Every finding on record at Mid-Wilshire Health Care CNTR

Based on interview and record review, the facility failed to implement a comprehensive care plan for one of three sample residents (Resident 1). This deficient practice had the potential to result in delay of nursing care and medical interventions causing Resident 1's condition to worsen and possible hospitalization. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was readmitted on [DATE] (original admission date 10/21/2025). With diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), overactive bladder (uncontrolled urge to urinate). During a review of Resident1's Minimum Data Set (MDS- a resident assessment tool), dated 4/23/2026, the MDS indicated Resident 1 had a brief interview for mental status(BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 2 (severe problems with thinking and memory) and required assistance from the nursing staff with bathing and toileting. During a review of Resident 1's History and Physical (H&P - document detailing a patients current and past medical history), dated 5/4/2026, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. Resident 1 has an assigned surrogate as the decision maker (Family 1).During a review of Resident 1's nursing progress notes, dated 1/1/2026, the nursing progress note indicated Resident 1 experienced three episodes of watery, yellowish, loose stool. Resident 1's physician was notified on 1/1/2026. During a review of Resident 1's care plan (CP - a document that outlines a patients specific health need and the steps nurses will take to address such needs), dated 4/3/2026, the CP indicated a long-term CP of Risk for Constipation with a goal of Resident will pass a soft formed stool. The CP indicated two revision dates, on 2/21/2026 and 4/3/2026, for episodes of loose bowel movement (BM). The interventions for the CP indicated give lactulose (a laxative used to treat chronic constipation) by mouth one time a day for constipation, hold if loose stool. The CP indicated two revisions to interventions, hold for loose stool on 3/22/2026, and hold due to loose stool for 10 days on 4/10/2026.During a review of Resident 1's lab results, dated 4/4/2026, the lab results indicated a positive result for clostridium difficile (C. Diff - highly contagious bacterial infection in the large intestine that causes severe watery diarrhea) bacteria in the resident's stool sample. During an interview on 5/14/2026, at 1:45p.m. with Registered Nurse Supervisor (RNS), the RNS stated, care plans are done upon admission by MDS. The MDS develops long-term care plans. The short-term care plans or the change of condition is developed by the RNS, Charge Nurse (CN), or Licensed Vocational Nurse (LVN). The RNS stated if a resident has a new diagnosis such C. Diff the resident's medical chart must reflect a new CP specific to that diagnosis. The RNS stated a CP for C. Diff cannot be under a general CP like diarrhea. The RNS stated, C. Diff needs a specific CP in order to have specific goals and interventions that are unique to C. Diff. During an interview on 5/15/2026, at 11:42a.m. with Director of Nursing (DON), the [NAME] stated that all residents must have CP's initiated upon admission and as needed with any change of condition. The DON stated the baseline care plans are done within the first 48hrs. If a resident has special needs or upon a change of condition, the nurse must develop a care plan immediately to ensure that the condition is resolved and improves. The DON stated if the CP is not developed the residents condition may worsen due to delay in care. The DON stated there is no CP for C. Diff in Resident 1's medical chart, it is incorporated in the constipation and Small Bowel Obstruction care plan; this can cause some confusion for the nursing staff since the interventions are completely different. The DON stated it can cause the residents diarrhea to worsen and can lead to dehydration, malnutrition, altered mental status, and hospitalization. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Plan of Care, dated 6/2025, the P&P indicated the facility will implement a comprehensive plan of care that will maintain the residents' highest practicable physical, mental and psychosocial well-being. The comprehensive plan of care will address the residents' individual needs.

Based on interview and record review, the facility failed to administer/hold medications per physicians' orders for one of three sampled residents, (Resident 1). This deficient practice had the potential to worsen Resident 1's condition, placing them at risk for electrolyte (essential minerals) imbalance, dehydration (a condition where the body loses more fluids that it takes in), hospitalization and death. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was readmitted on [DATE] (original admission date 10/21/2025). With diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), overactive bladder (uncontrolled urge to urinate). During a review of Resident1's Minimum Data Set (MDS- a resident assessment tool), dated 4/23/2026, the MDS indicated Resident 1 had a brief interview for mental status(BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 2 (severe problems with thinking and memory) and required assistance from the nursing staff with bathing and toileting. During a review of Resident 1's History and Physical (H&P - document detailing a patients current and past medical history), dated 5/4/2026, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. Resident 1 has an assigned surrogate as the decision maker (Family 1).During a review of Resident 1's nursing progress notes, dated 1/1/2026, the nursing progress note indicated Resident 1 experienced three episodes of watery, yellowish, loose stool. Resident 1's physician was notified on 1/1/2026, order to hold lactulose (medication that treats constipation) /senna (medication that treats constipation) if pt continues to have diarrhea, continue to monitor closely. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/2026, the MAR indicated lactulose was administered on 1/1/2026, and on 1/2/2026 after having multiple loose stools.During an interview on 5/14/2026, at 1:45p.m. with Registered Nurse Supervisor (RNS), the RNS stated, if someone is having diarrhea laxatives or stool softeners cannot be given. If a resident is experiencing loose stool all laxatives must be held until loose stool stops. The RNS stated according to the MAR in January, Resident 1 received Lactulose and Colace (medication that treats constipation by softening stool) after loose stools began.During an interview on 5/15/2026, at 11:42a.m. with Director of Nursing (DON), the [NAME] stated if a resident is having loose stool, they are not to be given lactulose. Lactulose will make the loose stool worse and places the resident at risk for dehydration, electrolyte imbalance, weight loss, and altered mental status. The DON stated if the physician orders for medications to be held and they are given; it is considered that the physicians orders are not being followed. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 2023, the P&P indicated that medication shall be administered per Physicians orders, and if there is a concern with the medication and the administration of the medication due to a residents condition, the medication will be clarified with pharmacy.

Based on interview and record review, the facility failed to follow up on assisting the residents with executing an advance directive (AD - a legal document indicating resident preference on end-of-life treatment decisions) for three of four sampled residents (Resident 2, 5, and 19). This failure had the potential to result in the residents' wishes regarding treatment and care needs not being met. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including but not limited to atherosclerotic heart disease (the hardening and narrowing of arteries due to plaque buildup), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and high blood pressure. During a review of Resident 2's History and Physical (H&P), dated 12/4/2025, the H&P indicated Resident 2 had the mental capacity to make their own decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), the MDS indicated Resident 2's mental status was moderately impaired and had not executed an AD . During a review of Resident 2's medical record, the AD acknowledgement form, dated 12/2/2025, indicated the AD acknowledgement form indicated Resident 2 wanted to execute an AD. The medical record did not indicate any follow up regarding assisting Resident 2 with AD. During an interview on 3/10/2026 at 11:00 a.m. with Resident 2, Resident 2 stated he wanted to execute an advance directive but has not done so. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was readmitted on [DATE] (original admission 7/13/2022) with diagnoses including but not limited to end stage renal disease (a kidney disease in which the kidneys can no longer function), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and neuromuscular dysfunction of bladder (a condition where nerve damage or disease causes loss of bladder control). During a review of Resident 5's History and Physical (H&P), dated 6/28/2025, the H&P indicated Resident 5 had the mental capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), the MDS indicated Resident 5's mental status was moderately impaired and had not executed an AD . During a review of Resident 5's medical record, the AD acknowledgement form, dated 11/7/2025, indicated Resident 5 wanted to execute an AD. The medical record did not indicate any follow up regarding assisting Resident 5 with AD. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was readmitted on [DATE] (original admission 7/16/2023) with diagnoses including but not limited to DM, vascular dementia (a disorder with reduced blood flow to the brain which cause memory loss and problems with thinking and behavior), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter waste). During a review of Resident 19's History and Physical (H&P), dated 9/2/2025, the H&P indicated Resident 19 did not have the mental capacity to understand and make decisions. During a review of Resident 19's MDS, the MDS indicated Resident 19's had not executed an AD . During a review o f Resident 19's medical record, the AD acknowledgement form, dated 8/31/2024, indicated Resident 19's Representative wanted to execute an AD. The medical record did not indicate any follow up regarding assisting Resident 19 with AD. During an interview on 3/10/2026 at 11:25 a.m. with Social Services Director (SSD), SSD stated AD acknowledgment forms are done on admission. SSD stated a copy of the AD is placed in the physical chart and uploaded to the electronic health record, if the resident has not executed an AD and wished to execute an AD, there is a lengthy process that involves the resident's family, a notary, and the Ombudsman. SSD stated in the two years working at this facility they have not experienced a resident expressing interest in executing an AD if they have not executed one at time of admission. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated February 2017, Reviewed June 2025, the P&P indicated if a resident has not executed an AD and wishes to execute one, the facility can obtain forms for AD from the state nursing facility association or state medical association, and should contact the facility's legal department representative if assistance is needed. P&P indicated the facility will document and maintain record in the clinical record regarding the provision of AD information.

Based on interview and record review, the facility failed provide education regarding risk and potential side effects of COVID 19 vaccine for five of five sampled residents (Resident 2, 14, 31, 36, and 58) and provide a declination form for all staff members declining COVID-19 vaccine boosters. These failures had the potential to affect the residents, residents' representatives, and staff's ability to make informed decisions regarding the COVID-19 vaccine.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on 12/ 02/2025 with diagnoses including but not limited to atherosclerotic heart disease (the hardening and narrowing of arteries due to plaque buildup), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and high blood pressure. During a review of Resident 2's COVID-19 booster vaccine (2025 - 2026 formula) consent form dated 12/03/2025, the COVID-19 consent form indicated Resident 2 did not give consent to receive the COVID-19 booster vaccine. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted on [DATE] with diagnoses including but not limited to encephalopathy (a brain dysfunction caused by infection, disease, or toxins), pneumonitis (swelling of the lung tissue), and dysphagia (difficulty swallowing). During a review of Resident 14's COVID-19 consent form dated 09/23/2025, the COVID-19 consent form indicated Resident 14 gave consent to receive the COVID-19 booster. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was readmitted on [DATE] (original admission date 1/31/2017) with a diagnoses including but not limited to type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter waste). During a review of Resident 31's COVID-19 consent form dated 9/11/2025, the COVID-19 consent form indicated Resident 31 gave consent to receive the COVID-19 booster. 1d. During a review of Resident 36's admission record, the admission Record indicated Resident 36 was admitted on [DATE] with diagnoses including but not limited to dementia (decline in mental function), hyponatremia (low blood sodium levels) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 36's COVID-19 consent form dated 9/09/2025, the COVID-19 consent form indicated Resident 36 gave consent to receive the COVID-19 booster. During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was admitted on [DATE] (original admission date 2/21/2022) with diagnoses including but not limited to urinary tract infection (UTI - an infection in the bladder/urinary tract), dysphagia (difficulty swallowing), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 58's COVID-19 consent form dated 9/08/2025, the COVID-19 consent form indicated Resident 58 gave consent to receive the COVID-19 booster. During an interview on 3/11/2026 at 10:20 a.m. with Director of Staff Development (DSD), DSD stated vaccine consent forms are completed at the time of admission by Social Services Director (SSD), if residents have any questions regarding immunizations the nursing staff will follow up and speak to the resident or the family. DSD stated a COVID-19 information sheet is provided to the residents or Resident Representative (RP), but it does not specify the side effects (unwanted or unexpected symptoms) that can occur after administration of the COVID-19 vaccine. DSD stated it is important to provide education regarding vaccine side effects, to residents and RP, in case a resident experiences unwanted vaccine reactions; they know what steps to take. DSD stated the facility only provides printed vaccination education in English.During a review of facility's staff vaccination records, the vaccination records did not indicate the facility provided and maintained vaccination declination forms for employees that have declined vaccinations.During an interview on 3/12/2025 at 3:18pm with DSD, DSD stated the facility does not collect vaccine declination forms to their employees. DSD stated it is important to have declination forms in case employees are exposed to infection. DSD stated keeping staff educated on vaccinations/vaccine boosters can help protect residents and the facility from possible disease outbreaks.

Based on observation interview and record review, the facility failed to provide treatment in accordance with professional standards of practice and established facility protocol for one of five sampled residents (Resident 77) for: a. The use of triple antibiotic ointment (topical antibiotic cream or ointment used to treat skin infections) without a physician order or monitoring every shift for seventy-two-hours for Resident 77. This failure had the potential to result in delayed treatment and compromised resident safety.During a record review of Resident 77's admission record indicated Resident 77 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bone) of pelvis (located at the lower part of the trunk), hyperlipidemia (abnormally high levels of fats in the blood), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 77's History and Physical (H&P), dated 3/3/2026, the H&P indicated, Resident 77 has the capacity (ability) to understand and make decisions. During concurrent observation and interview on 3/10/2026 at 9:48 a.m. in Resident 77's room. It was observed Resident 77 walking with a walker from the bed to the door with clean and dry dressing on the back of the left knee. Resident stated that she has a few skin tears that are being treated at the facility. During a review of Resident 77's Order Summary Report (OSR) dated 3/12/2026, the OSR included the following orders: Ordered on 3/5/2026, skin tear on back of left knee on admission: cleanse with normal saline pay dry, apply triple antibiotic ointment (topical medication used to prevent and treat minor skin infections), cover with dry dressing. Ordered on 3/5/2026, skin tear on Right ankle on admission: cleanse with normal saline pat dry, apply triple antibiotic ointment, cover with dry dressing. During an interview and record review on 3/11/2026 at 8:59 a.m. with Treatment Nurse (TXN), Resident 77's Treatment Administration Record (TAR) and physicians' orders were reviewed. TXN stated that Resident 77 has been receiving triple antibiotic ointment for skin tears. TXN stated that no physician order was placed for the triple antibiotic ointment and stated that the order was not required because the Director of Staff Development (DSD) supplied the ointments. TXN further reported that an initial assessment was performed on 03/05/2026; however, they had not yet documented it. TXN stated that treatment staff focus on wound care only and that TXT is not responsible for documenting wound progress. During a concurrent interview and record review on 3/11/2026 at 1:15 p.m. with the Director of Nursing (DON), Resident 77's OSR was reviewed. The DON stated that treatment nurses should assess skin on admission, weekly, and with significant changes; measure and document wounds; follow physician-ordered treatments; and inform physicians of new or worsening wounds. The DON further stated that triple antibiotic ointment is classified as an antibiotic and therefore requires a physician's order and ongoing monitoring. However, Resident 77 did not have an order for the triple antibiotic ointment. The DON emphasized that all antibiotics required a prescription and must be monitored by the nursing staff every shift. The DON stated that the treatment nurse should have contacted Resident 77's physician to obtain an order for the triple antibiotic ointment and documented in the nursing progress notes. During a review of the facility's policy and procedures (P&P) titled, Skin Breakdown, Prevention and Management dated 6/2025, indicated a description of the resident's skin condition will be included in the nursing documentation upon admission and every shift for seventy-two hours. The licensed nurse will notify the independent licensed practitioner for anu sites or area that requires any form of treatment.

Based on observation, interview and record review, the facility failed to ensure the nursing staffing information was posted and updated daily. This failure resulted in the total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors. Findings: During an observation on 3/10/2026 at 9:30 a.m. in nurse's station one, the nursing staffing information was not posted the bulletin board. During an observation on 3/10/2026 at 9:31 a.m. in nurse's station two, the nursing staffing information was not posted the bulletin board. During an interview on 3/11/2026 at 10:00 a.m. with the Director of Staff Development (DSD), DSD stated the required staffing information was not posted on a bulletin board for residents, staff, and visitors to view. The DSD stated the census and direct care service hours per patient day (DHPPD) form was kept in a binder at the nurse's station, and a blank form was posted directing individuals to the binder. The DSD stated staffing information should be posted on a bulletin board to ensure accessibility and awareness of staffing hours needed to meet resident care needs.

Based on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage practices in the kitchen when:1. A box of bananas were sitting next to an open container labeled Sanitizer disinfectant.2. A plastic container of barley in the dry storage area had no date label.3. A large clear plastic bag filled with chopped cabbage mixed with red pepper flakes with no label or date.These failures had the potential to result in cross contamination (transfer of harmful bacteria from one place to another) and an increased risk of foodborne illness (any illness resulting from eating contaminated or spoiled food) to residents.Findings:During an observation on 3/9/2026 at 7:30 a.m. under the kitchen sink, a box of bananas were sitting next to a small, open red container labeled Sanitizer disinfectant halfway filled with clear liquid.During an observation on 3/9/2026 at 7:35 a.m. in the dry food storage area, a container of barely had no date label.During an observation on 3/9/2026 at 7:40 a.m. in the walk-in refrigerator, a large clear plastic bag filled with chopped cabbage mixed with red pepper flakes had no label or date.During an interview on 3/10/2026 at 12:45 p.m. with the Dietary Supervisor (DS), the DS stated that if food stored in the kitchen is not labeled properly or is placed near sanitation chemicals, the residents are at risk of getting sick.During a record review of the facility's policy and procedure (P&P) titled, Food Storage Principles, dated April 2020, the P&P indicated that food must have a label with the expiration date, date of receipt, or when the item was stored after preparation. The P&P also indicated that cleaning supplies should be stored away from food storage.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated food shall be stored in a clean, dry location where it is not exposed to splash, dust, or other contamination.

Based on observation, interview, and record review, the facility failed to: 1.Perform hand hygiene for seven of seven sampled residents (Resident 5, 8, 9,19, 22, 59, and 70).2.Wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) in enhanced barrier precautions (EBP - infection control strategy requiring staff to use gowns and gloves during high-contact care for residents) rooms for four of four sampled residents (Resident 5, 9, 59, and 70). 3.Prevent cross-contamination during medication administration.4.Implement an effective Infection Prevention and Control Program (IPCP - a program designed to prevent healthcare-associated infections and antimicrobial resistance through education, policies, and surveillance).5.Implement the facility's water plan.These failures had the potential to result in contamination, the spread of infectious diseases, and antibiotic-resistant bacteria to the residents.Findings:1. and 2. During record review of Resident 70's order summary report dated 3/12/2026, the order summary report indicated Resident 70 is on EBP for history of multi drug resistant organism (MDRO - germs that have become resistant to multiple antibiotics). During an observation on 3/9/2026 at 12:14 p.m. in front of Resident 70's room, Certified Nursing Assistant (CNA) 4 entered and exited Resident 70's room without performing hand hygiene (HH) and without putting on PPE.During an observation on 3/10/2026 at 9:37 a.m. in front of Resident 8, 22, and 19's room, RN 2 went in and out of the room to administer medications without performing HH.During an observation on 03/11/2026 at 8:16 a.m. CNA 5 exited EBP room for Resident 5, 9, and 59 without performing hand hygiene (HH) and then entered Resident 8, 19, and 22's room without performing HH.During an observation on 3/11/2026 at 8:36 a.m. LVN 3 administered medications in EBP room for Resident 5, 9, and 59 without wearing a gown and did not perform HH before putting on gloves.During an observation on 3/12/2026 at 2:42 p.m. CNA 5 and RNA 1 were providing resident care in EBP room for Resident 5, 9, and 59 without wearing gowns.3. During an observation on 3/10/2026 at 8:02 a.m. in nurse station one, RN 2 took a plastic basket with an open box of tissues, medicine cups, and cups with tea from the medication cart to multiple resident's rooms. RN 2 placed the plastic basket on multiple residents' bedside tables, including EBP rooms, then returned to medication cart without disinfecting the plastic basket in between use.4. During an interview on 3/11/1026 at 10:20 a.m. with Director of Staff Development (DSD), DSD stated the facility staff do not attend the annual Department of Public Health Infection Prevention and Control (IPC) Training for Skilled Nursing Facilities.During an interview on 3/11/2026 at 10:20 a.m. with DSD and, DSD stated COVID-19 infected residents in transmission-based precautions rooms are advised and encouraged to wear a facemask when they walk out of their rooms or use the patio but they have the right to not wear a mask if they do not want to.During a review of the facility's antibiotic stewardship surveillance record, dated February 2026, the record indicated five of ten resident infections had urinary tract infections (an infection of the bladder/urinary tract). During an interview on 3/11/2026 at 10:20 a.m. with Infection Preventionist Nurse (IPN), IPN stated she did not know how to report infectious diseases to local or state public health authorities.5. During an interview on 3/11/2026 at 1:00 p.m. with Administrator, Administrator stated the facility's water management plan map is not accurate and they do not know where the water comes into the facility.During an interview on 3/11/2026 at 1:00 p.m. with Maintenance Supervisor (MS), MS stated the facility does not follow water management plan to do chlorine water testing.During a review of the facility's policy and procedure (P&P) titled, Scope of Infection Control Program, dated June 2022, the P&P indicated the facility will:1. Follow standard hand hygiene procedures when providing direct resident contact and use PPE to protect residents from cross-contamination.2.Follow standard and transmission-based precautions to prevent the spread of disease.3.Know when and to whom to report communicable diseases or infections.4.Have a system to prevent, identify, report, investigate, and control diseases for all residents.During a review of the facility's policy and procedure (P&P) titled, Infection Control Surveillance dated June 2022, the P&P indicated the IPCP should implement and monitor the facility's compliance with HH, use of PPE, and do routine observations to identify training needs and practice changes.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 31) was monitored for antibiotic use. This failure had the potential to result in severe organ damage and antibiotic resistance to the resident. Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was readmitted [DATE] (original admission 1/31/2017) with diagnoses including but not limited to type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter waste). During a review of Resident 31's History and Physical (H&P), dated 2/1/2026, the H&P indicated Resident 31 had a history of urinary tract infections (UTI - an infection in the bladder/urinary tract), and was hospitalized with an UTI in February 2025. During a review of Resident 31's Care Plan, dated 12/7/2025, the Care Plan indicated a long-term Care Plan for history of extended-spectrum beta lactamase (ESBL - multi drug resistant bacteria)/UTI with no updated interventions. During a review of Resident 31's physician's orders, dated 2/6/2026, the physician's order indicated an Resident 31 as ordered Macrobid (a type of antibiotic to treat UTI) 100 mg (milligrams) give one capsule by mouth two times a day for UTI for seven days. During a review of Resident 31's physician's order, dated 2/9/2026, the physician's order indicated an order for Macrodantin (a type of antibiotic to treat and prevent UTI) 100 mg give one capsule by mouth in the morning for UTI prophylaxis (a treatment or action taken to prevent disease) for 30 continuous days. During an interview on 3/12/2026 at 1:34 p.m. with Pharmacy Consultant (PC), PC stated he is unsure why Resident 31 was ordered Macrodantin for 30 days. This type of order would normally be questioned.

Based on interview and record review, the facility failed to develop and implement policies and procedures for influenza (Flu - an infection of the nose, throat and lungs) and pneumococcal (PNA - an infection that affects one or both lungs) vaccines (medications used to prevent diseases, usually given by injection or by mouth) for five of five sampled residents (Resident 2, 14, 31, 36, and 58). This failure had to the potential to affect the residents or resident representatives' (RP) right to make an informed decision regarding the Flu and PNA vaccines. Findings : During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including but not limited to atherosclerotic heart disease (the hardening and narrowing of arteries due to plaque buildup), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hypertension (high blood pressure). During review of Resident 2's Flu and PNA vaccine consent form, dated 12/3/2025, the consent form indicated Resident 2 declined Flu and PNA vaccines. During a n interview on 03/11/2026 at 10:50 am with Director of Staff Development (DSD) and Infection Preventionist Nurse (IPN), IP stated Resident 2 has declined all vaccines and knows that Resident 2 declined Flu and PNA vaccines on the same day they declined COVID 19 vaccination 12/03/2025. IP stated Resident 2 declines vaccines and is not interested in getting any vaccinations. During a Review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted on [DATE] with diagnoses including but not limited to encephalopathy (brain dysfunction caused by infection, disease, or toxins), pneumonitis (swelling of the lung tissue), and dysphagia (difficulty swallowing). During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was readmitted on [DATE] (original admission date 1/31/2017) with a diagnoses including but not limited to type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter waste). During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted on [DATE] with diagnoses including but not limited to dementia (decline in mental function), hyponatremia (low blood sodium levels) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was admitted on [DATE] (original admission date 2/21/2022) with diagnoses including but not limited to urinary tract infection (UTI - an infection in the bladder/urinary tract), dysphagia (difficulty swallowing), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During an interview on 3/11/2026 at 10:50 a.m. with DSD and IPN, DSD and IPN did not find current Flu and PNA vaccine consent forms for Resident 2, 14, 31, 36, and 58. DSD stated it is important to have consent forms so staff and residents can all be on the same page with resident care. During an interview on 03/12/2026 at 3:18 p.m. with DSD, DSD stated the importance of maintaining Flu and PNA P&P in accordance with national standards of practice. DSD stated it is important to have a P&P so the facility staff is all aware of what to do and how to handle situations according to standards of practice and to make sure that residents are receiving the care they need in accordance to regulations.

Based on observation, interview, and record review, the facility failed to ensure safe care of an arteriovenous (AV) fistula (abnormal connection of an artery and vein) for one of three sampled residents (Resident 28) receiving dialysis treatment (a procedure that cleanses the blood of waste and excess fluids when the kidneys have failed) by not using the correct arm to check blood pressure (B/P). This failure has the potential to result in injury for Resident 28 that can potentially damage the AV fistula. Findings: During a review of Resident 28's admission Record (Face Sheet) indicated Resident 28 was initially admitted to the facility on [DATE] with diagnoses including end-stage renal disease (irreversible kidney failure), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and dependence on dialysis. During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool), dated 1/25/26, MDS indicated that Resident 28 does not have cognitive (thought process, understanding, reasoning, or memory losses) problem. The MDS indicated that Resident 28 uses a walker and needs partial assistance with daily activities. The MDS also indicated that Resident 28 receives dialysis care. During a review of Physician's order dated 11/22/25, The order indicated Resident 28 has an AV fistula on the left middle arm with orders to monitor the fistula via an assessment every shift. Vital sign documentation for blood pressure (B/P, the force of blood pushing against the walls of arteries, measured by applying a cuff that causes high pressure) in the resident's chart indicates that blood pressure was taken on the left arm for the month of 3/2026: 3/12/26, 3/08/26, 3/07/26, 3/04/26, 3/03/26. During an observation on 3/10/26 at 2:45pm in Resident 28's room, no sign was present to indicate that blood pressure and blood draws are not to be taken on the Resident's 28 left arm due to an AV fistula. During a concurrent interview and record review on 03/11/2026 at 10:20 a.m. with Registered Nurse 1 ( RN 1), the vital signs tab was reviewed. RN 1 stated that BP should be taken on the right arm if the resident has a fistula on the left arm. RN 1stated that the pressure from the cuff can damage the fistula and cause bleeding. RN 1 stated that if the staff member is unfamiliar there is usually a sign above the head of the bed indicating that no BP or blood draw should be done on the affected side. RN 1 stated that the nurses who documented that BP was performed on the left arm should have known better. During a review of the facility's policy and procedures (P&P) titled Hemodialysis, Care of Residents, dated 06/2025, the P&P indicated, do not take blood pressure on arm with dialysis shunt (another commonly used name for a fistula).

Based on observation, interview and record review the facility failed to implement a Foley catheter dignity care plan for Resident 5 and ensure the Certified Nursing Assistant (CNA) 2 was seated at eye level during feeding one out of six sampled residents (Resident 16).This deficient practice has a potential for Resident's 5 and Resident's 16 dignity was not maintained.Findings:During a review of admission record Resident's 16 admission record (Face sheet) indicated Resident 16 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (impaired cognitive function, leading to dependence on others), depression (mood disorder characterized by sadness, hopelessness, helplessness), glaucoma (severe blurred vision), hearing loss, right shoulder osteoarthritis (pain and stiffness in joints), lack of coordination, dysphagia (difficulty swallowing).During a record review on 03/10/2026 of Minimum Data Set (MDS, Resident assessment tool) MDS (resident assessment tool) dated 01/06/2026, the MDS indicated Resident's 16 Brief Interview for Mental Status (BIMS) score was 1, meaning severe cognitive impairment. The MDS indicated Resident 16 required partial to substantial assistance with activities of daily living (eating, dressing, bathing, toileting, sitting, sitting, walking), maximum assistance and was dependent on transfers from bed to chair, toileting and showering.During a concurrent dining observation and interview on 03/10/2026 at 12:50 p.m. with CNA 2, CNA 2 was feeding Resident 16, pushing spoon with liquidized pureed (solid food blended with liquid and turned into puree) food into Resident16's mouth, standing in front towards the right side , facing Resident 16. CNA 2 stated that Resident 16 had a tray with pureed food which included a bowl of white mushroom soup, one pureed beef stew, a cup of orange color/vegetable soup, small cup of pureed kimchi, cup of milk, small bowl of apple sauce, and a cup of vanilla ice cream type pudding. CNA 2 alternated between offering soup and vanilla pudding. Resident 16 was observed clenching their jaw and keeping their lips tightly closed, with only occasional slight opening of the mouth-just enough for the tip of the spoon. With each spoonful offered, Resident 16 did not open their mouth wide, and much of the food dripped down onto the paper towel placed on the resident's chest. The tray ticket indicated the resident's diet as Puree (Liquified), Fortified, regular portion for lunch. During interview on 03/11/2026 03:13 p.m. with DSD stated the CNA 2 missed in-service for feeding Residents. No additional feeding assistance training provided to the nursing staff.During a record review of the facility's policy and procedures (P&P) dated 06/2025 titled Resident Dignity and Personal Privacy, the P & P indicated each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with the residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth.

Based on interview and record review, the facility failed to protect Resident 47's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by Resident 78 when he hit Resident 47 on the face. This failure had the potential to result in Resident 47 being exposed to the risk of physical injury. Findings:During a record review of Resident 47's admission record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a record review of Resident 47's Minimum Data set [MDS-a resident assessment tool), dated 2/2/26 indicated that Resident's cognitive was moderately impairment. The MDS indicated that Resident 47 required supervision or touching (helper provides verbal cues) assistance with eating. The MDS indicated that Resident 47 required substantial/maximal (helper does more than half the efforts) assistance with toileting, shower/bathe, lower body dressing and putting on/taking off footwear. During a record review of Resident 78's admission record indicated (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia, and history of falling. During a review of Resident 78's History and Physical (H&P) dated 11/14/2025, the H&P indicated that Resident 78 has fluctuating capacity (ability) to understand and make decisions. During a review of Resident 78's care plan report initiated on 10/31/2025 and titled, resident has behavior of screaming and cursing to others, throwing things and trying to hit. The care plan intervention indicated monitor for throwing things and trying to hit. Assist Resident 78 in developing more appropriate methods of coping and interacting. During a record review of Resident 47's interview report titled Content of interview dated 11/7/2025 indicated that Resident 47 was lying on the bed then suddenly Resident 78's hand hit my right side of the face. During record review of Resident 47's medical record titled Situation Background Assessment Recommendations (SBAR-a structured, four-step communication framework) Communication Form and Progress Note dated 11/07/2025 timed at 11:40 a.m., indicated that Resident 47 was lying in the bed and suddenly Resident 78 hand hit Resident 47's right side of the face. During a concurrent interview and record review on 3/11/2026 at 12:45 p.m. with the Director of Nursing (DON), Resident 47 and Resident 78's Incident Report titled Interdisciplinary Team (IDT-team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Summary and Recommendations were reviewed. The DON stated that the incident was reported by Housekeeper (HK) 1 to Licensed Vocational Nurse (LVN) 4. The DON stated that LVN 4 interviewed both residents. And documented on Resident 47 IDT note that Resident 78 was sitting on the edge of the bed while Resident 47 was in his bed. HK 1 observed Resident 78 stood up and took steps forward and suddenly leaned and fell on top of Resident 47. Resident 78 showed aggressive behavior and started cursing at Resident 47. The DON stated that staff should have immediately separated the residents. The DON further stated the incident could have been prevented if HK 1 had called for assistance when Resident 78 attempted to get up, rather than observing without intervening. The DON defined abuse as any action in which one person does harm to another. During an interview on 3/12/2026 at 9:03 a.m. with HK 1, HK 1 stated that on 11/7/2025 in the morning (unknown time) HK 1 entered Resident 47's room to clean. At the time, Resident 78 stood up from the bed to use the restroom, lost balance, and hit Resident 47's right side of face with his hand. HK 1 stated that Resident 47 was lying in bed and Resident 78 was sitting at the edge of the bed prior to the incident. HK 1 reported that after standing, Resident 78 remained next to Resident 47 until a nurse ( unknown name) entered the room. HK 1 stated that the incident was reported that same day to LVN 4. HK 1 further stated that when HK 1 returned later to continue cleaning, both residents still shared same room. During an interview and record review on 3/12/2026 at 12:30 p.m. with Director of Staff Development (DSD), Resident 47's interview report was reviewed. DSD stated that the day of the incident she was walking by Resident 47's room and HK 1 informed her that Resident 78 tried to get up and fell towards Resident 47's. DSD stated that Resident 47 interview report on 11/7/2025 indicated Resident 47 was lying on the bed then suddenly Resident 78's hand hit my right side of the face. DSD further stated that resident hitting another resident is considered abuse and it should be reported to the local law enforcement agency, ombudsman and to California Department of Public Health (CDPH). During a review of the facility's policy and procedures (P&P) titled, Abuse and Neglect Prohibition Policy dated 6/2024, indicated that the facility will provide the resident with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe.

Based on observation, interview and record review the facility failed to implement it's written abuse polies and procedures (P&P), titled, Abuse and Neglect Prohibition Policy designed to prevent, respond to and report abuse- related incidents after physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) when staff did not immediately separate roommates Residents 47 and 78 who had physical altercation on 11/7/2026.This failure demonstrates the facility did not effectively implement its abuse prevention and response policy and procedures and did not ensure resident safety as required.Findings:During a record review of Resident 47's admission record , the admission record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest).During a record review of Resident 47's Minimum Data set [MDS-a resident assessment tool), dated 2/2/26 indicated that Resident's cognitive was moderately impairment. The MDS indicated that Resident 47 required supervision assistance with activities of daily living (ADL's- toileting hygiene, shower/bathing).During a record review of Resident 78's admission record indicated Resident 78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia, and history of falling.During a review of Resident 78's History and Physical (H&P) dated 11/14/2025, the H&P indicated that Resident 78 has fluctuating capacity (ability) to understand and make decisions.During a review of Resident 47's interview report titled Content of interview dated 11/7/2025 indicated that Resident 47 was lying on the bed then suddenly Resident 78's hand hit my right side of the face.During an interview and record review on 3/11/2026 at 12:45 p.m. with Director of Nursing (DON), Resident 47 and Resident 78 nursing progress notes and care plan were reviewed. DON stated that there is no documentation in nursing progress notes indicating a room change. DON stated that nursing staff only documented in nursing progress notes on 11/7/2025 at 2:04 p.m. regarding the incident between Resident 47 and Resident 78. DON stated that nursing staff on each shift should have monitored Resident 47 for 72 hours after the incident.During an interview on 3/12/2026 at 9:03 a.m. with HK 1, HK 1 stated that on the morning of 11/7/2025 (exact time unknown), HK 1 entered Resident 47's room to clean. HK 1 reported that Resident 78 stood up from the bed to use the restroom, lost balance, and struck the right side of Resident 47's face with their hand. HK 1 stated that prior to the incident, Resident 47 was lying in bed and Resident 78 was sitting at the edge of the bed.HK 1 explained that after standing, Resident 78 remained next to Resident 47 until a nurse (name unknown) entered the room. HK 1 stated the incident was reported that same day to Licensed Vocational Nurse (LVN) 4. HK 1 further stated that when HK 1 later returned to continue cleaning, both residents were lying in bed and appeared calm. HK 1 confirmed that the residents were not separated immediately following the incident.During a review of the facility's policy and procedures (P&P) titled, Abuse and Neglect Prohibition Policy dated 6/2024, indicated that If you suspect abuse is a resident-to-resident incident, the resident who has in any way threatened or attacked another will be removed from the setting or situation.

Based on interview and record review, the facility failed to report allegations of abuse to the California Department of Public Health (CDPH) within the regulated time frame of two hours. a. by failing to report an allegation of physical abuse which occurred between Resident 47 and Resident 78 who are roommates on 11/07/2025. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.Findings:During a record review of Resident 47's admission record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a record review of Resident 47's Minimum Data set [MDS-a resident assessment tool), dated 2/2/26 indicated that Resident's cognitive was moderately impairment. The MDS indicated that Resident 47 required supervision assistance with activities of daily living (ADL's- toileting hygiene, shower/bathing). During a record review of Resident 78's admission record indicated Resident 78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia, and history of falling. During a review of Resident 78's History and Physical (H&P) dated 11/14/2025, the H&P indicated that Resident 78 has fluctuating capacity (ability) to understand and make decisions. During a record review of Resident 47's Incident report interview portion titled Content of interview dated 11/7/2025 indicated that Resident 47 was lying on the bed then suddenly Resident 78's hand hit my right side of the face. During an interview on 3/11/2026 at 12:45p.m. with the Director of Nurses (DON), the DON stated that the incident on 11/7/2026 was not reported for an unknown reason. The DON stated allegations of abuse, verbal, and physical are investigated and reported (to the Department). The DON stated that everyone in the facility is a mandated reporter and should follow the policy for abuse reporting. During an interview and record review on 3/12/2026 at 12:30 p.m. with Director of Staff Development (DSD), Resident 47's interview report was reviewed. DSD stated that the day of the incident 11/7/2025 she was walking by Resident 47's room and HK 1 informed her that Resident 78 tried to get up and fell towards Resident 47's. DSD stated that Resident 47 interview report dated11/7/2025 indicated Resident 47 was lying on bed suddenly Resident 78's hand hit Resident 47 right side of the face. DSD further stated that resident hitting another resident is considered abuse and it should be reported to the local law enforcement agency, ombudsman and to our agency. During an interview on 3/12/2026 at 11:18 a.m. with the Administrator (Admin), the administrator stated he was aware of the physical incident that occurred on 11/7/2025 between Resident 47 and Resident 78. The ADM stated that he was aware that allegations including physical abuse and must be reported to all appropriate agencies if needed as soon as possible During a review of the facility's policy and procedures (P&P) titled, Abuse and Neglect Prohibition Policy dated 6/2024, indicated that Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation the Administrator or designee will perform the following: all alleged violation immediately but not later than twenty four hours-if the alleged violation does not involve abuse and does not result in serious bodily injury. Report the incident to the local Ombudsman or the local law enforcement agency by telephone as soon as possible.

Based on observation, interview and record review, the facility failed to implement baseline care plan for physician orders for pain management and physical therapy (a healthcare specialty that helps individuals restore, maintain, and improve physical function, movement, and strength while reducing pain) for one of three sample residents (Resident 77).This failure had the potential to result in inadequate communication among staff regarding resident's 77 pain management needs and therapy interventions. Findings:During a record review of Resident 77's admission record it indicated Resident 77 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bone) of pelvis (located at the lower part of the trunk), hyperlipidemia (abnormally high levels of fats in the blood), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 77's History and Physical (H&P), dated 3/3/2026, the H&P indicated, Resident 77 has the capacity (ability) to understand and make decisions. During a concurrent interview and observation on 3/9/3036 at 9:04 a.m. in Resident 77's room, Resident 77 was sitting in bed brushing her teeth while stating that she has been having pain in left leg and left heel. Resident 77 stated that she had received pain medication early in the morning, but the pain was not relieved. Resident 77 also stated that she would like to receive physical therapy to help legs get stronger. During a review of Resident 77's Order Summary Report (OSR), dated 3/12/2026, the OSR included the following orders: Ordered on 3/4/2026, Hydrocodone-Acetaminophen (is a combination medicine that is commonly taken for severe pain) Oral tablet 5-325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) Give one tablet by mouth every 4 hours as needed for moderate pin (4-6) r/t pelvic fracture. Ordered on 3/4/2026, Hydrocodone-Acetaminophen Oral tablet 10-325 mg Give one tablet by mouth every 6 hours as needed for severe pain (7-100) r/t pelvic fracture. During a concurrent interview and record review on 3/11/2026 at 11:37 a.m. with Director of Rehabilitation (DOR), Resident 77's care plan (general) was reviewed. DOR stated that the facility evaluates all residents for Physical and occupational therapy upon admission. DOR stated that after completing the evaluation, the Physical Therapist (PT)/ Occupational Therapist (OT) should document Resident 77's goals and intervention in the care plan for all staff members to remain informed and consistent in the resident care. DOR further stated that staff had not initiated care plan addressing Resident 77 receiving physical therapy and pain management. The DOR stated that care plan should include Resident 77's pain medication orders. During an interview on 3/11/2026 at 1:15 p.m. with the Director of Nursing (DON), the DON stated that basic care plan included physician orders, dietary orders and therapy services. DON stated that basic care plans should be initiated within 48 hours of resident admission. DON stated that the care plan was important to initiate because it indicates the care the facility needs to provide for each resident. During a review of the facility's policy and procedures (P&P) titled, Baseline (Initial) Care Plan dated 6/2025, indicated the baseline care plans should address at a minimum, the following: initial goals based on admission orders, physician orders, physician orders, dietary orders, therapy services, social services and PASSR recommendations.

Based on observation, interview, and record review, the facility failed to revise resident care plans for two of four sampled residents (Resident 31 and 62). This failure had the potential to result in Resident 31 and 62 receiving inappropriate care due to conflicting information between care plan and medication orders. Findings: During a review of Resident 31's admission Record (Face sheet), the admission record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) and major depressive disorder (a serious, common mental health disorder characterized by persistent sadness, low mood, and a loss of interest in activities). During a review of Resident 31's Minimum Data Set (MDS) dated [DATE], The MDSSection B indicated that Resident 31 uses glasses and hearing aides The MDS indicated that Resident 31 has moderate mental impairment. The MDS also indicated that besides the occasional feeling of loneliness, Resident 31 does not show or express other symptoms of depression. During a review of Resident 31's Physician Orders e Resident 31 had previous orders for Remeron,( a medication used to treat depression and stimulate appetite). no longer an active order on Resident 31's medication administration record (MAR). During a review of Resident 31's care plan, care plan indicated that Remeron use of Remeron is still listed as an active plan with interventions and outcomes related to active use of Remeron. During a review of Resident 62's admission Record (Face Sheet), record indicated Resident 62 was initially admitted to the facility on [DATE] with diagnoses including heart failure, chronic kidney disease, and atrial fibrillation (heart condition which affects the muscle's ability to pump blood through the heart effectively, causing high risk of blood clots). During a review of Resident 62's MDS dated [DATE],The MDS indicated that Resident 62 does not have mental function or memory issues. It also indicated that no walking devices are needed and Resident 62 only needs supervision or minimal assistance with daily activities. The MDS indicated that Resident 62 is taking an anticoagulant (Eliquis). During a review of Resident 62's care plan, Atrial Fibrillation care plan with review start date of 2/18/26 states, Administer Metoprolol succinate 12.5mg oral once daily and Eliquis 2.5mg twice daily starting as ordered on 1/23/2026. Physician Orders dated 01/22/2026, medication order states, resident is ordered Eliquis 2.5 mg by mouth in the afternoon for atrial fibrillation. Stop if notice any bleeding and seek medical attention. During a concurrent record review and interview with RN 1, at Nurse Station 1 on 03/12/2026 at 8:51 AM, RN 1 stated that MD 1 addressed the Pharmacy Consultant's (PharmC/PC ) recommendation and disagreed. RN 1 states that the original dose was 2.5 mg twice daily, but the MD 1 decreased dose to 2.5 mg Daily in afternoon. In the paper chart, RN found handwritten physician order from Cardiologist for 2.5mg twice daily, but verbal phone order from resident's MD 1, dated 1/22/26, states 2.5mg once daily in afternoon. During a review of the facility's policy and procedure titled, Comprehensive Care Plan, dated June 2025, the policy indicated that care plans should be re-evaluated and modified to reflect changes in care service and treatment. This should be done as necessary, quarterly, and with a significant change in status assessment.

Based on observation, interview, record review, the facility failed to follow physician's order for pain management for one of three sampled resident (Resident 77). This failure had the potential to place Resident 77 at risk for adverse medication effects, including oversedation, respiratory depression and decline in overall health status. Findings:During a record review of Resident 77's admission record it indicated Resident 77 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bone) of pelvis (located at the lower part of the trunk), hyperlipidemia (abnormally high levels of fats in the blood), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 77's History and Physical (H&P), dated 3/3/2026, the H&P indicated, Resident 77 has the capacity (ability) to understand and make decisions. During a review of Resident 77's Order Summary Report (OSR), dated 3/12/2026, the OSR included the following orders the order on 3/4/2026, Hydrocodone-Acetaminophen (is a combination medicine that is commonly taken for severe pain) Oral tablet 5-325 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) give one tablet by mouth every 4 hours as needed for moderate pain (pain level 4-6) r/t pelvic fracture. The order summary report order on 3/4/2026, Hydrocodone-Acetaminophen Oral tablet 10-325 mg Give one tablet by mouth every 6 hours as needed for severe pain (7-100) r/t pelvic fracture. During an observation on 3/11/2026 at 8:38 a.m. in Resident 77's room, Licensed Vocational Nurse (LVN) 2 entered the room with a medication cup and stated to Resident 77 I have your pain medication. Resident 77 took the medication cup from the LVN 2 took the pills. LVN 2 then walked out of the room. During a concurrent interview and record review of Resident 77's Medication Administration Record (MAR) on 3/11/2026 at 1:41 p.m. with LVN 2, LVN 2 stated that Resident 77 received Hydrocodone-Acetaminophen oral tablet 10-325 mg for right shoulder pain rated 7 out of 10 at 8:47 a.m. LVN 2 stated that they returned at 11:30 a.m. to reassess Resident 77's pain. LVN 2 stated that staff should reassessed Resident 77 pain within one hour after administering pain medication. LVN 2 stated that timely reassessment is important to evaluate the effectiveness of pain medication and ensure that the Resident 77 does not remain in pain. LVN 2 stated that Resident 77 pain was not reassessed within the required timeframe. During interview and record review on 3/12/2026 at 9:49a.m. with Registered Nurse (RN) 1, Resident 77's MAR dated March 2026 was reviewed. The MAR indicated that Resident 77 reported a pain level 5 out of 10 on 3/9/2026 at 2:34 a.m. and received Hydrocodone-Acetaminophen Oral tablet 10-325 mg instead of the ordered Hydrocodone-Acetaminophen Oral tablet 5-325 mg, which is prescribed for pain level of 4-6. RN 1 stated that Resident 77 received an incorrect dose and should have received the lower dose. RN 1 further stated that the nurse (unknown) who administered the pain medication did not follow the physician's order for pain. RN 1 stated that staff must match the resident's reported pain level with the corresponding medication order on the pain scale. As a result, Resident 77 received a higher dose of pain medication than ordered. During a review of the facility's policy and procedures (P&P) titled, Pain Management Program dated 6/2025, indicated monitor appropriately for effectiveness and/or adverse consequences .re-assess the resident's pain and consequences of pain. Ongoing pain assessment will be documented on the medication sheet.

Based on observation, interview, and record review, the facility failed to ensure bed dimensions were inspected for appropriate size and weight for one of five sampled residents (Resident 47). This deficient practice has the potential to result in compromised resident safety associated with possible entrapment with bed rail use. Findings:During a record review of Resident 47's admission record it indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). During a record review of Resident 47's Minimum Data set [MDS-a resident assessment tool), dated 2/2/26 indicated that Resident's cognitive was moderately impairment. The MDS indicated that Resident 47 required supervision assistance with eating . The MDS indicated that Resident 47 required substantial/maximal (helper does more than half the efforts) assistance with toileting, shower and lower body dressing. The MDS indicated that Resident 47 requires partial assistance to roll from lying on back to left and right side. During an observation on 3/09/2026 at 9:05 a.m. Resident 47 was observed lying in bed facing the doorway with two bedside rails (are adjustable metal or rigid plastic bars that attach to the bed) up, bed side rails were not padded, During a review of Resident 47's Order Summary Report (OSR), the OSR indicated an order dated 9/20/2025 indicated May have bilateral 1/3 side rails as enabler bed mobility/ activity of daily living (ADL's) care. During an interview and record review on 3/11/2026 at 10:15 a.m. with Registered Nurse (RN) 1, Resident 47's physician orders and Rail/Restraint/Device Assessment were reviewed. RN 1 stated that the bedside rails are assessed every quarter for Resident 47 and no one in the facility measures or inspects the bed rails. RN 1 stated that the last Rail/Restraint/Device Assessment for Resident 47 was completed on 2/2/2026 and did not indicate the measurements. During an interview and record review on 3/12/2026 at 7:40a.m. with the Maintenance Coordinator (MC), bedside rail log was reviewed. The MC stated that he does not measure the bed rails. The MC states that he only checks the bed monthly to ensure that the motor and brakes are working well. During an interview on 3/11/2026 at 1:15p.m. with the Director of Nursing (DON), the DON stated that bedside rails are not measured to ensure that bed dimensions are appropriate for the resident's size and weight. DON stated that the facility only completes rail/restraint/device assessment every quarter and monitors for episodes of entrapment every shift. The DON states that the facility has not had any incident with entrapment. During a review of the facility's policy and procedures (P&P) titled, Bed Rail Assessment and Management dated 6/2025, indicated 'the facility is to assess resident prior to the implementation and use of bedside rails to ensure appropriate protocols have been followed such as ensure that the bed dimensions are appropriate for the resident's size and weight.

Based on observation, interview and record the facility failed to:Accurately account for Resident 62's home medications upon admission.Ensure the pharmaceutical waste container contained adequate liquid or chemical solution to render discarded tablets and capsules inaccessible and ensure the container's lid was secured according to manufacturer instructions.These deficient practices had potential to result in misappropriation or diversion of the medications.Findings:During record review of the admission Record, the record indicated Resident 62 was admitted to the facility on [DATE] with diagnoses of hypertensive heart failure (heart's muscle inability to pump blood efficiently due to long term untreated high blood pressure), abnormal gait and mobility (difficulty walking and maintaining balance), thrombocytopenia (disfunction in blood clotting causing bleeding, bruising) anemia (low red blood cells needed for oxygen transport to organs), chronic kidney disease (long term impairment in blood filtering ability and removal of wastes in urine), type 2 diabetes (long term disorder with unstable blood sugar levels ranging between high and low), atrial fibrillation (abnormal heart beat).During record review on 3/12/2026 of the Minimum Data Set (MDS - resident assessment tool), the MDS dated [DATE], indicated the Resident's 62 Brief Interview for Mental Status (BIMS) score was 13, meaning cognition was intact. The MDS indicated Functional Abilities of Resident 62 required helpers to set up, clean up with activities of daily living (eating, dressing, sitting, and toileting), and supervision on transfers from bed to chair, walking, and showering.During concurrent observation, interview, and record review on 03/10/2026 at 11:39 a.m. in the medication room with Registered Nurse (RN) 1, a bag containing Resident 62's home medications was observed. RN 1 stated she was unfamiliar with facility policy regarding home medications and did not know which or how many medications were in the bag. RN 1 stated the resident had been in the facility for almost two monthsDuring an interviews on 03/11/2026 at 11:15 a.m., RN 1 indicated that resident belongings should be documented by the social worker. During an interview on 03/11/2026 11:20 a.m. with Social Services Director (SSD), SSD stated when there is a new admission the process was to review the belongings list as completed by Certified Nurse Assistant (CNA) and entered the information into the electronic charting system SSD stated, When residents bring home medications, we don't keep it here, we ask family or friend to pick up and take home.2. During an observation on 03/10/2026 at 11:59 a.m., the pharmaceutical waste container was found to be full, with visible tablets and capsules not covered by any dissolving liquid or chemical agent. The lid was loose and not secured as tamper proof, allowing potential access to medications.During a subsequent interview on 3/10/2026 at 11:59 a.m. with RN1, RN 1 stated the Infection Preventionist (IP) was responsible for picking up the waste container, and stated that liquid should be added to dissolve wasted medications so they cannot be retrieved.During a review of an undated medication disposition log on 03/10/2026 at 12:15 p.m. showed the last entry dated 2/18/2026. The log lacked documentation identifying the residents' names associated with disposed medications.During a concurrent observation and interview on 03/10/2026 at 12:01 p.m., RN 2 opened the controlled medication compartment of the medication cart, showing two locked plastic kits for Schedule CII and CIV medications. RN 2 stated nurses account for these medications using the enclosed documentation slips. RN 2 also demonstrated a sharps container used to dispose of wasted controlled medications, emphasizing the importance of secure medication disposal.During review of belongings list for Resident 62 , the list showed no documentation indicating that home medications were brought in.During a concurrent interview and record review on 3/11/2026 at 1:24 p.m. with the Director of Nursing (DON), DON stated that upon discharge, leftover facility issued medications could be sent home if ordered by the physician. The DON stated that staff are responsible for accounting for and documenting resident belongings, including any home medications, which should be reviewed for comparison and then returned to family.During a concurrent interview and record review on 3/11/2026 at 2:05 p.m. of the Prescription Medication Disposition Record Pass Log dated 2/18/2026 with the DON, the DON stated this was an outdated form and that staff should have recorded the resident's name.During an interview on 03/12/2026 at 8:02 a.m., the DON stated the resident inventory list should be in the chart. The DON further stated that if home medications were brought in, staff must document the medication names and quantities, seal the items, label them with the patient's name, and store them securely until they can be sent home.During an interview and record review on 03/12/2026 at 8:29 a.m., the SSD stated they do not count medications and that only medications ordered by the attending physician may be administered. The SSD stated that Resident 62's belongings list include clothing and luggage, but no medications.During a phone interview on 03/12/2026 at 2:02 p.m., the Pharmacist Consultant (PC) stated home medications may be kept for short term use up to two months and must not include controlled substances. For longer storage, nurses or the DON should inventory the medications and arrange for disposal or return. The PC also stated the pharmaceutical waste container should not be full, should have a secure lid, and should contain liquid to dissolve medications.During a review of the facility's policy titled Residents' Personal Property, dated 06/2025, indicated that any personal items, including over the counter medications retained by the facility, must be inventoried upon admission, documented, and accounted for. The policy further required documentation of the release or disposal of resident belongings in the medical record.

Based on interview and record review, the facility failed to ensure one of eight sampled residents' (Resident 1) food consistency and texture brought in by Resident 1's son on 9/18/23 was allowed and in compliance with her mech soft, finely chopped diet being the food was fed to the resident, and that Resident 1 was assisted, supervised, and monitored for choking when eating. The facility failed to ensure: 1.There was a system in place to check/screen food brought into the facility from outside for consistency and texture to match that which the physician had ordered.2.The physician's order was followed to monitor choking signs and symptoms while feeding the resident.3. Certified Nursing Assistant (CNA 1) did not feed Resident 1 while resident is drowsy on 9/19/2023. Resident 1 who had a diagnosis of dysphagia (difficulty swallowing) oropharyngeal phase (second stage of swallowing when the food goes from the back of the mouth to into the esophagus [tube that connects the throat to the stomach]) and had a choking incident a day prior (9/18/2023).As a result of these failures, Resident 1 had a choking incident at dinner time on 9/18/2023, when the resident was being fed a noodle soup brought in from outside the facility. The second choking incident the next morning on 9/19/2023 during breakfast time which resulted in Resident 1 being found in his room by LVN (Licensed Vocational Nurse) 1 unresponsive (not reacting or moving at all) with no pulse (the number of times the heart beats) and not breathing with egg custard on her bib and inside her mouth. Resident 1 expired at the facility on 9/19/2023.On 7/25/2025 at 4:43 pm, the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) and the Director of Staff Development (DSD) related to the failures to ensure Resident 1 received care and services in accordance with Resident 1's physician's orders, care plan, and the facility's policies and procedures. The above failures resulted in Resident 1 being fed outside food on 9/18/2023 for dinner, which was not screened for consistency or texture resulting in a choking incident and not providing assistance with eating, as well as not monitoring for choking the next morning on 9/19/2023 during breakfast as per the physician's orders and care plan.On 7/26/2025 at 5:30 pm, the Department removed the IJ situation in the presence of the ADM, DON, and DSD, while onsite after the surveyors verified the facility's implementation of the IJ removal plan through observation, interview and record review, which included:1.On 9/19/2023 Resident 1 expired.2.On 7/25/2025 at 5:15 pm DON/designee (a person selected or designated to carry out a duty or role) audited the diets of 49 residents with ordered modified diets (eating plan designed to address specific nutritional needs or health conditions) for dinner service to determine any discrepancies in diet order and meal trays - none found.3.On 7/25/2025 at 7:30 pm and outside consultant provided an in-service (ongoing, job-related training provided to staff to enhance their knowledge and skills, ensuring they can deliver high-quality care to residents) to DON and ADM and later the consultant provided in-service training to licensed nurses and nursing assistants in the facility at 10 pm and 11 pm on:Understanding the importance of checking and inspecting food brought in from outside sources for residents. Verifying that outside food aligns with the resident's dietary orders and texture requirements. Identifying the risks of non-compliance with prescribed diets, including choking, aspiration, and medical complications. Communicating effectively with residents and families about dietary restrictions, food safety and associated risks. Providing education to family members who prepare to feed the resident, including proper feeding techniques and the risks associated with feeding. And recognizing and responding appropriately to suspicious or potentially unsafe food items. Also, understanding the importance of education family members about residents' special dietary needs. Identifying appropriate foods and feeding techniques for residents on various special diets (e.g., diabetic, low sodium, pureed and mechanical soft). Effectively communicating dietary restrictions, risks, and safe feeding practices to family members. Demonstrating how to train family members in proper feeding techniques that reduce risks such as choking and aspiration. Documenting education provided and family member understanding in resident records.4.On 7/25/2025 at 10 pm, ADM and DON created Log for Visitors who bring in food from the outside. The log included name of the resident, visitor/family member who is visiting, what food was brought/texture, Education training column if done, and/or modified and last column will have nurse initial to confirm and/or provide comment if necessary.5.On 7/26/2025 at 10:45 am, DSD created new sign was posted in English and Korean at front door and garage entrance for visitors with outside food to go to Nurses station when bringing in food. Attn: all family members & visitors. If you bring outside food or beverages for the residents, please do not provide them with until you have spoken with our licensed nurse and received permission. If any food/beverage brought in does not meet the resident's current diet, food will be denied and not allowed for safety concerns. Please head directly to the nursing station for screening. Thank you for your cooperation to ensure the safety of our residents.6.The Interdisciplinary Team (IDT - collaborative meeting where various healthcare professionals discuss and coordinate a resident's care plan), which involved Nurse Consultant, ADM, DON, Staff Developer (DSD), Social Worker, and Activities convened on 7/25/2025 at 7 pm to revise the food brought from home policy, includes education and training of family members on what food is appropriate and when feeding the resident.7.Starting 7/26/2025, all admissions, residents and families will be given a copy of this new policy and offered a handout on safe food handling practices.8.In-service training for staff license nurses started on 7/25/2025 at 10 pm on how to address food coming from outside and how nurses will check food brought in for patients. A total of 42 out of 67 nurses have been trained and will continue training until all staff nurses have attended by 7/28/2025. The four of the 67 nursing staff members who are on vacation or out on leave, will be in-serviced prior to them working on the floor.9.Ad hoc (for this purpose) Quality Assurance and Performance Improvement (QAPI, data-driven approach to improving the quality of care and services in healthcare settings) Committee, which includes Medical Director, ADM, DON, DSD, Social Services, and Activities will be conducted on 7/26/2025, a root cause analysis (RCA) will be completed to determine key issues for food brought from home, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions. During a review of Resident 1's Record of Admission (undated), indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), lack of coordination, muscle weakness (generalized), dysphagia (difficulty swallowing) oropharyngeal phase (second stage of swallowing when the food goes from the back of the mouth to into the esophagus [tube that connects the throat to the stomach]).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/7/2023, indicated, Resident 1 had severe cognitive (ability to think, understand and make daily decisions) impairment. The same MDS further indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist when eating.During a review of Resident 1's History and Physical (H&P), dated 7/10/2023 indicated, Resident 1 did not have the capacity to understand and make decisions. The H&P further indicated the resident had left side weakness due to a cerebrovascular accident (stroke), and dementia (a progressive state of decline in mental abilities). During a review of Speech Therapist (ST) notes titled, Recertification & Updated Plan of Treatment, Dysphagia Therapy, certification period 8/6/2023 - 9/4/2023, indicated objective progress/short-term goals' Patient will safely swallow mechanical soft and thin liquids, successive swallows using lingual sweeps/re-swallow, rate modification, bolus size modification, hard throat clear/re-swallow techniques/precautions with 80% of attempts and with 20% verbal cues in order to decrease s/s (signs and symptoms) of oral and/or pharyngeal dysphagia. The same ST notes indicated to please Resident 1 in an upright posture during meals and up to 30 minutes after meals. During a review of Resident 1's physician's orders dated 8/25/2023 indicated an order for mechanical soft finely chopped diet (foods that are modified in texture to be easier to chew and swallow, i.e., ground, chopped or mashed) with thin liquids.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) progress note dated 9/18/2023, indicated the resident had an incident of choking at dinner time (at 5:30 pm), requiring the Heimlich maneuver (a first-aid procedure used to treat choking by dislodging a foreign object from a person's airway) to be performed in addition to a finger sweep (a first aid technique used to remove a visible foreign object from a choking victim's mouth or throat) of mouth and suction of oropharynx (middle part of the throat, behind the mouth, soft palate [the back muscular part of the roof of the mouth], the side and back walls of the throat, the tonsils, and the back one-third of the tongue), to remove the food and clear the airway.During a review of Resident 1's physician's orders dated 9/18/2023 at 5:30 pm, indicated an order to have oral suction (procedure to remove mucus or saliva from a person's mouth when they are unable to clear it themselves through coughing or swallowing with a suction device) as needed and monitor every shift for signs and symptoms of choking.During a review of Resident 1's care plan for high risk for choking due to dysphagia and requiring assistance during meals but she wants to initiate eating by herself (undated), indicated an intervention of monitor for signs and symptoms of aspiration (the inhalation of food, liquid, or other material into the lungs, instead of the esophagus and stomach) such as coughing, trouble breathing, choking, wheezing, etc. and Restorative Nurse Assistant (RNA, a specialized certified nursing assistant, CNA, who is trained to help patients regain or maintain their physical abilities and independence) if needed. During a review of Resident 1's Nursing Assistant Activities of Daily Living (ADL, fundamental self-care tasks that individuals perform independently to maintain their well-being and independence such as eating and dressing) flow sheet for September 2023 indicated the resident needed supervision (oversight, encouragement, cueing) with one person physical assist for breakfast and lunch and was dependent (full staff performance) at dinner times., indicating a discrepancy in the amount of help the resident needed during the meal times. Further review of the same ADL flow sheet indicated no entries for breakfast on 9/19/2023, lunch and dinner were strike through and indicated expired 9/19/2023.During a review of Resident 1's Nursing Notes dated 9/19/2023 at 8:30 am, the note indicated CNA passed breakfast tray at 7:20 am. Helped the resident get up in bed in sitting position. resident had no SOB (shortness of breath) or respiratory distress (difficulty breathing, often involving rapid, shallow breaths or gasping), no cough, no complaint of pain, no facial grimacing during the passing the breakfast tray. When charge nurse went to give resident her morning medications around 7:35 am, the resident was found with yellow face, lips were not blue or purple in color, closed eyes, unresponsive to verbal and tactile (touching) stimuli, with soft egg pudding spilled on her bib. Charge nurse stated he didn't hear any coughing sounds or sounds of choking this morning.resident is unresponsive, no pulse, no breathing noted. removed about one tablespoon of visible soft egg pudding from mouth and provided oral suctioning nothing came out. started oxygen at 15 liters per minute via non-rebreather mask (an oxygen delivery system used during emergencies to deliver a high concentration of oxygen) and called 911 (universal emergency number) . paramedics called time of death at 7:59 am.During a review of Resident 1's autopsy report signed 4/2/2024, indicated date of death [DATE] and date of autopsy 9/21/2023, the report further indicated the cause of death asphyxia (a condition where the body is deprived of oxygen, leading to potential loss of consciousness and even death) resulting from obstruction of airway passages by food product, manner of death accidental.During an interview with CNA 1 on 7/24/2025 at 12:33 pm, she stated on that day (9/19/2023), she saw Resident 1 was sleeping so she put the tray to the side of the bed and went to her other residents to feed them. She stated when she returned to Resident 1's room, she tried to wake Resident 1 up and Resident 1 opened her eyes. CNA 1 stated she gave her (Resident 1) a spoonful of the egg (pudding), and then she (Resident 1) shut her eyes again. CNA 1 further stated she tried to wake Resident 1 again and then she called the charge nurse because Resident 1 was not swallowing. CNA 1 stated she didn't know of the choking incident a day before, if she knew she would not leave Resident 1 alone to eat. CNA 1 stated that she was present. However, there was no documentation to support her report nor was there any witness that confirmed that CNA was present in the room.During an interview with Licensed Vocational Nurse (LVN) 1 on 7/24/2025 at 12:47 pm, LVN 1 stated that at the beginning of the shift, huddle (a brief, structured meeting held by nurses and other healthcare professionals, usually at the start of a shift, to discuss patient care, safety concerns, and workload distribution) is completed between the oncoming and off-going shifts. After the huddle, LVN 1 then checks the communication notes (are the written or electronic records used by nurses and other healthcare professionals to document and share important information about a resident's condition, care, and progress) for events that may have occurred overnight and informs CNAs about safety instructions involving the residents they are assigned to, such as residents at high risk for falls and aspiration risks. LVN 1 stated that for residents who have a diagnosis of dysphagia or aspiration risk, nursing staff check the diet orders to ensure that they are receiving the appropriate diet and place a sign above their bed. If a resident has a history of choking, LVN 1 stated that the resident is monitored closely to ensure that they are swallowing ok because they are now at increased risk for choking and placed in a feeding program where the RNA assists or monitor them during meals. LVN 1 stated that the families of residents at risk of choking must be educated, and all food brought in carefully screened to ensure that it is compliant with the ordered diet, otherwise notify the supervisor and schedule an Interdisciplinary Team (IDT - collaborative meeting where various healthcare professionals discuss and coordinate a resident's care plan) meeting.During a follow up interview with LVN 1 on 7/24/2025 at 2:52 pm, LVN 1 stated that Resident 1, was not on the feeding program, even though she was an aspiration risk, but the facility staff monitored her because she slept most of the time and did not like to participate in activities. LVN 1 stated that on 9/19/2023 while reviewing the communication notes, they learned that Resident 1 had a choking incident which required staff to perform a Heimlich maneuver on her. LVN 1 finished reviewing the notes and started looking for CNA 1 (who was assigned to Resident 1) to inform her about the incident and to be extra cautious. LVN 1 stated that when he walked in Resident 1's room, Resident 1 was noted to be in bed and sitting upright and appeared to be yellowing. LVN 1 stated that Resident 1 was not responsive and was not breathing so he went to look for his supervisor to assist. LVN 1 stated that many staff came to the room to assist with Resident 1 and that one of the staff (does not recall whom) swept (a first aid technique used to clear an obstructed airway in an unconscious person by using a finger to remove a visible object from the mouth or throat) her mouth. LVN 1 stated that cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardia arrest) was not performed because Resident 1 was a Do Not Resuscitate (DNR, order is a medical order instructing healthcare professionals not to perform CPR if a person's heart stops or they stop breathing).During a concurrent telephone interview and record review of Resident 1's nursing notes with Registered Nurse (RN) 1 on 7/24/2025 at 3:57 pm, RN 1 stated that she recalled a staff member informing her that Resident 1 was unresponsive, so she rushed to the room and found that Resident 1 was unresponsive and was not breathing. The breakfast tray was in the room at the bedside of Resident 1. RN 1 stated that when she checked Resident 1's mouth, she (RN 1) found about two tablespoons of food residual which appeared to be a yellow egg pudding. RN 1 confirmed that leaving food in a resident's mouth or not supervising them could result in a resident choking. RN 1 stated that when a resident chokes, that food blocks their airway depriving them of oxygen and may result in death. RN 1 confirmed that Resident 1 had an order for aspiration monitoring which must be completed at every meal or anytime anything is placed in the mouth.During the same telephone interview RN 1 stated that she did not personally see the resident eat but found out from the CNA that she (CNA 1) had taken the tray to Resident 1 and fed Resident 1 a little because she appeared (Resident 1) to refuse the food. RN 1 stated she does not recall if the resident was an aspiration risk and was not aware that the resident had a choking incident the day before. RN 1 further stated staff need to make sure that they (facility staff) do not leave a resident with food in her mouth, resident could be at risk for aspiration which may result in a blocked airway and result in death.During an interview with the ST on 7/24/2025 at 4:58 pm, ST stated that dysphagia oral pharyngeal phase required a lot of queueing and cannot clear the mouth of residual. She stated that training included reminding the residents to sweep their mouth but if they are not at that point, then supervision is required.During a concurrent interview and record review on 7/25/2025 at 11:23 am with DON (Director of Nursing), Resident 1's progress notes, physicians orders and care plans reviewed as above. The DON verified there was no documentation in the resident's records indicating the CNA stayed in the room to monitor the resident after passing the trays and positioning the resident to eat on 9/19/2023 at 7:20 am. DON stated resident should be fully awake, if the resident is drowsy staff should stop the feeding.During an interview with ADM on 7/25/2025 at 2:19 pm, he stated that the facility talked about the post incident of choking in 9/2023 but didn't know if the facility documented it. He also stated that there is no policy specific to the outside food being brought in for the residents that is on a specialized diet for screening the food to comply with the diet ordered.During an interview with DON on 7/25/2025 at 3:05 pm, she stated that there was no specific facility policy at this time (time of interview) to address the process when residents or family members bring in outside food. She stated that a system and a policy will be added to include IDT must be implemented, a care plan initiated, and an order placed if resident or family bringing outside food.During the same interview and record review of the facility policy for Resident Nutritional Services and Assistance with Meals dated 6/2025, were the exact same policies that were used and active at the facility in September 2023.During an interview with CNA 4 on 7/25/2025 at 4:14 pm, he stated family should not bring food from outside.During an interview with LVN 4 on 7/25/2025 at 4:17 pm, he stated that when a family brings food from home, they need to check the chart for the diet, check the food and inform the facility if they bring in a different diet. He stated that he was not aware about an order should be entered in the resident's chart about food brought from outside. He stated that he was not sure about making a care plan for food brought from home. He further stated that he would have to check with the supervisor because he was new to the facility. LVN 4 also stated he was not aware of the facility of having a policy of having an IDT and care planning when family will be bringing food.During an interview with the Medical Director (MD) for the facility on 7/26/2025 at 9:58 am, MD stated that residents diagnosed with dysphagia must have Speech Therapy (ST) consult for evaluation, treatments, and recommendation on the appropriate diet as bedside nursing is not enough. MD stated that food brought in by family from outside must adhere and be consistent with residents ordered diets. MD stated that residents on aspiration risk must be monitored by nursing not only during meals, but also at any point that a resident is consuming anything orally which includes snacks, candy, etc. the MD stated that it was really important to have a policy and procedure on dysphagia, aspiration precautions, and outside food to ensure resident safety.During a review of the facility's policy and procedures (P&P), titled, Resident Nutritional Services, reviewed June 2024 and the active P&P during the time of the incident, the P&P indicated, Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance.During a review of the facility's P&P, titled, Assistance with Meals, reviewed June 2024 and the active P&P during the time of the incident, the P&P indicated, The facility shall provide assistance for all patients with meals in a manner that meets the individual needs of each patient. Ensure that all patients are assisted with meals according to physician's orders and preferences. Nursing staff and/or Feeding Assistants will serve the patient trays and will help patients who require assistance with eating. Patients who cannot feed themselves will be fed with attention to safety, comfort and dignity.

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 1), who had diagnosis of dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), had history of fall, and was assessed as high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: -Develop a comprehensive care plan for Resident 1's fall prevention, per the facility's policy and procedure (P&P) titled, Person Centered Plan of Care. -Frequently monitor Resident 1 and anticipate resident's needs to ensure the resident's safety to prevent fall accidents. As a result, on 6/8/2024 (two days after admission), Resident 1 was found on the floor, complaining of pain, and was transferred to the General Acute Care Hospital (GACH) where Resident 1 was diagnosed with a left femur fracture (broken thigh bone). The GACH recommended surgery. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 6/6/2024, with diagnoses including a history of falling, dementia, and osteoporosis (bone disease that develops when the structure and strength of the bone weakens). A review of Resident 1's Admission assessment dated [DATE], indicated the resident's Morse Fall Score (method of assessing a patient's likelihood of falling) was 75. A score of 45 or higher indicated Resident 1 was a high risk for falls. A review of the Activities of Daily Living Self Care Performance Deficit Care Plan dated 6/6/2024 indicated the resident had activity intolerance due to disease process of dementia. The care plan goal indicated Resident 1 would improve current level of function and the care plan interventions included the following: -Provide the resident with 1-2 staff for repositioning and turning in bed every two hours and as necessary. -Provide the resident with total assistance for eating. -To have a side rails 1/5 up per physician's order for safety during care provision, to assist with bed mobility, reposition every two hours and as necessary to avoid injury. -Provide the resident with two staff for transferring. A review of Resident 1's Nursing Progress Note dated 6/7/2024, indicated the resident was alert and oriented with periods of confusion and forgetfulness. The Nursing Progress Note indicated Resident 1 did not have any complaints of pain or discomfort. According to a review of the medical record, Resident 1 did not have a care plan for falls developed and there was no documentation regarding monitoring Resident 1 for 6/7/2024. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated 6/8/2024 at 7:21 AM, indicated Resident 1 was observed sitting on the floor. The SBAR indicated Resident 1 complained of pain but refused pain medicine. The SBAR indicated Resident 1's bed was in the lowest position and a floor mat was placed at bedside. The SBAR indicated the family and physician were notified of the incident. A review of Resident 1's Pain assessment dated [DATE] at 7:30 AM, indicated Resident 1's pain level was assessed as a three out of 10 for left knee pain, using the zero to 10 pain rating scale (zero equals no pain, and 10 equals the worst possible pain). The Pain Assessment indicated Resident 1's acceptable level of pain was a one. According to a review of the Nursing Progress Note dated 6/8/2024 at 12:53 PM, Resident 1 had mild left knee pain with facial grimacing but refused pain medication. The Nursing Progress Note indicated Resident 1 was alert with confusion and a floor mat was ordered for safety. A review of Resident 1's Nursing Progress Note dated 6/8/2024 at 10:33 PM, indicated Resident 1 continued to complain of pain on the left hip but stated the pain was tolerable and refused pain medication. A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/9/2024, indicated Resident 1 had severe cognitive impairment (problems with a person's ability to think, remember, and make decisions). The MDS indicated Resident 1 required substantial to maximal assistance of facility staff with toileting hygiene, rolling to the left and right side and sit to lying and lying to sitting on the side of the bed. The MDS indicated Resident 1 was dependent on facility staff for transfers and the fall history on admission was unable to be determined. A review of Resident 1's Laboratory and Radiology Patient Report dated 6/9/2024 at 1:49 AM, indicated Resident 1 had a left subcapital impaction fracture (type of intracapsular fracture in the proximal femur, where the fracture line runs through the junction of the head and neck of the femur) with minimal callus (thickening of or a hard thickened area on skin or bark, and mild displacement (change in position). The Report indicated the joint (part of the body where two or more bones meet to allow movement) showed no dislocation (separation of two bones where they meet at a joint). A review of Resident 1's SBAR dated 6/9/2024 at 6:55 AM, indicated Resident 1 had a left hip fracture and orders to transfer the resident to the GACH for further diagnosis and treatment was implemented. According to a review of the GACH History & Physical (H&P) dated 6/9/2024, Resident 1 was admitted for left hip pain and was noted to have a left hip fracture. The GACH H&P indicated Resident 1 was confused, disoriented, and complained of left hip pain. A review of Resident 1's GACH Computed Tomography (CT - diagnostic imaging procedure that uses a computer linked x-ray machine to create detailed images of the inside of the body) of the left hip, dated 6/10/2024, indicated Resident 1 had a subcapital fracture of the left femur (thigh bone) without significant displacement. A review of the GACH General Notes dated 6/10/2024, indicated Resident 1's legal guardian did not want the resident to have the recommended surgery. As a result, the surgery was canceled. A review of Resident 1's H&P dated 6/12/2024, indicated Resident 1 was unable to provide accurate history of medical issues and did not have medical decision-making capacity. During an observation on 6/24/2024 at 10:45 AM in Resident 1's room at the facility, Resident 1 was observed lying in bed, call light within reach, a mat to the right and left side of the bed, and the bed was in the lowest position. Resident 1 stated there was pain in the left hip but refused pain medication. During an interview on 6/24/2024 at 11:15 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 1 was a high risk for falls and the facility should have been monitoring Resident 1 for the risk for falls more frequently, because the resident was confused. On 6/24/2024 at 2:19 PM, during a concurrent interview and record review with LVN 1, Resident 1's care plans were reviewed. LVN 1 stated Resident 1 did not have a care plan for a history of falls developed or implemented since admission on 6/6/2024 (over two weeks). LVN 1 stated there should have been a care plan developed and implemented so the facility could anticipate and plan accordingly to accommodate the residents needs to prevent falls. LVN 1 stated because there was a history of falls, that was a repeated issue and should have been assessed further to prevent harm to Resident 1. LVN 1 stated this incident could have been prevented. During a concurrent interview and record review on 6/24/2024 at 2:44 PM with the Director of Nursing (DON), Resident 1's care plans were reviewed. The DON stated because the resident had a history of falls, a care plan should have been developed and implemented upon admission to the facility, to prevent Resident 1 from another fall or injury. The DON stated the fall could have been prevented if a Fall care plan was developed with interventions such as frequent monitoring to prevent injury. A review of the facility's policy and procedure (P&P) titled, Person Centered Plan of Care, dated June 2023, indicated the person-centered care plan must describe services that were provided to the resident to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being that would accommodate resident needs, request, and refusal to treatment. The P&P indicated the person-centered care plan would include interventions to attempt to manage risk factors and be periodically reviewed and revised by the Interdisciplinary Team as changes in the resident's care and treatment occur. The P&P indicated to re-evaluate and modify care plans as necessary to reflect changes in care, service, and treatment, quarterly, and with significant change in status assessment. Care plan evaluation must occur in response to changes in the resident's physical, emotional, functional, psychosocial, or communicative status as they occur. A review of the facility's P&P titled, Post Fall Management Program, dated June 2023, indicated the plan of care for each resident would be accelerated post fall, as indicated, to enhance the standard and medium to high preventative measures and decrease the risk of further falls in a manner that meets the individual needs of the resident. The P&P indicated to consider updating the plan to prevent repeat fall.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), a history of multiple falls, and was a high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: 1. Implement facility's policy and procedure (P&P) titled Fall Prevention Program, to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. 2. Evaluate interventions for effectiveness and implement new interventions to prevent repeated fall incidents after Resident 1 fell on [DATE], 3/20/2024, and 4/17/2024. 3. Monitor the resident for the behavior of trying to get out of bed without assistance as per physician's order dated 11/10/2023. As a result, Resident 1 had repeated fall incidents and on 4/17/2024 was found on the floor with a laceration (a deep cut or tear in the skin) to the right eyebrow requiring transfer to the General Acute Care Hospital 1 (GACH 1). Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 9/11/2023, with diagnoses including history of falling, dementia, lack of coordination and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Resident 1's admission Fall Risk assessment dated [DATE], indicated the resident had a very high risk for potential for falls. The assessment indicated the resident had not had any falls 90 days to the assessment date. The assessment indicated the resident had adequate vision, was confined to bed (unable to get up from bed without assistance), did not use the call light (a device with a button or touch pads a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) or the bathroom call cord reliably (in a way that can be trusted). A review of Resident 1's admission Risk for Falls Care Plan initiated on 9/11/2023, indicated Resident 1 had a history of falls prior to admission to the facility and the resident had dementia and Alzheimer's disease. The care plan goal for the resident was to have reduced occurrence of injury from falls for three months. The care plan interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent falls were to monitor the resident`s whereabouts daily, help with transfers and ambulation, provide proper fitting shoes, provide safe and clutter free environment, and to keep the call light and personal items within the resident's reach. A review of Resident 1's History and Physical dated 9/14/2023, indicated the resident did not have the capacity to understand and make decisions due to dementia. A review of Resident 1`s Physician orders dated 11/10/2023, indicated facility staff was to monitor the resident for the behavior of trying to get out of bed without assistance every shift. A review of Resident 1's Situation, background, assessment, and recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) Communication Form dated 12/7/2023, indicated the charge nurse found Resident 1 on the floor next to the bathroom door. The SBAR form indicated Resident 1 stated she went to the bathroom (on 12/7/2023) to void (urinate) and when she was returning to the bed, lost balance and fell on the floor. A review of Resident 1's Post Fall assessment dated [DATE], indicated Resident 1 was forgetful and confused, had impaired hearing, impaired judgment skills (the ability to make effective decisions), and impaired safety awareness. The post fall assessment indicated Resident 1 exhibited declined (lessening) cognitive skills, and loss of coordination due to Alzheimer's disease and dementia and was not using ambulation aid (walker, wheelchair) or appropriate footwear. A review of Resident 1's Fall Scene Investigation Report dated 12/7/2023, indicated Resident 1 lost her balance and was found on the floor in her room. The investigation report indicated Resident 1 refused help and tried to go to the bed from bathroom after voiding. A review of Resident 1's Interdisciplinary Team Summary and Recommendation (IDT, a team of health care professions, which include the facility's medical director, Director of Nursing [DON], social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents) dated 12/7/2023, indicated the IDT team recommended the following: to instruct the resident not to get out of bed without assistance, monitor the residents behavior of trying to get out of bed without assistance every shift, apply floor mats (a small piece of strong material that covers and protects part of a floor and is designed to absorb impact and reduce the risk of injury) at bedside, place the resident on Falling Star Program (a fall prevention program, that focuses on promoting a safe environment and anticipating the patient's needs to prevent a fall) for three months, and offer toileting program (helping a resident ambulate to the toilet, scheduling regular bathroom trips to avoid accidents, or changing adult diapers). A review of Resident 1's Risk for Falls Care Plan revised on 12/11/2023, indicated Resident 1 was found on the floor in front of the bathroom on 12/7/2023. The care plan indicated Resident 1 complained of pain to the left hip area. The care plan indicated the X-Ray (digital image of part of the body) results indicated no fracture. The care plan interventions indicated the resident was to be placed on the Falling Star program for three months, staff was to perform visual checks every hour for four (4) weeks, apply floor mats to the bedside, monitor for the behavior of trying to get out of bed, instruct the resident not to try to get out of bed without assistance, use the call light, keep the bed in the lowest position, and to start the resident on toileting program. The care plan intervention indicated Resident 1 refused toileting program on 12/13/2023. A review of Resident 1's Physical Therapy (PT- certain exercises, massages, and treatments that relieve pain and help you move better) Evaluation and Plan of Treatment dated 12/12/2023, indicated the resident was referred to PT due to falling. The evaluation form indicated Resident 1 presented with generalized weakness, incoordination (lack of coordination), and impaired balance resulting in overall decline with functional mobility skills. The evaluation form indicated Resident 1 required extensive assistance with task performance and was at risk for falls and immobility (unable to move). A review of Resident 1's Medication Administration Record (MAR) for the month of January 2024, indicated the resident did not demonstrate the behavior of trying to get out of bed during any shift in January 2024. A review of Resident 1's Occupational Therapy (OT-therapy that focuses on helping people do all the things that they want and need to do in their daily lives) Evaluation and Plan of Treatment dated 2/22/2024, indicated the resident demonstrated decreased safety and dynamic sitting/standing balance which placed the resident at risk for falling. A review of Resident 1's MAR for the month of February 2024, indicated the resident did not demonstrate behavior of trying to get out of bed during any shift in February 2024. A review of Resident 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive status [brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions], functional status, and care needs) dated 3/7/2024, indicated the resident had severely impaired cognition. The MDS indicated the resident was dependent on facility staff for showering. The MDS indicated Resident 1 required maximum facility staff assistance with toileting hygiene, personal hygiene, lower body dressing, sit to stand (the ability to come to standing position from sitting in a chair, wheelchair and or on the side of the bed), and chair/bed to chair transfer (the ability to transfer to and from a bed to chair or wheelchair). The MDS indicated Resident 1 required partial/moderate assistance from facility staff with oral hygiene, upper body dressing, toilet transfer (the ability to get on and off a toilet or commode) and sit to lying (the ability to move from sitting on side of the bed to lying flat on the bed). A review of Resident 1's Quarterly Fall Risk assessment dated [DATE], indicated the resident was at a very high risk for potential falls. The fall risk assessment form indicated Resident 1 had 1-2 falls within the last 90 days prior to the assessment date (3/7/2024), displayed behaviors which placed the resident at risk for falls, had impaired safety awareness, had adequate vision, was incontinent (not able to control the flow of urine from the bladder or the escape of stool from the rectum), did not use call light or bathroom call cord reliably, and did not have adequate safety awareness to wait for help. A review of Resident 1's Incident Report dated 3/20/2024, indicated Certified Nursing Assistant (CNA- unnamed) reported she heard sounds (on 3/20/2024) coming from Resident 1's room. Upon entering, CNA (unnamed) found Resident 1 on the floor next to her bed. A review of Resident 1's SBAR Communication Forms for 3/20/2024, indicated no SBAR communication form was documented by licensed staff after Resident 1 fell on [DATE]. A review of Resident 1's Fall Morse assessment dated [DATE], indicated the resident had fallen previously, had impaired gait, and overestimated (think they are stronger than they really are) or forgot her limits. The fall assessment did not indicate whether Resident 1 was considered a high risk for fall or not. A review of Resident 1's Post Fall assessment dated [DATE], indicated Resident 1 was forgetful and confused, exhibited loss of coordination due to Alzheimer's disease and dementia, had impaired safety awareness and hearing, and was not using ambulation aid (walker, wheelchair) and appropriate footwear. A review of Resident 1's Fall Scene Investigation Report dated 3/20/2024, indicated Resident 1 lost her balance and strength and was found on the floor in her room. The investigation report further indicated Resident 1 stated she was trying to go to bathroom. A review of Resident 1's IDT Summary and Recommendation dated 3/20/2024, indicated the following recommendations: remind resident to use the call light when assistance needed, instruct the resident not to get out of bed without assistance, monitor behavior of trying to get out of bed without assistance every shift, apply floor mats at bedside, keep the resident`s bed in the lowest position, answer the call light in timely manner, provide frequent visual checks, and to offer toileting program. A review of Resident 1's Actual Fall Care Plan initiated on 3/25/2024, indicated on 3/20/2024 at 7:35 PM, Resident 1 was observed on the floor at the bedside. The care plan indicated the resident stated she lost her balance and fell on the floor while trying to go to the restroom by herself. The care plan indicated a goal for the resident was to minimize episodes of falls or injury within the next 30 days. The care plan interventions were to anticipate and meet the resident`s needs, place the call light within his reach, encourage the resident to use the call light for assistance as needed, educate and remind the resident to request assistance prior to transfer/ambulation, conduct frequent visual checks, keep her bed in a low position, monitor her behavior of trying to get out bed without assistance, and to provide non-skid (designed to prevent sliding), proper fitting socks/shoes as indicated. A review of Resident 1's SBAR Form dated 4/17/2024, indicated the resident had a fall on 4/17/2024 with a laceration to the right eyebrow with moderate bleeding and pain. The SBAR communication form indicated Resident 1`s physician ordered to transfer the resident to GACH 1. A review of Resident 1's Fall Morse assessment dated [DATE], indicated the resident had fallen previously, had weak gait, and overestimated or forgot her limits. The fall assessment did not indicate whether Resident 1 was considered a high risk for fall or not. A review of Resident 1's Post Fall assessment dated [DATE], indicated Resident 1 had diagnoses of dementia and Alzheimer's, and incontinence, was forgetful and confused, exhibited declined cognitive skills and a loss of coordination due to Alzheimer's disease and dementia, had impaired safety awareness, judgment skills and hearing. A review of Resident 1's IDT Summary and Recommendation dated 4/17/2024, indicated the following recommendation: Rehabilitation services as needed, continue to monitor behavior of trying to get out of bed without assistance, remind the resident to use the call light when assistance needed, visual checks every hour for three months, and to instruct the resident not to get out of bed without assistance. A review of Resident 1's GACH 1 Emergency Department (ED) Summary of Care dated 4/18/2024 at 4:23 AM, indicated the resident was sent to ED for head injury and laceration to right eyebrow which was treated in the ED. A review of Resident 1' MAR for the month of April 2024, indicated the resident did not display the behavior of trying to get out of bed during any shift in April 2024. During a concurrent observation and interview on 4/22/2024 at 9:10AM, inside Resident 1's room, observed Resident 1 laying in her bed. Resident 1 had a dressing over her right eyebrow. The Certified Nursing Assistant 1 (CNA1) present at Resident 1's bedside stated Resident 1 was confused and was trying to get out of bed. During an interview on 4/22/2024 at 9:30AM, Licensed Vocational Nurse 1 (LVN1) stated Resident 1 was forgetful and confused. LVN1 stated Resident 1 was not able to walk independently and required assistance with walking. LVN1 stated She [Resident 1] tried to get up on her own. Today [4/22/2024] she did not get up without assistance and she was calm. She [Resident 1] said, 'I want to go outside, or I want to go see my son or go to the restroom'. She cannot walk on her own. LVN1 stated Resident 1 was at high risk for falling. LVN1 stated [Resident 1] fell ,d+[DATE] times in the facility. We were monitoring her every two hours and sometimes every hour. However, there were times that charge nurses and CNAs were busy and could not check the residents often. LVN1 stated there is no bed alarm (pressure-sensitive alarms go off when a resident gets up) on Resident 1's bed. We did not try to put the alarm. Some residents do not like the alarm. During an interview on 4/22/2024 at 10:05AM, the Registered Nurse Supervisor 1 (RN1) stated Resident 1 was not alert, was confused, and sometimes what the resident said did not make sense. RN1 stated Resident 1 fell on [DATE], suffered an injury to the right forehead, and was sent to ER. RN1 stated She [Resident 1] got out of bed on her own. RN1 stated [Resident 1] tries to get out of bed. Sometimes she sits on the edge of her bed. She does not use the call light. She does not call for help. During a concurrent interview and record review on 4/22/2024 at 10:15 AM with RN1, Resident 1's Fall incidents care plans and SBAR Communication forms for fall incidents were reviewed. RN1 stated RN1 stated Resident 1 was non-compliant (not doing what someone asks you to do) with seeking assistance and did not use the call light. RN1 stated licensed staff did not initiate a care plan with person-centered interventions for Resident 1's non-compliance with calling for help. RN1 stated [Resident 1's] care plan for fall interventions were not revised properly after each fall and it appears that the same interventions are implemented for the resident over and over after each fall. It seems like these interventions are not effective because Resident 1 fell and had an injury on 4/17/2024. Resident 1 needs different care plan interventions for fall to prevent her from falling. We could have placed an alarm on her bed to notify the staff when she tried to get out of her bed. RN1 stated The DON said bed alarm is considered a restraint (controlling the actions or behavior of someone by force). During a concurrent interview and record review of Resident 1's MAR for January, February, and April 2024 on 4/22/2024 at 10:35AM, RN1 reviewed the MARs and stated the licensed staff documented there were no incidents of Resident 1 trying to get out of bed for the months of January, February, and April 2024. RN1 stated the documentations were not accurate because Resident 1 did in fact attempt to get out of bed on numerous occasions. RN1 stated the staff did not document correctly and did not indicate the number of times Resident 1 tried to get out of bed. RN1 stated Resident 1 got out of bed and had a fall on 4/17/2024, However the documentation did not reflect the attempt to get out of bed which led to the fall on 4/17/2024. During an interview on 4/22/2024 at 12:56 PM, the Director of Staff Development (DSD) stated, On 4/17/2024 around 7:30 PM, I was at the nursing station when we heard a scream. We went inside [Resident 1's] room and found her on her floor laying on her right side. We noticed a laceration to [Resident 1`s] right eyebrow which was bleeding. We could not stop the bleeding and perform treatment to her right eyebrow ourselves, so we called the physician and received an order to transfer her to the hospital. The DSD stated Resident 1 was transferred to GACH 1 on 4/17/2024 at 9 PM and returned to the facility on [DATE] at around 6 AM. The DSD stated on 3/20/2024 Resident 1 had another episode of fall. The DSD stated I have seen Korean nurses communicating with [Resident 1]. However, she is unable to retain any information and she has episodes of confusion. I don't know if she would be able to remember educations about using the call light or asking the staff to assist her when she wants to go to the bathroom or get out of bed. During a concurrent interview and record review on 4/22/2024 at 1:15 PM with DSD, Resident 1's fall incidents care plans were reviewed. The DSD stated, [Resident 1`s] fall care plan interventions are the same for all fall incidents. The intervention to instruct the resident to call for assistance is not effective for [Resident 1] because she is forgetful. The DSD stated Resident 1 was non-compliment in using the call light to ask for help. The DSD stated educating Resident 1 to use a call light for help was not an effective intervention because the resident was confused and forgetful. The DSD stated licensed staff did not develop any care plan for Resident 1's non-compliance with asking for assistance. The DSD stated licensed staff were required to develop person centered care plans with resident specific interventions. The DSD stated Resident 1`s fall care plan interventions were not person-centered, and the potential outcome was recurrent falls and injures. The DSD stated bed alarm could be an intervention for [Resident 1]. During an interview on 4/22/2024 at 2 PM, RN2 stated Resident 1 tried to get out of bed and had history of several falls in the facility. RN2 stated Resident who has a behavior of trying to get out of bed, we require CNAs to stay in front of the resident`s room. We asked them to watch the resident frequently. RN2 stated staff were conducting frequent visual checks for Resident 1. However, it seemed like frequent visual monitoring did not work for Resident 1. RN2 stated Resident 1 was unable to remember facility staff instructions to call for assistance. RN2 stated [Resident 1] did not have a bed alarm. Previously, we had an intervention to assign a sitter for high risk for fall residents. It might be an appropriate intervention to prevent [Resident 1] from falling. During a concurrent interview and record review on 4/22/2024 at 2:10 PM, RN2 reviewed Resident 1's fall incidents care plans. RN2 stated licensed staff did not evaluate the effectiveness of the care plan interventions to prevent falls for Resident 1. RN2 stated care plan interventions were not revised and updated effectively for Resident 1 after each fall. RN2 stated licensed nurses were required to revise and update care plan interventions for each resident after each fall. RN2 stated licensed nurses were required to evaluate the effectiveness of care plan interventions and change the interventions if ineffective. RN2 stated the potential outcome of not developing person-centered fall care plan interventions were the risk of recurrent falls and injuries. A review of the facility`s policy and procedure titled Fall Prevention Program, reviewed June 2023, indicated the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If the resident is at risk for falls, it will be identified on the care plan. All precautions will be implemented to protect the resident according to the fall prevention and reduction program. Care plan interventions should include the treatment prescribed by the physician and interdisciplinary recommendations, if any. A resident's condition and the effectiveness of the plan of care interventions will be evaluated if revisions are necessary to justify for continuing the existing plan based upon the outcome and/or effects of goals and interventions. A review of the facility`s policy and procedures (P&P) titled Fall Prevention Interventions, dated December 2016, indicated residents who were scored high risk on Morse Fall Scale were required to be reassessed after each episode of fall and their current care plan interventions were required to be evaluated for effectiveness and revised if ineffective. The P&P indicated the significant decline in the use of mechanical and chemical restrains to prevent high risk residents' falls had stimulated the proliferation (rapid growth/development) of bed alarm systems which were designed to warn nursing staff if a resident was attempting to leave the bed unassisted. A review of the facility's P&P titled Falling Star Program revised 12/16/2020, indicated identify residents for potential repeated falls with fall risk assessment. Fall risk assessment is initiated upon admission, quarterly, when significant changes occur and when fall incidents occur.

Based on observation, interview, and record review, the facility failed to provide protection from sexual (non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault) by facility staff, for one of three sampled residents (Resident 1). Resident 1 alleged sexual abuse by Certified Nurse Assistant (CNA) 1, when CNA 1 touched the resident ' s private parts and held Resident 1's hand on his (the CNA's) private part. This deficient practice resulted in Resident 1 having psychological distress (a state of emotional suffering), was crying and reported feeling afraid, ashamed, anxious and guilty. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 3/15/2024 with the diagnoses including the lack of coordination (impaired balance) and abnormalities of gait (walking pattern) and mobility. A review of Resident 1's History and Physical dated 3/18/2024, indicated the resident was transferred to the facility for physical therapy (care that helps people with physical and functional limitations caused by injury or disease) after suffering a fall on 3/12/2024. The History and Physical further indicated Resident 1 had medical decision-making capacity. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/20/2024, indicated the resident was cognitively intact (able to think, understand, and reason). A review of the Nurse Staffing Assignment dated 3/23/2024, indicated CNA 1 was assigned to take care of Resident 1 during the 7 AM to 3 PM shift. According to a review of the Situation, Background, Assessment, and Recommendation (SBAR, a structured communication framework that can help teams share information about the condition of a patient) Communication Form and Progress Note dated 3/25/2024 at 2 PM, the resident was not feeling good and felt weird. The note indicated Resident 1 called Caregiver (CG) 1 around 2 PM on 3/23/2024 and informed CG 1 the assigned CNA touched Resident 1's private parts and held the resident's hand on his (the CNA's) private part. The note indicated Resident 1's family and physician were notified. A review of Resident 1's Social Services Note dated 3/25/2024 at 5:40 PM, indicated staff were informed Resident 1 wanted to report something that happened on 3/23/2024. The note indicated Resident 1 stated that her CNA improperly touched her private area. The note indicated CNA 1 was no longer at the facility and a psychologist (a mental health professional who uses psychological evaluations and talk therapy to help people learn to better cope with life and relationship issues and mental health conditions) consultation (a meeting with an expert or professional, such as a medical doctor, to seek advice) was scheduled for 5 PM that day. The note indicated Resident 1's emotions and behavior would be continuously monitored for any changes, and indicated support would be provided as needed. A review of Resident 1's Psychotherapy Note dated 3/25/2024, indicated the therapist inquired about the resident' recent sexual abuse allegation. The note indicated the therapist addressed Resident 1's feelings of guilt and shame. The note indicated Resident 1 initially presented as generally calm with a congruent affect (when a mood matches a person ' s behavior) but later became tearful at various points during the session. The note indicated Resident 1 reported sleep disturbance due to frequent urination and distressing dreams. The note indicated Resident 1 was able to revisit the event, fully described related details, and processed associated thoughts and feelings that included guilt, shame, humiliation, anxiety, fear, confusion, butterflies in the stomach, some anxiousness due to intrusive thoughts since the event, and fear of CNA 1. During an interview on 3/27/2024 at 8:53 AM, Resident 1 stated the incident happened on Saturday 3/23/2024 around 1 PM to 2 PM. Resident 1 stated she had to have her incontinent brief changed and called her CNA who was male. Resident 1 stated CNA 1 told her to lie back down and then started to touch her vagina and move his hand in circles. Resident 1 stated she was frightened. Resident 1 stated CNA 1 then took her hand and put it over his private area and she felt CNA 1's private area getting bigger. Resident 1 stated she tried to move her hand, but CNA 1 grabbed it and placed it back on his private area. Resident 1 stated she said 'no' three times. Resident 1 stated afterwards CNA 1 started massaging her shoulders. Resident 1 stated she was scared because the CNA's usually just change her incontinent brief and leave; but this CNA stayed a while. Resident 1 stated she did not know who to talk to and remembered she had a previous caregiver at home. Resident 1 stated she called the caregiver and told them what happened. Resident 1 stated the caregiver came to the facility on Monday 3/25/2024. Resident 1 stated she did not remember the CNA's name, but indicated the CNA was tall, wearing black scrubs, and had a little darker skin. Resident 1 stated she saw CNA 1 again on Monday, which made her scared. Resident 1 was observed crying and tearful. Resident 1 stated she was afraid and indicated she was worried she would get moved from the facility and not get taken to activities, because she told someone what happened. During an interview on 3/27/2024 at 11:50 AM, the Social Services Director (SSD) stated she heard of what happened on 3/25/2024 at 2 PM, that Resident 1 was crying, and was afraid and ashamed that she could not talk about the incident the day it happened. The SSD stated Resident 1's caregiver from home encouraged her to tell the facility about what happened. The SSD stated she along with the Administrator, Director of Staff Development (DSD), and Activities gathered in Resident 1's room. The SSD stated Resident 1 indicated the incident happened on Saturday 3/23/2024 during the 7 AM to 3 PM shift. The SSD stated Resident 1 could not remember the exact time but remembered the CNA was on the morning shift, because he left after 3 PM. The SSD stated Resident 1 indicated CNA 1 came to the resident's room to change her incontinent brief; and once he opened the incontinent brief the CNA put his finger on the resident ' s private area. The CNA then took the resident ' s hand and put it on his private area. The CNA stated Resident 1 indicated she said 'no' three times, but he kept rubbing the resident ' s private area. The SSD stated Resident 1 was crying and was afraid her son might get upset if he found out. The SSD stated Resident 1 stated she never had any similar experiences in the past. The SSD stated Resident 1 felt ashamed. During an observation on 3/27/2024 at 1:09 PM, the facility's surveillance video was viewed. The video revealed on 3/23/2024 at 2:05 PM, CNA 1 entered Resident 1's room and put on gloves. At 2:06 PM CNA 1 was observed pulling the curtain around Resident 1's bed. At 2:07 PM, CNA 1 was observed coming out from behind the curtain of Resident 1's bed and exiting the resident's room. At 2:16 PM, CNA 1 was observed re-entering Resident 1's room. At 2:19 PM, CNA 1 was observed pulling the curtain around Resident 1's bed. At 2:20 PM CNA 1 was observed coming out from behind the curtain of Resident 1's bed not wearing gloves. At 2:25 PM CNA 1 was observed entering Resident 1's bathroom by himself, was observed in the bathroom for a few minutes, and then observed leaving Resident 1's room. On 3/27/2024 at 3:30 PM, during a telephone interview, CNA 1 stated he did not touch Resident 1's vagina. CNA 1 stated he did not make Resident 1 touch his private area. CNA 1 stated he was only doing his job to clean Resident 1. During a telephone interview on 3/28/2024 at 11:39 AM, CG 1 stated she knew Resident 1 for over two years and knew the resident before she was transferred to the facility. CG 1 stated Resident 1 called her on Saturday 3/23/2024 and informed her that a CNA touched the resident ' s private area when he was changing the resident ' s incontinent brief. CG 1 further stated Resident 1 informed her the CNA also made the resident touch his private area. CG 1 stated she went to the facility on Monday 3/25/2024 and Resident 1 got sacred when she saw CNA 1. CG 1 stated Resident 1 felt very uncomfortable and that was when she informed the facility staff about what had happened between Resident 1 and CNA 1. During an interview on 3/28/2024 at 12:02 PM, the DSD stated CNA 1 was from the registry and after the allegation, CNA 1 was asked to leave the facility. The DSD stated CNA 1 would not be returning to the facility. During an interview on 3/28/2024 at 2:58 PM, the Administrator stated Resident 1 explained that CNA 1 came into her room and touched her vagina area. The Administrator stated CNA 1 was asked to make a statement and leave the facility. The Administrator stated CNA 1 would not be allowed back in the facility and that Resident 1 was cognitively intact. The Administrator stated Resident 1's story never changed when she told it to the facility staff and to the police officers. A review of the facility's Follow-Up Investigation Report dated 3/29/2024, indicated on Monday 3/25/2024 around 2:15 PM, indicated the Administrator asked the SSD to ensure Resident 1 was safe with frequent visits for the next few days. The report indicated CNA 1 was moved away from Resident 1, was asked to make a statement, and was asked to leave the facility. The report indicated the psychologist came to meet with Resident 1 the same day. The report indicated the police came to the facility at 5:30 PM and took a statement from Resident 1. The report indicated Resident 1 told the police officers the same story. The report further indicated Resident 1 told the psychologist the same story. The report indicated the facility could not disregard Resident 1's allegations and safety concerns because the resident was alert and oriented. The report indicated the facility would continue to provide room visits with Resident 1 to reinforce safety. The report further indicated CNA 1 was no longer allowed in the facility. A review of the facility's policy and procedure titled, Abuse and Neglect Prohibition Policy, reviewed 6/2023, indicated it was the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion of all residents. The purpose of the policy was to ensure facility staff were doing all that was within their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all residents. Abuse was defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which were necessary to maintain physical or mental health including the following. Sexual abuse was non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault.

Based on observation, interview, and record review, the facility failed to prevent a fall and injuries for one of two sampled residents (Resident 1). For Resident 1, who was at risk for falls, the facility failed to: 1. Ensure Resident 1 had a proper posture when sitting in the wheelchair, with her back and hip resting on the backrest and the feet on the footrest of the wheelchair. 2. Implement Resident 1's plan of care by not providing a safe environment and not handling Resident 1 gently and carefully. As a result, on 5/18/19, at 11:04 a.m., Resident 1 was sitting at the edge of the wheelchair with the feet on the floor and without correcting Resident 1's posture, Certified Nursing Assistant 1 (CNA 1) wheeled Resident 1 to the patio. Resident 1's feet caught a mat before the door to the patio, and Resident 1 fell off the wheelchair on her face sustaining a laceration (skin cut) on the nose, nasal bleeding, discoloration to her right hand, and broken dentures. Resident 1 required transferring to General Acute Care Hospital 1 (GACH 1), the same day of the fall, where she was diagnosed with [REDACTED]. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted a [AGE] year old, female resident (Resident 1) on 11/15/16, with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 5/10/19, indicated Resident 1 had severely impaired cognition (gaining and understanding knowledge). Resident 1 required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. Resident 1 was dependent on staff with locomotion (movement between locations) and toilet use. A review of Resident 1's Fall Risk Assessment form dated 5/18/19, indicated Resident 1 had a fall risk score of 16. A total score of ten or above represented a high risk. A review of Resident 1's Fall Risk Care Plan dated 9/11/18, indicated the interventions included providing Resident 1 a safe and clutter-free environment. A review of Resident 1's Fracture Risk Care Plan dated 9/11/18, indicated the interventions included handling Resident 1 gently while giving care. A review of the Report of Unusual Occurrence dated 5/18/19, indicated Resident 1 fell from the wheelchair, landing on her face when CNA 1 pushed Resident 1's wheelchair out to the patio. A review of the Incident Report form dated 5/18/19, at 11:04 a.m. indicated CNA 1 said Resident 1 was up in the wheelchair restless, and CNA 1 took her to the patio. Before CNA 1 reached outside, Resident 1 fell out of the wheelchair. Resident 1 sustained a laceration on the nose, nasal bleeding, discoloration to her right hand, and broken dentures. A review of Resident 1's nursing notes dated 5/18/19 indicated the physician ordered the transfer of Resident 1 to GACH 1 on 5/18/19 at 11:15 a.m. A review of Resident 1's GACH 1 Procedures and Tests notes dated 5/18/19, indicated Resident 1 had a depressed nasal bone fracture with associated soft tissue swelling. On 7/9/19, at 9:35 a.m., Resident 1 was observed to be in the Activities Room. Resident 1 had a small scar on the bridge of her nose. The Director of Nursing (DON) stated this scar was the result of her fall from the wheelchair (5/18/19). On 7/9/19, at 9:58 a.m., during a concurrent observation of the video surveillance recording with the Director of Staff Development (DSD), on 6/14/19 at 11:04 am, CNA 1 was observed wheeling Resident 1 towards the patio. Resident 1 was leaning forward in her wheelchair with both feet touching the ground. When reaching the exit door to the patio, CNA 1 did not carefully check for any hazard such as the floor mat. Resident 1 went forward and fell . The DSD stated CNA 1 did not carefully handle Resident 1 when wheeling her to the patio. On 7/9/19, at 10:05 a.m., during an interview, the Occupational Therapist (OT) and a concurrent review of the facility's surveillance camera recording video, CNA 1, is seen wheeling Resident 1 to the patio. Resident 1 was restless and sitting on the front edge of the wheelchair, leaning forward and with the feet on the ground. The OT stated Resident 1's back should be resting on the wheelchair backrest and her feet on the footrest. The OT said there was a doormat on the floor before the exit to the patio. The OT stated it appeared Resident 1's feet caught the front edge of the mat, causing her to fall forward. A review of the policy on Safety and Accident Prevention, revised 9/2009, indicated the facility's objective was to provide a safety and health program to reduce the number of injuries to an absolute minimum.