATION NAME] pills were in the facility's possession. There was no signature or date of receipt of the [MEDICATION NAME] on the form. A review of the updated Record of Controlled Substances provided by the facility on 7/12/19 listed 58 [MEDICATION NAME] pills as being in the facility's possession. This was 32 pills less than the day before. During a concurrent interview and record review on 7/12/19 at 9:34 AM, the DON stated the Record of Controlled Substances form with the last entry on 7/11/19 showed the count as 58, the prior count was 90. The DON did not know how the count went from 90 to 58 in a matter of hours. The DON asked LVN 6 to explain the discrepancy. LVN 6 stated the Record of Controlled Substances master copy sheet used to make copies has three columns with 30 spaces, in each column. The master copy had the number 30 circled indicating there were 30 pills in the facility's possession. The DON stated this could lead to an inaccurate medication count. A review of the facility's policy titled Medication Storage in The Facility ID3: Controlled Medication Storage (undated), indicated a controlled medication accountability record must be created, kept in MAR, and include information such as: Name of resident, prescription number, name, strength, and dosage form of medication, date received, quantity received, and name of person receiving medication supply. The policy indicated inventory of controlled substances should be done at each shift, conducted by two nurses, and documented in medication accountability record. The policy indicated any discrepancy must be reported immediately and if a major discrepancy or pattern of discrepancy occurs administration and pharmacy need to be notified immediately. b. A review of Resident 1's Face Sheet indicated an admission to the facility on [DATE]. The [DIAGNOSES REDACTED]. A review of Resident 1's Physician order [REDACTED]. 1. [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 300 milligrams (mg), give one capsule by mouth (PO) twice a day (BID) for [MEDICAL CONDITION] (disease of one or more peripheral nerves, typically causing numbness or weakness). 2. [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 600 mg, give one tablet PO at bedtime (Q HS) (indication not specified). 3. Levetiracetam (used to treat [MEDICAL CONDITION]) 500 mg, give three tablets PO twice a day (BID) for [MEDICAL CONDITION]. 4. [MEDICATION NAME] ER (used to treat [MEDICAL CONDITION]) 150 mg, give two capsules PO Q HS for [MEDICAL CONDITION]. 5. [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 300 mg, give two and 1/2 tablets PO Q HS for [MEDICAL CONDITION]. A review of Resident 1's Care Plan: [MEDICAL CONDITION] Disorder dated 6/10/19, indicated Resident 1 was at risk for injury and ineffective breathing patterns related to altered state and consciousness due to [MEDICAL CONDITION] activity. The care plan goal indicated Resident 1 would demonstrate a patent (open) airway and be free from injury if [MEDICAL CONDITION] occurs for 90 days. The approaches included to administer medications as ordered, note and chart frequency, time, involved body parts and length of [MEDICAL CONDITION] and notify the physician and responsible party, monitor Resident 1 for changes in level of consciousness and protect during [MEDICAL CONDITION]. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 6/12/19, indicated Resident 1 was able to communicate, cognitively intact, and required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. During an interview and concurrent record review of Resident 1's Medication Administration Record (MARs) for (MONTH) 2019 on 7/12/19 at 10:40 a.m., the Director of Nursing (DON) acknowledged the MARs had missing documentation and signatures. The DON stated the [MEDICATION NAME] 300 mg BID was not signed that it was given on 7/10/19 and 7/11/19 at 5 p.m. The [MEDICATION NAME] 600 mg Q HS was not signed that it was given on 7/10/19 and 7/11/19 at 9 p.m. The Levetiracetam 500 mg, 3 tablets, BID was not signed that it was given on 7/10/19 and 7/11/19 at 5 p.m., [MEDICATION NAME] ER 150 mg, 2 capsules PO Q HS was not signed that it was given on 7/10/19 and 7/11/19 at 9 p.m. The [MEDICATION NAME] 300 mg, 2.5 tablets Q HS was not signed as given on 7/10/19 and 7/11/19 at 9 p.m. The DON stated if the MARs were not signed, it meant the medications were not given. During an interview and concurrent record review, on 7/12/19 at 11:43 a.m., Licensed Vocational 7 (LVN 7) stated, while looking at Resident 1's MARs for (MONTH) 2019, that she was Resident 1's medication nurse on 7/11/19 during the 3 p.m. to 11 p.m. shift. LVN 7 stated she administered all of Resident 1's medications at 5 p.m. and 9 p.m. including [MEDICATION NAME], Levetiracetam, [MEDICATION NAME], and [MEDICATION NAME]. LVN 7 stated she did not get a chance to sign the MARs because she did not want to be late on giving other residents' medications. During an observation and concurrent interview on 7/12/19 at 1:20 p.m., the DON checked and counted the number of medications remaining in the evening and night bubble packs of [MEDICATION NAME] 300 mg, [MEDICATION NAME] 600 mg, Levetiracetam 500 mg, [MEDICATION NAME] ER 150 mg, and [MEDICATION NAME] 300 mg and reconciled it with the MARs. The DON stated the counts for [MEDICATION NAME], Levetiracetam, [MEDICATION NAME] and [MEDICATION NAME] did not match the counts documented on the MARs. The DON stated the licensed nurses were popping the medication bubble packs randomly instead of following the designated days on the bubble pack. According to the DON, the medication count and documentation on the MARs should be consistent and accurate. A review of the undated facility's policy and procedures titled Medication Administration - General Guidelines indicated the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. The policy indicated the resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature in the space provided. On 7/12/19 at 4:20 PM., the Department informed the skilled nursing facility administrator about the Immediate Jeopardy (IJ) situation at the skilled nursing facility. The IJ included the facility's failure to have systems in place to conduct post assessments after a resident was found on the floor and reported having a [MEDICAL CONDITION], notify the physician that Resident 7 reported having a [MEDICAL CONDITION], follow physician orders [REDACTED]. medications. On 7/14/19 at 2:35 p.m., while onsite the surveyor verified and confirmed the Immediate Jeopardy was removed. The administrator presented an acceptable plan of correction. The plan of correction included: In-services given by the Director of Nurses, Clinical consultant, Pharmacy Staff, to the licensed nurses regarding: 1. [MEDICAL CONDITION] assessments, Plan of care, Change of condition and physician notification, emphasizing on post-assessment for [MEDICAL CONDITION], and obtaining and following physician's orders [REDACTED]. 2. Medication administration, notifying the physician of missing medication and doses not given, accurate documentation on the Medication Administration Record (MAR), focusing on refusals and missing doses, reordering medications timely, and faxing or calling the pharmacy to reorder medications. Medication cycles are delivered 48 hours prior to the utilization. The medications are checked by the pharmacy staff and licensed nurse. Missing medication are from the monthly cycle are called to the pharmacy immediately. Understanding the implication of delayed significant medication and following the facility's policy and procedures. 3. The pharmacy staff completed a triple check audit on the four medication carts and a triple check on all of Resident 7's medications.

Based on interview, and record review the facility failed to provide significant change in assessments for 1 of 13 sampled residents (Resident 1) with [MEDICAL CONDITION] disorder (episodes of uncontrolled electrical activity in the brain can cause changes in your behavior, movements or feelings, or level of consciousness) by failing to provide an accurate assessment and documentation after Resident 7 reported having a [MEDICAL CONDITION] on 7/2/19, 7/8/19, 7/10/19, 7/12/19 and 7/13/19. This failure resulted in Resident 7 complaining he had several (5) [MEDICAL CONDITION]. The onset of the [MEDICAL CONDITION] made the resident feel fearful that the licensed staff did not believe he had [MEDICAL CONDITION] and by not taking his [MEDICATION NAME], he would have another [MEDICAL CONDITION] and possibly die. Cross Reference: F755 Findings: A review of Resident 7's Face Sheet indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 7's History & Physical dated 5/10/19 indicated the resident has the capacity to understand and make decisions. A review of Resident 7's MDS (standardized assessment and care screening tool) indicated Resident 7's cognition (mental process of acquiring knowledge and understanding) dated 10/01/18, was intact and the resident had no mental impairment (a physical or mental defect). The MDS (a standardized assessment and care- screening tool) indicated Resident 7 required assistance with mobility and transferring. A review of Resident 7's care plan started on 5/19/19, for being at risk for injury and ineffective breathing patterns related to [MEDICAL CONDITION]. The interventions included administering [MEDICATION NAME] as ordered and monitor for change in level of consciousness. A review of Resident 7's care plans dated 7/3/19, 7/8/19, and 7/10/19 indicated a problem of found on ground by bed and recent falls. The care plan interventions included to assess for presence of injury and notifying the appropriate parties. The care plan indicated Resident 7 had no concerns for [MEDICAL CONDITION]. A review of Resident 7's Interdisciplinary Team (IDT, a team of health care professions, who work together to establish plans of care for residents) conference record dated 7/3/19, indicated a meeting was held due to Resident 7 having unsteady gait (poor balance when walking), a medical condition (not specified which one), and poor safety judgement. The IDT meeting did not discuss Resident 7's [MEDICAL CONDITION] episodes. The IDT recommendations included frequent visual checks and reminding Resident 7 to use the call light. A review of Resident 7's IDT Conference record dated 7/8/19 indicated a meeting due to the resident falling and reporting having [MEDICAL CONDITION]. The IDT recommendations included floor mats, call lights within reach, and side rails, which the resident refused due to his preference to have grab bars (a support bar to assist a person get off the toilet or assist out of the shower). The attending physician was not present for the meeting. The care plan indicated Resident 7 had no indications for [MEDICAL CONDITION]. A review of Resident 7's IDT Conference records dated 7/9/19, indicated a meeting due to a fall, but there was no indication of the resident's [MEDICAL CONDITION] episodes. The attending physician was not present for meeting. The IDT did not update the care plan to include the resident's episode of [MEDICAL CONDITION]. A review of Resident 7's IDT Conference records dated 7/10/19 indicated another meeting due to another fall, but there was no indication of the [MEDICAL CONDITION] episodes. The attending physician was not present for the meeting. The IDT did not update the care plan to include the resident's episode of [MEDICAL CONDITION]. A review Resident 7's Situation Background Assessment and Recommendation (SBAR- a framework for communication between members of the health care team about a resident's condition) dated 7/8/19 at 11:20 AM, indicated Resident 7 had an unwitnessed fall and Resident 7 had reported having had a [MEDICAL CONDITION] because he was cold. The SBAR indicated the nurse did not notify the physician. A review of Resident 7's SBAR dated 7/10/19 at 11:48 AM indicated Resident 7 had another unwitnessed fall on 7/10/19 at 8:14 AM. During an interview on 7/10/19 at 11:25 AM, Resident 7 stated his [MEDICAL CONDITION] medication had not been available since 7/9/19 and this was not the first time this has happened. Resident 7 stated he went to an appointment at the Veterans Administration (VA) hospital (date not specified) and was given a 90-day supply of [MEDICATION NAME] (medication used to prevent [MEDICAL CONDITION]) because his medical doctor did not trust the (skilled nursing) facility would provide it to him. Resident 7 stated the facility staff took his 90-day supply of [MEDICATION NAME] and now cannot find the medication. Resident 7 stated he had two [MEDICAL CONDITION] that morning (7/10/19) and was accused by a certified nursing assistant (CNA) of throwing himself out of bed. Resident 7 stated the medication nurse told him they did not know when his medication would arrive. Resident 7 stated he feared they would not get the medication and he would continue to have [MEDICAL CONDITION], which could be deadly. During a concurrent interview and record review on 7/10/19 at 11:48 AM, the Director of Nursing (DON) stated Resident 7 reported having had a [MEDICAL CONDITION] that morning (7/10/19). The SBAR dated 7/10 19 at 8:14 AM indicated an unwitnessed fall occurred and the physician was notified of the fall. There was no mention of [MEDICAL CONDITION]. The DON stated the [MEDICAL CONDITION] episode was documented as fall because it was unwitnessed by a nurse. During a concurrent interview and record review on 7/10/19 at 11:48 AM, the DON stated the SBAR dated 7/8/19 at 11:20 AM, which indicated an unwitnessed fall was not properly completed. The DON was not sure if the nurse notified the physician. During an interview on 7/10/19 at 2:33 PM, Licensed Vocational Nurse 1 (LVN 1) stated she had not called the physician to notify him about Resident 7's reported [MEDICAL CONDITION] episode. During an interview on 7/11/19 at 12:53 PM, Attending Physician 1 (AP 1) stated the nurse notified him on 7/10/19 and 7/8/19 regarding Resident 7 falling. AP 1 stated he was told each instance was an unwitnessed fall and he had specifically asked if the resident had a [MEDICAL CONDITION] or reported he had a [MEDICAL CONDITION] on 7/10/19. AP 1 stated the response he got from the nurse was the Certified Nurses' Assistant (CNA) said the resident threw himself off the bed and the resident did not report a [MEDICAL CONDITION] episode. A review of Resident 7's Nurses Note, dated 7/12/19 at 6:30 AM, documented as a late entry indicating the staff found Resident 7 lying on the floor mat at his bedside. The note did not indicate if the resident had a [MEDICAL CONDITION]. A review of Resident 7's Physician order [REDACTED]. A review of Resident 7's Medication Administration Record [REDACTED]. During an interview on 7/13/19 at 3:55 PM, Resident 7 stated he fell on [DATE] and early in the morning on 7/13/19. The resident stated he had a [MEDICAL CONDITION] that morning (7/13/19) because he was cold and being cold is one of his triggers for [MEDICAL CONDITION]. Resident 7 stated he had been calling for the CNA to close the window and cover him, but the CNA ignored the call light. Resident 7 stated he yelled for assistance, but there was no response. Resident 7 identified his triggers for [MEDICAL CONDITION] episode as getting cold, flickering lights, pump alarms, trauma (unspecified), and stress. Resident 7 stated he informed the nurse and DON that he had a [MEDICAL CONDITION] that morning (7/13/19). During an interview on 7/13/19 at 4:20 PM, AP 1 stated the facility called him, that morning, to inform him that they found Resident 7 sitting on the floor mat, awake and alert with no injuries, and they would perform neurological checks over the next 3 days. AP 1 stated he was not told the resident reported a [MEDICAL CONDITION] episode. A review of the facility's policy titled [MEDICAL CONDITION] and [MEDICAL CONDITION] - Clinical Protocol with a revised date of (MONTH) 2012, indicated [MEDICAL CONDITION] assessments by nurse's should include documentation and reporting of the following: vital signs, neurological assessment, change in level of consciousness, any [MEDICAL CONDITION] activity in detail (location, duration, severity, recurrence, etc.), and injury occurring with [MEDICAL CONDITION]. A review of the facility's policy titled Charting and Documentation with a revised date of (MONTH) 2008, indicated all observations, medications administered, etc. must be documented in resident's clinical records. The policy indicated all accidents or changes in condition must be recorded. A review of the facility's policy titled Preparation and General Guidelines IIA2: Medication Administration - General Guidelines (undated), indicated if a dose of regularly scheduled medication is withheld an explanatory note needs to be entered on the reverse side of the MAR. On 7/12/19 at 4:20 PM., the Department informed the skilled nursing facility administrator about the Immediate Jeopardy (IJ) situation at the skilled nursing facility. The IJ included the facility's failure to have systems in place to conduct post assessments after a resident was found on the floor and reported having a [MEDICAL CONDITION], notify the physician that Resident 7 reported having a [MEDICAL CONDITION], follow physician orders [REDACTED]. medications. On 7/14/19 at 2:35 p.m., while onsite the surveyor verified and confirmed the Immediate Jeopardy was removed. The administrator presented an acceptable plan of correction. The plan of correction included: In-services given by the Director of Nurses, Clinical consultant, Pharmacy Staff, to the licensed nurses regarding: 1. [MEDICAL CONDITION] assessments, Plan of care, Change of condition and physician notification, emphasizing on post-assessment for [MEDICAL CONDITION], and obtaining and following physician's orders [REDACTED]. 2. Medication administration, notifying the physician of missing medication and doses not given, accurate documentation on the Medication Administration Record [REDACTED]. Medication cycles are delivered 48 hours prior to the utilization. The medications are checked by the pharmacy staff and licensed nurse. Missing medication are from the monthly cycle are called to the pharmacy immediately. Understanding the implication of delayed significant medication and following the facility's policy and procedures. 3. The pharmacy staff completed a triple check audit on the four medication carts and a triple check on all of Resident 7's medications.

Based on observation, interview, and record review, the facility failed to protect one of two sample residents (Resident 2) from physical abuse by failing to: a. Implement the plan of care for Resident 1's poor impulse control manifested by hitting others. b. Implement the facility's policy regarding abuse prevention. Resident 1 physically abused Resident 2, causing severe injuries to Resident 2's face, chest, and arms, resulting in severe pain to Resident 2 whenever care was provided. Findings: Record review indicated Resident 1 was 34- year old admitted to the facility on [DATE], and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. True [MEDICAL CONDITION] is a mood disorder, which can interfere with everyday life for an extended time); impulse disorder (resident manifested behaviors including: hitting, scratching, and pulling hair). A Minimum Data Set (MDS), a standardized assessment and care screening tool dated November 2, 2015 indicated Resident 1 was usually understood and usually able to understand others. Resident 1 required one person physical assist for activities of daily living including dressing, eating, toileting, and hygiene. An untitled care plan dated September 24, 2013, and reviewed on November 5, 2014 indicated Resident 1 had impaired cognition with manifested behaviors of scratching, hitting, pulling hair, and banging on the rails. Nursing interventions included: encouraging the resident to communicate using the letter board and always having two staff present during care. An untitled care plan dated April 19, 2013, indicated Resident 1 had poor impulse control manifested by hitting others. Nursing interventions included to provide frequent visual checks. Review of a Nurse ' s Note dated December 17, 2015 at 3p.m., indicated Resident 1 refused to remain in bed. According to the Nurse's Note Resident 1's bed was in the lowest position. Resident 1 used the stronger arm (the right arm) to log roll herself off of the bed and maneuver her body onto mattress located on the floor next to her bed. A review of the Social Services Progress Notes dated 12/2/15 indicated that nursing informed Social Services that Resident 1 was throwing things such as cups all over the place. Another Social Services Progress Notes dated 12/14/15 indicated an increased behavior of throwing things all over the place. The note indicated that Social Services talked to Resident 1 regarding the possibility of the roommate being hit by the things that Resident 1 was throwing all over the place. Record review indicated Resident 2 was 107-yrs old admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), a standardized assessment and comprehensive assessment and care screening tool, dated December 7, 2015, indicated Resident 2 was understood and able to understand others. The resident required extensive assistance with one person physical assist for activities of daily living. A review of an untitled care plan dated June 10, 2015, indicated Resident 2 had a potential for bleeding/bruising/skin tears secondary to aspirin and [MEDICATION NAME] (anticoagulant used to treat/prevent blood clots) use. An Interdisciplinary (IDT) Progress Note in Resident 2's clinical record dated December 25, 2015, at 9 a.m., indicated the licensed nurse from the 11 p.m. to 7 a.m. shift notified the registered nurse, (RN 1) regarding a resident to resident abuse. RN 1 assessed Resident 2 and found Multiple skin tears, 2 centimeters in length, scratches on the scalp and multiple discolorations along the right side of the face. An IDT Progress Note dated December 29, 2015 at 9 a.m., indicated Resident 2 was noted with multiple discoloration to the right side of her face, a right cheekbone skin tear measuring 2 centimeters (cm), a right lower jaw skin tear measuring 2cm, a right eyebrow skin tear measuring 2cm. Another IDT Progress Note dated December 29, 2015 at 8:45 a.m. indicated the certified nursing assistant CNA 2 was making rounds. Upon entering Resident 1 and 2's room, Resident 2 was observed making, Physical Contact, with Resident 1 and was separated from Resident 2. CNA 2 separated the residents and Resident 1 continued to Strike out and attempted to hit and kick staff. Resident 1 was noted to have three large rings on the right hand with moderate amounts of blood. Resident 2 had multiple discolorations, skin tears, bleeding and moderate swelling. The IDT progress note indicated the physician and family were notified of the incident. On December 29, 2015 at 2:17 p.m., Resident 2 was observed sitting in a wheelchair, with bruises (injuries appearing as areas of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on the left cheek. The entire right side of her face was bruised dark brown/black. On her right upper arm she had a dark red and black bruise. Her left arm had a black and red bruise towards the top of the elbow. The upper chest area under the neck had mild bruising. The left lower leg had a dry scab and some light bruising, the right lower leg had a dry scab, thin skin and no bruising. During an interview at the time of the observation, Resident 2 was asked about the incident, she was not able to narrate. When asked how she felt, she stated, It hurts referring to her face. During an interview on December 29, 2015 at 2:29 p.m., certified nursing assistant (CNA 1) stated she was assigned to care for Resident 2 often and that since the incident on December 25, 2015, Resident 2 Flinches like she's in pain whenever her face is being cleaned. CNA 1 narrated Residents 1 and Resident 2 were roommates. They both have low beds, and each had a mattress next to each other on the floor between their beds. She stated Resident 1 was able to pull herself to the floor, and Resident 2 sometimes flop from the bed over to the mattress on the floor. On December 29, 2015 at 2:57 p.m., Resident 1 was observed in a room by herself. She did not have a roommate. In an interview on December 29, 2015 at 3:10 p.m., Resident 1 communicated with an erasable board. Resident 1 wrote that Resident 2 called her a bad name. Resident 1 denied hitting Resident 2. On 12/29/15, at 3:40 p.m., a review of Resident 1's clinical record with registered nurse (RN1), there was no documentation of how frequently the visual checks were to be done. During an interview at the same time, RN 1 was not able to describe how frequently visual checks are done. RN 1 was not able to show documentation of frequent visual checks in Resident 1's clinical record. On May 6, 2016 at 1:40 p.m., during a telephone interview, CNA 2 stated she had gone on her break on the night of the incident and upon returning at about 4 am from her break time, she heard Resident 2 calling for help. She went to the residents' room and found both Residents 1 and 2 on the floor. She stated upon entering, Resident 1 was hitting Resident 2. Resident 1 had rings on her hand and she was hitting Resident 2 with that hand and the rings were covered with blood. CNA 2 stated she called another CNA and the licensed staff to help her separate the residents. Resident 1 continued to strike out and attempted to hit staff. On the same date, an attempt was made to interview the licensed vocational nurse (LVN 1) but LVN 1 was not available for interview. A review of an undated written statement by LVN 1 about the altercation that took place on December 25, 2015, indicated CNA 2 entered the residents' room at 4:33 a.m. after hearing shouts for help. Residents 1 and 2 were lying side by side on the floor mattresses. Resident 2 was holding her hands on her face, while Resident 1 hit Resident 2 with her right hand. Resident 2's hands had blood on them as she covered her face, and Resident 1's right hand had three rings covered with blood. Resident 2 complained of throbbing pain to the right side of her face. Review of the Abuse Policy, revised December 2011, indicated the facility will make every effort to identify events that may lead up to abuse situation including: staff will monitor residents with behaviors that may lead to abusive situations. An untitled care plan, for using rings as weapons, was created for Resident 1 on December 25, 2015. Nursing interventions included removing rings, bed in low position and bedside mattress. Resident 1's rings were removed following the incident with Resident 1. Another care plan for Resident 1's aggressive behavior towards other residents dated December 25, 2015, indicated nursing interventions including frequent visual checks for safety and maintaining a calm attitude. During an interview on 6/10/16, at 10:30 a.m., when asked about how frequent checks should be done, the Director of Nurses (DON) stated all staff was doing rounds every 2 hours. When asked where it is documented, he stated they do not document this activity. When asked to show the nursing progress notes from December 18 thru 25, 2016, the DON reviewed Resident 1 ' s record and stated there were no nursing notes for Resident 1 from December 18-25, 2015. There was no evidence staff implemented the plan of care for Resident 1's abusive behavior. There was no documented evidence the facility made every effort to identify events that may lead to abuse situation, in accordance with their policy. There was no documented evidence the Social Worker coordinated with nursing staff about Resident 1's escalating aggressive behavior to prevent abuse/aggression to Resident 2.