Every finding on record at North Long Beach Post Acute

Based on interview and record review, the facility failed to ensure facility staff supervised the residents' whereabouts to prevent the resident from leaving the facility without facility staffs' knowledge for one of one resident (Resident 1) on 8/27/2026. This deficient practice resulted in Resident 1 eloping from the facility for a second time in two months (6/20/2026) on 8/27/2026, putting Resident 1 at risk for serious injury, harm, or death from hazards in the community, including traffic accidents, falls, or exposure to environmental conditions.Findings:During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Dementia (group of thinking and social symptoms that interfere with daily functioning), Depression (person feels very sad, hopeless, or uninterested in things they usually enjoy for a long period of time) , unspecified psychosis (a mental condition where a person has trouble telling what is real from what is not) and heart failure (heart does not circulate blood throughout the body leading to major organ failure). During a review of Resident 1's History and Physical (H&P), dated 2/18/2025, the H&P indicated Resident 1 did not have the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 8/19/2026, the MDS indicated Resident 1 needed set up assistance or clean-up assistance (helper set up or clean up; resident completes activity. Helper assists only prior to or following the activity) with activities of daily living such as eating, personal hygiene and getting dressed). The MDS indicated Resident 1 used a wheelchair for ambulation. During a review of Resident 1's Order Summary, dated 6/21/2026, the Order Summary indicated Resident 1 had an active order for one-to-one monitoring for safety and whereabouts. During a review of Resident 1's Care Plan titled Resident Noted to have Episode of Elopement Identified Episode of Having Eloped Out of the Building Found Outside of the Facility, dated 6/20/2026, the Care Plan indicated Resident is on one-to-one monitoring for safety and whereabouts. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to encephalopathy, anemia, and major depressive disorder. During a review of Resident 2's History and Physical (H&P), dated 1/15/2026, the H&P indicated Resident 2 did not have the capacity to make medical decisions. During an interview on 8/29/2026 at 10:19 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the last time she saw Resident 1 was on 8/27/2026 at 1 p.m. CNA 1 stated Resident 1 eloped at 2:00 p.m. CNA 1 stated Resident 1 had attempted to elope before. CNA 1 stated no alarm sounded when Resident 1 eloped. CNA 1 stated she was with another resident and saw staff running in the hallways but was not aware of Resident 1's elopement. CNA 1 stated there were no interventions in place to prevent Resident 1 from leaving the facility. During an interview on 8/30/2026 at 12:08 P.M. with Resident 2, Resident stated he saw the Resident 1 jump out of the window and fall onto the ground. During an interview on 8/30/2026 at 1216 pm with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 1 was unable to make medical decisions. During an interview on 8/30/2026 at12:54 p.m. with Scheduler (SCH) 1, SCH 1 stated on 8/27/2026 at 2:40 p.m. SCH 1 saw the window open and saw a chair next to the window. SCH 1 stated Resident 2 stated Resident 1 went out the window. SCH 1 stated she told the Administrator and all the staff went out to look for Resident 1. SCH 1 stated Resident 1 was close to a bus stop crossing the street. SCH 1 stated she was able to get Resident 1 back across the street without any resistance. SCH 1 stated Resident 1 was said he was trying to go with his wife. During a concurrent interview and record review on 8/30/2026 at 1:58 p.m. with RNS 1 Resident 1's Every 15-Minute Visual Check, dated 8/27/2026, was reviewed. The Every 15 Minute Visual Check indicated from 6:36 a.m. to 3:00 p.m. there was no documentation of visual checks for Resident 1. RNS 1 stated we needed to make sure we knew the whereabout of Resident 1 every 15 minutes and document it. RNS 1 stated when CNA 1 went for break a nurse was supposed to cover for CNA 1 and check Resident 1 every 15 minutes. RNS 1 stated the residents could hurt themselves or elope if not checked. During a review of the facility's policy and procedure (P&P) titled Leave of Absence Without Notice (LAWN), dated 1/16/2026, the P&P indicated, The interdisciplinary team members (IDT) are recommended to evaluate if a resident is deemed at risk of leaving the facility without notice and identify resident-specific measures in a least restrictive environment.

Based on interview and record review, the facility failed to create and implement a person-centered care plan for one of one sampled residents (Resident 4) who inappropriately (not suitable or proper in the circumstances) touched a female staff (unknown) on the chest. As a result of this deficient practice there was a potential for Resident 4 to inappropriately touch another female staff or resident. Findings: During a review of Resident 4's admission Record (face sheet), the admission Record indicated Resident 4 was admitted to the facility 6/15/2026 with diagnoses of schizophrenia (a severe, chronic mental health disorder that affects how a person thinks, feels, and behaves, often making it hard to tell what is real and what is imagined) and insomnia (unable to sleep). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 7/16/2026, the MDS indicated Resident 4 was cognitively intact (memory, thinking, and reasoning work well).During a review of Resident 4's SBAR (Situation, Background, Assessment, and Recommendation) Summary for Providers dated 7/23/2026, the SBAR Summary for Providers indicated Resident 4 was observed inappropriately touching staff (unknown) and the staff reported that resident 4 grabbed her chest. During a review of Resident 4's care plans, a care plan was created on 7/23/2026 for: Resident exhibited sexually inappropriate behavior by inappropriately touching staff. The care plan was Resolved (discontinued) five days later on 7/28/2026. During an interview on 8/13/2026 at 12:39 p.m. the MDS Nurse (MDSN) stated she resolved Resident 4's care plan for his sexually inappropriate behavior towards staff because he was only on monitoring for three days after the incident. During an interview on 8/13/2026 at 12:42 p.m. the Director of Nursing (DON) stated the care plan for inappropriate behavior should not have been resolved and if they discontinue a care plan too early there was a risk staff would not know the history of what occurred and they would not know how to care for the resident to be aware of the behaviors he had. During a review of the facility's policy and procedure (P/P) titled Care planning- Interdisciplinary Team dated 8/25/2021, the P/P indicated the Interdisciplinary Team was to develop an individual comprehensive care plan for each resident.

Based on observation, interview, and record review the facility failed to ensure the controlled substances (a drug or chemical whose manufacture, possession, and use are strictly regulated by the government due to a risk of abuse or dependence) for one of one sampled residents (Resident 6) who was discharged from the facility were properly disposed of and an accurate record was kept for the medication count. As a result of this deficient practice there was a potential for drug diversion (the transfer of a legally prescribed controlled substance from its intended patient to another person for illicit use ) to occur. Findings: During a review of Resident 6's admission Record (Face sheet), the admission Record indicated Resident 35 was admitted to the facility 6/10/2026 with diagnoses of schizophrenia (a chronic brain disorder characterized by psychosis (hallucinations and delusions), disorganized thinking, and reduced emotional expression), unspecified mood disorder (affect your persistent emotional state), and other stimulant use (a mental health condition characterized by the repeated, uncontrollable use of stimulant (psychoactive substances that speed up the central nervous system and bodily functions) drugs, which continues despite significant negative consequences on a person's life, health, and relationships).During a review of Resident 6's Order Summary Report, physician's orders were placed on 6/10/2026 for Clonazepam (Klonopin, a controlled substance that is used to treat certain seizure (a sudden, uncontrolled burst of electrical activity in the brain that can change how a person acts, moves, feels, or looks) disorders) oral tablet 0.5 milligrams (mg, a unit of measurement): give one tablet by mouth one time a day for seizure and Clonazepam oral tablet 1 mg: give one tablet by mouth at bedtime for seizure. On 6/19/2026 a physician's order was placed for Midazolam Nasal Solution (Nayzilam, a fast-acting rescue medicine used to stop severe or clustered seizures) 5mg/ 0,1 milliliter (mL, a unit of measurement): 1 spray in left nostril as needed for seizures lasting more than 5 minutes, 2 doses maximum in a single episode and transfer to the emergency room (ER). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool) dated 6/17/2026, the MDS indicated Resident 6 was cognitively intact (an individual has sufficient judgment, planning, organization, and self-control to manage the normal demands of their environment without assistance).During a review of Resident 6's Nurses Progress Note dated 8/3/2026, the Nurse Progress Note Indicated Resident 6 left the facility at approximately 8:15 a.m. via facility transport for a court appearance. During a review of Resident 6's Nurses Note dated 8/4/2026, the Nurse Progress Note indicated family member (FM) 1 picked up all of Resident 6's medications except the controlled substances (Midazolam and Clonazepam).On 8/12/2026 at 8:15 a.m., during a concurrent observation and interview and record review, with licensed vocational nurse (LVN) 1, a medication storage observation was completed for medication cart number two. A brown unlabeled paper bag was found in the controlled substances drawer containing Resident 6's medications including bubble packs (pre-sorted card packages that organize your pills by the specific day and time you need to take them) of 1.) 26 tablets of Clonazepam 0.5 mg 2.) 10 tablets of Clonazepam 1 mg and two nasal sprays labeled Nayzilam 5mg nasal spray each containing 2 doses. Resident 6's Antibiotic or Controlled Drug Records for the 4 medications were also found in the brown paper bag and the last date signed on the medication count was 8/3/2026 for all 4 medications. LVN 1 stated Resident 6 had been discharged from the facility, but she was new, so she did not know why the medication was still in the cart and she did not know what to do with the medications. LVN 1 stated Resident 6's medications were not part of the controlled substance count at the change of shift. During an interview on 8/12/2026 at 9:33 a.m., the Director of Nursing (DON) stated Resident 6 was discharged from the facility on 8/3/2026 after her court appearance. The DON stated FM 1 came and picked up all of Resident 6's medications except for the controlled substances after the discharge. The DON stated the nursing staff (unknown) should remove the controlled substances from the medication cart and give them to her (DON) to be stored and then destroyed with the pharmacist, but it was not done. The DON stated if the controlled medications were still in the cart they should have been included in the narcotic count (last day signed was 8/3/2026) but per policy they should be immediately removed to be destroyed. The DON stated the controlled substances needed to be removed from the cart to prevent others from taking the medications (drug diversion). During a review of the facility's policy and procedure (P/P) titled Medication Storage in the Facility dated 8/2014, the P/P indicated a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and was to be documented on the controlled medication accountability record (Antibiotic and Controlled Drug Records). The P/P indicated medications remaining in the facility after the order has been discontinued are retained in the facility in a secure double locked area with restricted access until destroyed by the facility's DON or a registered nurse employed by the facility and a pharmacist.

Based on observation, interview, and record review the facility failed to provide one of one sampled resident (Resident 5) a window to see outside to help the resident orient to day, night, and weather. As a result of this deficient practice, Resident 5 was not provided with a homelike environment and had the potential for Resident 5 to be disoriented to time of day and to feel confined. Findings: During a review of Resident 5's admission Record (face sheet), the admission Record indicated Resident 5 was admitted to the facility 5/1/2026 with diagnoses of schizophrenia (a severe, chronic mental health disorder that affects how a person thinks, feels, and behaves, often making it hard to tell what is real and what is imagined) and depression (a serious mood disorder that causes a persistent feeling of sadness and loss of interest in daily life). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 5/8/2026, the MDS indicated Resident 5 was cognitively intact (memory, thinking, and reasoning worked well). On 8/13/2026 at 8:15 a.m., during a concurrent observation and interview with Resident 5, Resident 5's window was observed to be covered by a frosted privacy decal (plastic film) and Resident 5 was unable to see out of his window. Resident 5 stated he felt couped up because he could not see outside and he wanted to look at the birds. On 8/13/2026 at 9:30 a.m., during a concurrent observation and interview with the Maintenance Supervisor (MS), the MS checked Resident 5's window and removed the frosted privacy decal. The MS stated he was unsure why Resident 5's window had the frosted privacy decal and stated he removed it because Resident 5 was unable to see out of his window. During an interview on 8/13/2026 at 12:42 p.m., the Director of Nursing (DON) stated the facility was the resident's home and they should have the choice to be able to see out of the window. During a review of the facility's policy and procedure (P&P) titled Bedrooms dated 1/2025, the P/P indicated each bedroom was to have at least one window leading to the outside.

Based on observation, interviews and record reviews, the facility failed to provide adequate supervision for three out of nine residents sampled (Resident 6, 7, and 12) in the secured Behavioral Unit of the facility. a. The facility failed to prevent a physical altercation between Resident 6 and 7 during a smoke break in the patio on 7/16/2026. This failure resulted in Resident 6 sustaining a superficial linear scratch, measured at 0.1 centimeter (cm) by 1 cm, to the left side of the bridge of the nose with scant amount of blood. Resident 6 also sustained a superficial scratch to the left upper lip with scab (dry, protective crust that forms over a cut) forming, measured at 1 cm by 0.1 cm. Resident 6 had a 5th metacarpal neck/head fracture of the right hand (broken bone in the hand) which was still healing and the current altercation caused localized swelling in the same hand. Resident 7 sustained an abrasion (minor skin wound caused by scraping or rubbing) to the upper lip and a scratch to the right ear and neck. b. The facility failed to ensure Resident 12 did not leave the facility without prior authorization. On 7/24/2026, Resident 12, who had previously exited Station 2 on 6/23/2026 through the same door, pushed a staff member aside and proceeded to walk approximately 0.2 miles, crossing three street intersections. This failure exposed Resident 12 to environmental hazards, placing Resident 12 at high risk for traffic accidents, harsh weather, and other dangerous conditions. Findings:a. During a review of Resident 6's admission record, the admission record indicated the facility admitted Resident 6 on 4/14/2026 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), cannabis (commonly called marijuana, weed, or pot) dependence, psychoactive (substances that alter the central nervous system, affecting how the brain functions and changing a person's mood, thoughts, feelings, awareness, or behavior) substance dependence, and a nondisplaced fracture (broken or cracked bone where the fragments stay lined up in normal position) of the neck of fifth metacarpal bone (the narrow area of the hand's outer long bone just below the pinky knuckle). During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool), 7/2/2026, the MDS indicated Resident 6's cognition was intact. The MDS indicated Resident 6 was independent with eating, oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 6's Psychiatry ((medical specialty in treating mental illness) Progress Note, dated 7/15/2026 at 4:30 p.m., the note indicated Resident 6 continued to experience persistent psychotic (losing touch with reality) symptoms. Resident 6's admission condition to date had been notable for mood lability and an altercation on 06/23/2026, which resulted in fractures to his right hand and cheek.During a review of Resident 6's care plan titled, Resident 6 exhibits physical/aggressive behavior towards peers related to: Poor impulse control, initiated 6/23/2026. The care plan goal indicated Resident 6 will not harm others until 10/17/2026. One of the interventions indicated Programming Staff visits to provide support, as needed.During a review of Resident 6's Change of Condition Evaluation, 7/16/2026 at 6:02 p.m., the evaluation indicated Resident 6 reported an argument over limited smoking seating and was hit by another resident (Resident 7).During a review of Resident 6's Body Check, 7/16/2026 at 6:02 p.m., the document indicated that Resident 6 had a superficial linear scratch, measured at .1 centimeter (cm) by 1 cm, to left side of the bridge of the nose with scant amount of blood. Resident 6 also had a superficial scratch to left upper lip with scab forming 1cm by .1 cm.During a review of Resident 6's Radiology Results report, performed on 7/17/2026 at 8:27 a.m., the right hand, 2 views indicated right hand had mild swelling. The findings were consistent with healing 5th metacarpal neck/head fracture compared to 7/7/2026.During a review of Resident 7's admission record, the admission record indicated the facility admitted Resident 7 on 2/13/2026 with diagnoses including schizophrenia, Attention deficit hyperactivity disorder (condition marked by persistent patterns of inattention, hyperactivity, and impulsivity), Tourette's disorder (condition that causes sudden, repeated, and uncontrolled body movements and sounds called tics), anxiety disorder (mental health condition characterized by persistent worry and fear), and psychoactive substance dependence.During a review of Resident 7's MDS, 5/22/2026, the MDS indicated Resident 7's cognition was intact. The MDS indicated Resident 7 was independent with eating, oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 7's Psychiatry Progress Note, dated 6/24/2026 at 4 p.m., the note indicated Resident 7's judgement and insight was impaired. The note indicated his placement in the current structured supervised setting is significant protective factor against substance use relapsing.During a review of Resident 7's Progress Notes, dated 7/16/2026 at 7 p.m., the note indicated Resident 6 was involved in a physical altercation.During a revie of Resident 7's Body Check, 7/16/2026 at 7:43 p.m., the note indicated Resident 7 sustained an abrasion to the upper lip and a scratch to the right ear and neck.During an interview on 7/28/2026 at 7:50 a.m., in Resident 6's room, Resident 6 stated that during the last smoke break he was seated and Resident 7 went after his seat. Resident 7 socked him in the left eye and Resident 6 defended himself. Resident 6 stated staff could not see the altercation, but the residents were separated after Primary Counselor (PC) 4 saw Resident 6 and 7 fighting each other. During a concurrent interview and record review on 7/28/2026 at 11:23 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 6 and 7's medical records were reviewed. RNS 2 confirmed Resident 6 and 7 both have mental health issues and were admitted in the facility and were under the Office of Diversion and Reentry ([ODR] government or community agency that helps people avoid jail or criminal records by redirecting them into treatment and support services) program as a court mandate. During a concurrent interview and record review on 7/28/2026 at 11:34 a.m., with RNS 2, PC 4 statement regarding the altercation on 7/16/2026 was reviewed. RNS 2 confirmed and stated that PC 4 was behind the crowd of residents, as he moved forward the group PC 4 witnessed then finally broke off the fight. RNS 2 stated the group of residents needed more supervision.During an interview on 7/28/2026 at 1:13 p.m. with PC 4, PC 4 stated after he retrieved group 2 smoke break box (plastic receptacle that contained group 2 residents' cigarettes and lighter), he walked back to the hallway with the residents outside patio door. When PC 4 was in middle of the crowd, PC 4 told Group 2 residents to start going outside the patio. Once the crowd of residents all got in the patio, PC 4 made his way to the front and that's when PC4 saw Resident 6 and 7's physical altercation and then PC 4 separated them. PC 4 stated he was the only staff in the smoke break for fifteen residents. b. During a review of Resident 12's admission record, the admission record indicated the facility admitted Resident 12 on 3/12/2026 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), opioid (class of drugs that include prescription pain relievers, synthetic versions made in labs, and illegal drugs like heroin) and stimulant (class of consumed legal substances or illicit drugs that increase alertness, energy, and cognitive focus) dependence, and anxiety disorder.During a review of Resident 12's MDS, 6/17/2026, the MDS indicated Resident 12's cognition was intact. The MDS indicated Resident 12 was independent with all activities of daily living (activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 12's History and Physical (H&P), dated 3/13/2026, the H&P indicated resident was forgetful, an inaccurate historian, and was not able to make his own medical decisions.During a review of Resident 12's Leave of Absence Without Notice (LAWN) Evaluation Form (elopement evaluation form), 6/30/2026 at 1:23 p.m., the form indicated Resident 12 had a history of exhibiting exit-seeking behavior, either while at home or from the facility without informing staff. The form indicated Resident 12 wandered in or out of the facility premises and the Interdisciplinary team (IDT the residents health care team consisting of various specialties) had determined the resident was at risk for Leave of Absence Without Notice.During a review of Resident 12's Situation Background Assessment Recommendation (SBAR) Summary for Providers, 6/23/2026 at 4:11 p.m., the note indicated Resident 12 was involved in a physical altercation, the police came to take Resident 12 to the hospital for aggression. Resident 12 refused and when mental health evaluator came to assess the resident, Resident 12 ran through the kitchen. The mental health evaluator called the police; resident was taken to the General Acute care hospital for 5150 (person is placed on a 72-hour involuntary psychiatric hold during a mental health crisis).During a review of Resident 12's Change in Condition Evaluation, 7/24/2026 at 1:30 p.m., Resident 12 left the facility through the kitchen door and staff immediately followed the resident. During an observation and interview on 7/27/2026 at 10:56 a.m., with Certified Nurse Assistant (CNA) 5, CNA 5 stated on 7/24/2026 She was punching the security code on the kitchen door to open the door when Resident 12 then pushed her and ran down the hallway. CNA 5 stated there was another door in the kitchen hallway and on that day (7/24/2026), the kitchen hallway door was propped open with a chair so Resident 12 was able to go outside. CNA 5 showed how the chair was positioned to hold the door open. During an interview on 7/27/2026 at 11 a.m., with Resident 12, Resident 12 stated he left the facility last Friday (7/24/2026). During a concurrent interview and record review on 7/27/2026 at 2 pm with the staff scheduler (SCH), Google maps showing the map of the facility with the surrounding neighborhood were reviewed. The SCH pointed where Resident 12 traveled. The map indicated Resident 12 walked approximately 0.2 miles away from the facility and had to cross three street intersections. The SCH stated that when Resident 12 left the facility, SCH, who was amongst other staff (unidentified), followed Resident 12 on the street on foot. Licensed Vocational Nurse 1 and CNA1 brought their car, so the SCH jumped in the car and the three staff were able to follow Resident 12 more closely. SCH stated Resident 12 walked out of the facility through Market street, then made a left on [NAME] street then right on [NAME] street then when he was on Elm street. SCH stated that before getting to 55th street, CNA 3, who was not working that day, was riding his scooter and SCH, LVN 1, and CNA 1 waved him down for assistance and CNA 3 on his scooter was able to go in front of Resident 12, Resident 12 stopped, and was convinced to walk back to the facility. During an interview and record review on 7/28/2026 at 11:39 a.m., with RNS 2, Resident 12's medical records were reviewed. RNS 2 confirmed and stated Resident 12 had previously run out of the building through the kitchen door on 6/23/2026 but was apprehended by authorities. RNS 2 stated that on 7/24/2026 at approximately 1:30 p.m., Resident 12 exited the facility through the kitchen door without prior notice. RNS 2 stated he should not have been able to leave facility premises twice. RNS 2 stated Resident 12 should have been redirected, have more activities, or supervision may not have been enough.During an interview with the Interim Director of Nursing (IDON) on 7/8/2026 at 1:45 p.m., the IDON stated adequate monitoring and supervision of residents in the Behavioral Unit was important. The IDON stated residents have the right to be free from abuse. The IDON stated Resident 12 should not have been able to exit the facility without advanced notice. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition, revised 10/25/2024, the P&P indicated, the facility prohibits abuse and the facility will implement an abuse prohibition program by preventing occurrences. During a review of the facility's P&P titled, Smoking, effective 8/9/2022, the P&P indicated the facility will provide a safe environment for residents. During a review of the facility's P&P titled, Safety of Residents, effective 6/27/2022, the P&P indicated the facility will provide a safe environment for residents and residents who display combative behaviors will receive prompt and appropriate intervention. The P&P indicated residents will be monitored for behavioral triggers like increased anger and frustration.

Based on interviews and record reviews the facility failed to accommodate one of one resident's (Resident 11) family member's (FM 1) request to not have Certified Nurse Assistant (CNA) 6 as a care giver.The failure violated residents' rights and had the potential to result in negative psychological outcomes.Findings:During a review of Resident 11's admission Record, the admission Record record indicated the facility readmitted Resident 11 on 3/30/2021, with diagnoses including hepatic failure (liver loses ability to function), spinal stenosis (narrowing of the spaces within your spine that puts pressure on your spinal cord and nerves) lumbar region, dementia (a progressive state of decline in mental abilities), and cataracts (eye problem causing blurry vision).During a review of Resident 11's minimum data set (MDS a resident assessment tool), dated 6/8/2026, the MDS indicated Resident 11 had severely impaired cognition (make decisions regarding tasks of daily life). The MDS indicated Resident 11 was dependent on facility staff for all activities of daily living (activities such as bathing, dressing and toileting a person performs daily). During an interview on 7/27/2026 at 9:57 a.m., with Resident 11's Family Member (FM 1), FM 1 stated they did not want CNA 6 to take care of Resident 11. FM 1 stated one day two weeks ago CNA 6 was assigned to take care of Resident 11 and FM 1 was upset.During a concurrent interview and record review on 7/27/2026 at 11:55 a.m., with the facility staff Scheduler, an untitled signage dated 7/16/2026 was reviewed. The signage indicated that effective 7/16/2026, CNA 6 should not be assigned to Resident 11. The scheduler stated the signage was in Station 1 to make sure that CNA 6 did not get assigned to Resident 11 as requested by FM1. During a concurrent interview and record review on 7/28/2026 at 11:20 a.m., with Registered Nurse Supervisor (RNS) 2, the 11 p.m. to 7 a.m. Shift Assignment for 7/16/2026 was reviewed. RNS 2 confirmed and stated CNA 6 was assigned to Resident 11 on 7/16/2026 11 a.m. to 7 p.m. shift and should not have been.During an interview on 7/28/2026 at 1:45 p.m., with the Interim Director of Nursing (IDON), the IDON stated residents' preferences need to be honored and respected.During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised 1/2020, the P&P indicated the residents' preferences will be accommodated to the extent possible.

Based on interviews and record reviews, the facility failed to complete an annual performance evaluation (a regular check-in where a company looks at how well an employee does their job) for Certified Nurse Assistant (CNA) 6 who was facing allegations of abuse from one out of five sampled residents (Resident 8) and complaints from Resident 11's family member (FM 1). The failure to conduct a performance evaluation on an employee facing complaints places the residents at risk for compromised safety, poor service and poor quality of care which can be detrimental to the residents' health.Findings:During a review of Resident 8's admission Record, the record indicated the facility readmitted Resident 8 on 3/26/2026 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one entire side of the body), following cerebral infarct( death of brain tissue) affecting the right dominant side, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 8's Minimum Data Set ([MDS] a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 8 can make herself understood and understand. The MDS indicated Resident 8 needed supervision eating and was dependent (helper does all effort to perform task) on staff for oral hygiene, toileting hygiene, dressing, showering, and personal hygiene. During a review of Resident 8's Situation Background Assessment Recommendation Communication (SBAR) Form, dated 7/17/2026, Resident 8 complained that CNA 6 smacked her on the right hand.During a review of Resident 11's admission Record, the record indicated the facility readmitted Resident 11 on 3/30/2021 with diagnoses including hepatic failure (liver loses ability to function), spinal stenosis (narrowing of the spaces within your spine that puts pressure on your spinal cord and nerves) lumbar region, dementia (a progressive state of decline in mental abilities), and cataract (eye problem causing blurry vision).During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11's had severely impaired cognition (make decisions regarding tasks of daily life). The MDS indicated Resident 11 was dependent on all activities of daily living (activities such as bathing, dressing and toileting a person performs daily). During an interview on 7/27/2026 at 9:57 a.m. with Resident 11's family member (FM 1), FM 1 stated they did not want CNA 6 to take care of Resident 11, FM 1 was unsatisfied with CNA 6's work.During an interview on 7/28/2026 at 7:35 a.m. with Resident 8 in Resident 8's room, Resident 8 stated CNA 6 smacked her and pointed to her right wrist. During a concurrent interview and record review on 7/28/2026 at 1:45 p.m., with the Interim Director of Nursing (IDON), CNA 6's personnel files were reviewed. The IDON confirmed and stated CNA 6's last documented performance evaluation was 2012. The Interim DON stated it was important to complete performance evaluations so the facility can see what the staff was lacking in and areas of improvement that need to be addressed.During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, revised 2/2026, the P&P indicated the job performance of every employee was reviewed and evaluated at least annually.

Based on interview and record review, the facility failed to:a. Protect the residents' rights to be free from physical abuse from each other. Resident 36, Resident 54 and Resident 55 were involved in a physical altercation for two of three sampled residents (Resident 54 and Resident 55) reviewed for physical abuse sustained injuries, when facility staff were unable to de-escalate Resident 54's behavior.b. Protect the residents' rights to be free from sexual abuse (unwanted touching) by staff to resident for one of one resident (Resident 35) reviewed for sexual abuse, when Primary [NAME] (PC) 2, touched Resident 35's leg inappropriately. c. Protect the residents' rights to be free from physical abuse by Resident 36 for one of one resident Resident 44, when Resident 36 hit Resident 44 in the face.These failures resulted in Resident 54 sustaining a laceration (deep, ripped cut or gash caused by a hard blow or blunt impact) to the anterior (front) scalp (the skin on top of the head) and Resident 55 sustaining bruising and swelling on the right zygomatic arch (curved boney bridge on the side of the skull) and a nondisplaced fracture (broken or cracked bone where the fragments stay lined up in normal position) of the distal (further from point of attachment) fifth metacarpal bone (long bone in the palm that connects the wrist to pinky finger) requiring a cast on the right hand and the potential for Resident 35, Resident 36 and Resident 44 for continued abuse, and psychosocial decline. Findings: a.During an interview on 7/7/2026 at 10:20 a.m. with Resident 54, Resident 54 stated, while in the outdoor patio (on 6/23/2026), Clinical Therapist (CT) 1 put him on blast (called out his behavior) in front of other residents that made him feel shitty, hurt, and put into a corner. Resident 54 stated he would not have hit CT 1 because CT 1 was a [NAME]. Resident 54 stated he instead punched Resident 55 on the head, when Resident 55 got up from his (Resident 55) seat, and got him good (powerful hit). During an interview on 7/7/2026 at 10:30 a.m. with Resident 55, Resident 55 stated, Resident 54 started a fit (screaming) towards CT 1 while they were in the outside patio (on 6/23/2026), and Resident 54 seemed like he wanted to hit CT 1. Resident 55 stated that Resident 54 started charging towards him and hit him multiple times in the face causing him (Resident 54) to fall to the ground. Resident 55 stated while Resident 54 was on the ground, he kicked Resident 54 on the side (of the body) and hit him on the side of the head. During an interview on 7/7/2026 at 10:40 a.m. with Resident 36, Resident 36 stated, Resident 54 was arguing with CT 1 (on 6/23/2026) and got in CT 1's face (screaming). Resident 36 stated, when Resident 54 punched Resident 55, he (Resident 36) grabbed Resident 54 by wrapping his (Resident 36) arm around his (Resident 54) neck and pinned Resident 54 to the ground. Resident 36 stated he never got along with Resident 54. Resident 36 stated, Resident 54 was always agitated, always in people's business, disrespectful, and problematic. During an interview on 7/7/2026 at 10:50 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, she witnessed Resident 54 and Resident 55 fighting (on 6/23/2026). CNA 2 stated she was with Resident 55 when he was transferred to the hospital for his injuries (after Resident 55's altercation with Resident 54 on 6/23/2026). CNA 2 stated, Resident 55 had a black eye on his right eye and got a cast for his right hand from the hospital. During an interview on 7/8/2026 at 1:10 p.m. with CT 1, CT 1 stated Resident 54 was trying to take a chair from Resident 86 (on 6/23/2026), so he went over to de-escalate the situation but Resident 54 was not coming down from his heightened state (was verbally aggressive and shouting F this and F you). CT 1 stated, Resident 54 rushed towards him with a balled fist, when Resident 55 and Resident 36 stood up and approached Resident 54. CT 1 stated, Resident 54 hit Resident 55 a couple of times. During an interview on 7/8/2026 at 1:29 p.m. with Primary Counselor (PC) 1, PC 1 stated the incident between Resident 54, Resident 55 and Resident 36 happened around 3 to 4 p.m. in the facility's patio (on 6/23/2026), when Resident 54 tried to take a seat from Resident 86. PC 1 stated she attempted to de-escalate the situation but was unable to, so she called CT 1 to come out to assist her. PC 1 stated CT 1 attempted to redirect Resident 54 but was also unsuccessful. PC 1 stated CT 1 offered Resident 54 to go inside the building but Resident 54 refused. PC 1 stated, Resident 54 then walked towards CT 1 with a closed fist, that was when Resident 55 and Resident 36 got involved. PC 1 stated, Resident 54, Resident 55, and Resident 36 all hit each other. PC 1 stated Resident 54 had a gash on his head and Resident 55 was later found to have had an injury to his hand. During a concurrent interview and record review on 7/9/2026 at 4:14 p.m. with Registered Nurse Supervisor (RNS) 1, the Resident 54's Nurses Progress Notes, dated 6/18/2026 were reviewed. The Nurses Progress Notes indicated Resident 54 was having increasing aggression after having multiple altercations with Resident 36. Resident 54 was angry at Resident 36 because Resident 36 had been bugging him all day. RNS 1 stated, Resident 54 and Resident 36 had a prior incident where they were annoying each other (on 6/18/2026). RNS 1 stated, after that incident (on 6/18/2026), Resident 54 and Resident 36 were not separated to different nursing stations. RNS 1 stated Resident 54 and Resident 36 were only assigned to different nursing stations after the altercation on 6/23/2026. RNS 1 stated, if Resident 54 and Resident 36 were separated after the incident on 6/18/2026, the physical altercation between Resident 54 and Resident 36 (on 6/23/2026) could have potentially been prevented. RNS 1 stated, Resident 36 may have been triggering (an external or internal cue that causes a strong emotional reaction) for Resident 54. During an interview on 7/10/2026 at 11:19 a.m. with the Administrator (ADMIN), the ADMIN stated, staff should ensure a safe environment and intercept and intervene to prevent abuse. The ADMIN stated, staff should recognize the resident population with psychiatric (a related to mental health conditions, mental disorders, or the medical care and treatment of those conditions) diagnosis are erratic and unpredictable and the resident population with schizophrenia (a mental illness that can affect thoughts, mood, an behavior) hear voices and lash out. During an interview on 7/10/2026 at 4:35 p.m. with the Director of Nursing (DON), the DON stated she was aware of the physical altercation between Resident 54, Resident 36, and Resident 55 (on 6/23/2026). The DON stated based on the report provided to her, Resident 54 hit Resident 55, then Resident 54 and Resident 55 threw punches (hit each other). The DON stated, Resident 36 then grabbed Resident 54 on the shirt of his collar. The DON stated, Resident 54 sustained a cut on his scalp, which she stated would be classified as a major injury. The DON stated, Resident 55 sustained discoloration to the face and a fracture (broken bone) on his right hand, which she stated would also be classified as a major injury. During a review of Resident 54's admission Record, the admission Record indicated the facility admitted Resident 54 on 3/12/2026 with diagnoses including schizoaffective disorder (a chronic mental health condition characterized by a combination of symptoms including hallucinations or delusions and depression or mania), opioid dependence (a physical adaptation where the body becomes reliant on opioid medications (medications that interact with receptors in the brain and nervous system to block pain), signals stimulant dependence (substances that increase brain and nervous system activity), and anxiety disorder (mental health condition that is characterized by experiences of intense, ongoing, and uncontrollable fear or worry). During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool), dated 6/17/2026, the MDS indicated, Resident 54 was cognitively intact (able to recall and understand). The MDS indicated, Resident 54 had potential indicators of psychosis (a state in which a person loses touch with reality), including hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions of beliefs that are firmly held, contrary to reality). During a review of Resident 54's Change of Condition (COC) Evaluation, dated 6/23/2026, the COC Evaluation indicated Resident 54 was observed antagonizing another resident during patio time. When Resident 54 was about to hit a counselor (CT 1), another resident (Resident 36) tackled him, resulting in Resident 54 sustaining a one-centimeter (cm, unit of length) cut to left forehead. During a review of Resident 54's Consultation Report from the hospital, dated 6/23/2026, the Consultation Report indicated Resident 54 had a small laceration on his anterior scalp and lip. During a review of Resident 55's admission Record, the admission Record indicated, the facility admitted Resident 55 on 4/14/2026 with diagnoses including schizophrenia, cannabis [(commonly called marijuana, weed, or pot) dependence, and psychoactive (substances that alter the central nervous system, affecting how the brain functions and changing a person's mood, thoughts, feelings, awareness, or behavior) substance dependence. During a review of Resident 55's MDS, dated [DATE], the MDS indicated, Resident 55 was moderately cognitively impaired (decline in thinking, memory, and reasoning that interferes with complex daily activities). The MDS indicated Resident 55 had a potential indicator of psychosis, including hallucinations. During a review of Resident 55's COC Evaluation, dated 6/23/2026, the COC Evaluation indicated Resident 55 was observed having a physical altercation with another resident, resulting in Resident 55 having left cheek redness and pain in his right fifth finger. During a review of Resident 55's X-Ray (a medical imaging test to create pictures of the inside of the body) results for the right hand, dated 6/23/2026, the X-Ray results indicated Resident 55 had a nondisplaced fracture deformity of the distal end of the fifth metacarpal bone. During a review of Resident 36's admission Record, the admission Record indicated, the facility admitted Resident 36 on 3/13/2026 with diagnoses including schizophrenia, anxiety disorder, psychoactive substance (any substance that affects the brain and alters mood, perception, thinking, or behavior) abuse use, opioid dependence, stimulant dependence, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 was cognitively intact. The MDS indicated Resident 36 had potential indicators of psychosis, including hallucinations and delusions. During a review of Resident 36's COC Evaluation, dated 6/23/2026, the COC Evaluation indicated Resident 36 was observed in a physical altercation with another resident (Resident 54) while in the patio. During a review of the facility's policy and procedure titled, Abuse Prevention Program, revised 12/2016, indicated, As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. b. During a review of Resident 35's admission Record (Face sheet), the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of schizophrenia (a chronic brain disorder characterized by psychosis (hallucinations [hearing things not based in reality] and delusions [believing things not based in reality], disorganized thinking, and reduced emotional expression), unspecified mood disorder (affect your persistent emotional state), and other stimulant use (a mental health condition characterized by the repeated, uncontrollable use of stimulant (psychoactive substances that speed up the central nervous system and bodily functions) drugs, which continues despite significant negative consequences on a person's life, health, and relationships). During a review of Resident 35's Psychiatric Intake Note dated 6/16/2026, the Psychiatric Intake Note indicated Resident 35 had history of trauma (a deeply upsetting and scary experience that makes a person feel unsafe, overwhelmed, or hurt either physically or emotionally) involving men and endorsed feeling depressed (a common but serious mood disorder that causes persistent feelings of sadness, loss of interest, and physical fatigue). The psychiatric intake note indicated Resident 35 reported having Post Traumatic Stress Disorder (PTSD, a mental health condition triggered by witnessing or experiencing a terrifying or life-threatening event). During a review of Primary Counselor (PC) 2's Notice to Employee as to Change in Relationship dated 6/16/2026, PC 2 was discharged from employment on 6/16/2026 for violation of policy. During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 6/17/2026, the MDS indicated Resident 35 was cognitively intact (an individual has sufficient judgment, planning, organization, and self-control to manage the normal demands of their environment without assistance). During an interview on 7/8/2026 at 2:10 p.m., Resident 35 stated roughly two weeks ago (unknown exact date), PC 2 was fired after he touched her on her leg inappropriately and she did not like how PC 2 spoke to her as a woman. Resident 35 stated the day PC 2 touched her leg inappropriately they were in the counselor's office and she was able to smell liquor from under PC 2's face mask and PC 2 was stumbling when walking. Resident 35 stated she became loud and upset and told PC 2, do not ever fucking touch me again. Resident 35 stated PC 3, Clinical therapist (CT) 1, and the Program Manager of the Behavioral Unit (PMBU) were all aware of what happened with PC 2. During an interview with the PMBU on 7/8/2026 at 4:11 p.m., the PMBU stated at the end of PC 2's employment she became aware PC 2 was trying to provide comfort to Resident 35 and touched Resident 35 on her upper leg towards the knee. The PMBU stated she talked to PC 2 and told him it was inappropriate to touch a resident and most of their residents do not like being touched at all. The PMBU stated she never spoke to Resident 35 about the situation but had PC 3 who had witnessed the incident talk to Resident 35. The PMBU stated unwanted touch from staff to residents should never happen and it could be considered sexual abuse. The PMBU stated PC 3 informed her that Resident 35 stated she did not like being touched by PC 2 and she did not want PC 2 touching her anymore. During a review of Resident 35's Investigation Statement taken on 7/8/2026 at 5:20 p.m., the statement indicated Resident 35 alleged PC 2 told her, Babe it is going to be okay while he rubbed her leg up and down and she felt like there was a pervert in the room. Resident 35 alleged PC 2 was intoxicated, dirty, and inappropriate. During an interview on 7/9/2026 at 9:20 a.m., with the Administrator (ADMIN), the Admin stated the PMBU and PC 3 were suspended for failing to notify and report the allegation of abuse by PC 2 to Resident 35. The ADMIN stated she did not know about the allegation of abuse and it was a complete shock. During an interview on 7/9/2026 at 10:17 a.m., with PC 3, PC 3 stated she was in the counselor's office the day of the incident between PC 2 and Resident 35 and witnessed PC 2 reach out and touch Resident 35 on the thigh. PC 3 stated the moments leading up to the touching incident PC 3 had secretly texted the PMBU to inform her that PC 2 was not acting right and he was stumbling with blood shot eyes, so she felt he was drunk or hungover. PC 3 stated PC 2 was trying to speak to Resident 35, but she would not respond to him. PC 3 stated she heard PC 2 say terms of endearment such as sweetie to Resident 35. PC 3 stated she told PC 2 to stop talking to Resident 35 because she did not want to speak to him and PC 2 was persistent and kept trying to make Resident 35 speak to him and when PC 2 called Resident 35 sweetie, PC 3 turned around to see what was going on and that was when she witnessed PC 2 touch Resident 35 on her thigh. PC 3 stated right after that, the PMBU walked into the counselor's office and escorted PC 2 out of the building, but she could not tell the PMBU about the leg touching until one to two hours after the incident. PC 3 stated the PMBU asked PC 3 to speak to Resident 35 about the incident so she did and Resident 35 confirmed PC 2 touched her on the thigh and Resident 35 felt disgusted by PC 2, she did not consider him a counselor, questioned why he was being persistent with her, and did not want him talking to her again. PC 3 stated she believed the incident was sexual abuse due to unwanted touching and she felt it was weird and inappropriate that PC 2 touched Resident 35 on the thigh. During an interview on 7/9/2026 at 10:55 a.m., with CT 1, CT 1 stated days after the incident (unknown exact date), Resident 35 informed him that PC 2 had touched her (Resident 35) on the leg, but it was already after PC 2 was permanently removed from the facility. CT 1 stated Resident 35 had previously disclosed during one of their group sessions that she was sexually abused by a man and CT 1 was afraid the touching by PC 2 may trigger Resident 35's sexual abuse trauma. CT 1 stated when Resident 35 first came to the facility she was very guarded (uses emotional self-protection to prevent vulnerability) and guarded towards male staff but CT 1 was able to work with Resident 35 to break down her wall so he was afraid she would lose progress due to this situation. CT 1 stated Resident 35 reported feeling uncomfortable due to the situation. During an interview on 7/9/2026 at 2:45 p.m., with Resident 35, Resident 35 stated she felt as though PC 2 was using his power against her to take advantage of a mentally ill person. Resident 35 reported having trouble with male staff and she is not used to being in places with male authority because she has history of sexual abuse. During an interview on 7/10/2026 at 11:30 a.m., with the Director of Nursing (DON), the DON stated the allegation of abuse by PC 2 to Resident 35 should have been reported when the incident occurred to ensure the resident was safe and protect the resident's right to be free from abuse. The DON stated the touch on the leg by PC 2 to Resident 35 could have been seen as sexual abuse because it was unwanted touch and he was in Resident 35's personal space. During a review of the facility's P&P titled Abuse Prohibition Policy and Procedure dated 2/23/2021, the P&P indicated sexual abuse was any non-consensual sexual contact of any type with a resident. The P&P indicated the facility was to identify, correct, and intervene in situations in which abuse of a patient was more likely to occur. The P&P indicated anyone that witnessed an incident of suspected abuse was to tell the abuser to stop immediately and report the incident to his/ her supervisor immediately. The notified supervisor was to report the suspected abuse to the ADMIN right away in accordance with state law. The P&P indicated the facility was to report allegations of abuse no later than two hours after the allegation was made to the State Survey Agency and local law enforcement. c.During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), schizophrenia, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44 had intact cognitive (thinking process) functioning. The MDS indicated Resident 44 was independent for self-care abilities such as eating, hygiene, dressing and putting on footwear. The MDS indicated Resident 44 was independent on mobility such as sitting, standing and transfers. During a review of Resident 44's H&P dated 5/25/2026, the H&P indicated Resident 44 was alert and oriented (a medical term used to describe a patient's level of consciousness and cognitive awareness) to self, place and time but unclear if resident was able to make his own medical decisions at this time. During a review of Resident 44's social service progress note, dated 6/14/2026, the social service progress note indicated around 8:20 p.m., this writer (of the social service progress note) observed Resident 44 and another peer (Resident 36) speaking in room [ROOM NUMBER] (Resident 44's room) as writer was walking down the hallway.writer was returning down the hallway, writer observed Resident 44 bleeding from the face in his room. During a review of Resident 44's change in condition (any sudden or major deviation from a person's baseline physical, mental, or functional health) evaluation note, dated 6/14/2026, the change in condition evaluation note indicated Resident 44's had a laceration in the oral cavity, oral cavity bleeding with laceration (rip or tear in body tissue) to the left upper inner lip. During a review of Resident 44's follow up documentation by staff, dated 6/15/2026, the follow up documentation note indicated resident was on monitoring for recent wound to left upper inner lip with slight swelling noted. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including schizophrenia, anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36's MDS dated [DATE], the MDS indicated Resident 36 had intact cognitive functioning. The MDS indicated Resident 36 was independent of self-care abilities such as eating, hygiene, dressing and putting on footwear. The MDS indicated Resident 36 was independent on mobility such as sitting, standing and transfers. During a review of Resident 36's H&P dated 3/12/2026, the H&P indicated Resident 36 was alert and oriented to person, place and time but was forgetful, and not able to make his own medical decisions. During a review of Resident 36's social service progress note, dated 6/14/2026, the social service progress note indicated around 8:20 p.m., this writer (of the social service progress note) observed Resident 36 and another peer (Resident 44) speaking in room [ROOM NUMBER] (Resident 44's room) as writer was walking down the hallway.writer was returning down the hallway, writer observed peer (Resident 44) bleeding from the face and Resident 36 was in the bathroom washing his hands. During an interview on 7/9/2026 at 10:03 a.m., with Clinical Therapist ([CT], a licensed mental health professional who diagnoses and treats emotional, behavioral, and psychological disorders) 1, CT 1 stated one month ago (no exact date), CT 1 was reading the social service progress note and the social service progress note indicated that Resident 44 had injury to the nose. The CT 1 stated he talked to Resident 44 and Resident 44 stated that something happened, but Resident 44 did not want to say more. CT 1 stated he talked to Resident 36 but Resident 36 kept stating it was not a big deal. During an interview on 7/9/2026 at 4:17 p.m., with RN Supervisor (RNS) 1, RNS 1 stated there was an incident that happened between Resident 44 and Resident 36. RNS 1 stated she asked Resident 44 if he was okay but Resident 44 did not want to talk about it. RNS 1 stated she asked Resident 36 what happened but either him or Resident 44 wanted to talk about it. RNS 1 stated if a resident was found with an injury, the resident should be treated and assessed to make sure they are okay. RNS 1 stated all residents should be safe in the facility and free from harm and injury. During an interview on 7/10/2026 at 10:29 a.m., with the Director of Nursing (DON), the DON stated she was aware of the incident that happened between Resident 36 and Resident 44 but that neither of the residents wanted to say what happened, so they did not pursue the matter. The DON stated all residents should be free from abuse, injury or harm. The DON stated all residents in the facility should be free from abuse, whether it was from another resident, staff or visitors. During an interview on 7/10/2026 at 11:09 a.m., with Resident 44 near the dining room in Station 3, Resident 44 stated he remembered the incident that happened between him and Resident 36. Resident 44 stated Resident 36 hit him in the face. Resident 44 stated he had blood on his face; he was bleeding from his mouth. Resident 44 stated he told Resident 36 that he wanted privacy, wanted to be left alone but Resident 36 hit Resident 44 in his face. During an interview on 7/10/2026 at 11:19 a.m. with the Administrator (ADMIN), the ADMIN stated she was the abuse coordinator (a designated professional within a facility responsible for preventing, investigating, and reporting instances of abuse or neglect) and all abuse or allegations of abuse should be reported to her. The ADMIN stated the expectations all residents should have from staff was freedom from abuse. The ADMIN stated the expectation of all the staff was to ensure a safe environment for the residents. The ADMIN stated all staff should be aware of the different types of abuse, intercept and intervene to keep the residents safe. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention Program, revised December 2016, indicated, the administration will protect the residents from abuse by anyone including facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. During a review of the facility's P&P titled Abuse Prohibition Policy and Procedures, dated 2/23/2021, indicated, staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property for all patients.

Based on observation, interview, and record review the facility failed to uphold resident's rights to receive visitors of their choosing for two out of 63 sampled residents (Resident 35 and Resident 78). As a result of this deficient practice Resident's Rights were violated for Resident 35 and Resident 78. All 63 residents in the behavioral unit were also affected by the rules on visitation imposed by the facility. Findings:a. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of schizophrenia (a chronic brain disorder characterized by psychosis (hallucinations [hearing things not based in reality] and delusions [believing things not based in reality], disorganized thinking, and reduced emotional expression) , unspecified mood disorder (affect your persistent emotional state), and other stimulant use (a mental health condition characterized by the repeated, uncontrollable use of stimulant (psychoactive substances that speed up the central nervous system and bodily functions) drugs, which continues despite significant negative consequences on a person's life, health, and relationships).During a review of Resident 35's Minimum Data Set (MDS a resident assessment tool) dated 6/17/2026, the MDS indicated Resident 35 was cognitively (ability to make decisions of daily living) intact. During an interview on 7/8/2026 at 2:10 p.m., Resident 35 stated the facility had a very strict visitation policy and residents in the unit could only get visitors from family members and friends from 12:30 p.m. to 1 p.m. and 5:30 p.m. to 6 p.m. Resident 35 stated it was not right that she could only spend 30 minutes with her visitors. Resident 35 stated she felt as though the rules were too strict, not fair, and they affected her mood.b.During a review of Resident 78's admission Record, the admission Record indicated the facility admitted Resident 78 on 6/10/2026 with diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with a foot ulcer (a wound caused by poor circulation and damaged nerves).During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment and was independent for eating, oral hygiene, toileting hygiene, bathing, and dressing.During an interview on 7/9/2026 at 11:45 a.m. in the hallway in station 2 with Resident 78, Resident 78 stated a family member drove two hours to visit Resident 78. Resident 78 stated the visitor arrived outside the visiting hours of 5:30 p.m. to 6 p.m. Resident 78 stated the visitor was allowed to leave items for resident 78 but not stay to visit. Resident 78 stated he (Resident 78) would want the option to have meals with the visitor, but the visiting hours are too limited.During an interview on 7/9/2026 at 5 p.m., the receptionist (RCP) 1 stated the behavioral unit (stations 2 and 3) had set visitation hours from 12:30 p.m. to 1 p.m. and 5:30 to 6 p.m. RCP 1 stated the rest of the residents in the facility that did not reside on the behavioral unit did not have set visitation hours. During an interview on 7/10/2026 at 9:22 a.m., the Case Manager (CM) 1 became tearful and stated she was very passionate about the behavioral unit residents because they were young and she felt as though the new rules were treating the residents like animals and as though the residents were still incarcerated (kept in prison). CM 1 stated it was not fair to impose these rules on the residents because they were not incarcerated. CM 1 stated she voiced her concerns regarding the rules to management (unknown), but they did not listen. CM 1 stated there were different rules for visitation on the behavioral unit versus the rest of the facility residents in which she stated she opposed the different visitation rules because she felt as though it was violating the resident's rights.During an interview and concurrent record review on 7/10/2026 at 11:25 a.m., with the Director of Nursing (DON), the California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities was reviewed. The DON stated the residents residing on the behavioral unit were considered skilled nursing facility (SNF) residents, and they all had resident's rights. The DON stated there was different rules imposed on the behavioral unit based on the resident population. The DON reviewed the California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities given to all of the facility's residents upon admission and stated the Resident [NAME] of Rights indicated the facility would ensure the facility provided privacy for visits with family and friends. The DON stated resident's visitors from the behavioral unit had to schedule an appointment to come to the facility to visit and a counselor had to be present during the visit. The DON stated the behavioral unit residents received 30 minutes per visit. The DON stated the different rules implemented on the behavioral unit infringed on the residents' rights and the outcome of treating the behavioral unit residents differently was discrimination. The DON stated the residents on the behavioral unit were admitted straight from jail and came to the facility to finish their sentence, but they were not still in jail, they were admitted to the facility to complete a program. During a review of the facility's policy and procedure (P&P) titled Visitation undated, the P&P indicated the facility permitted residents to receive visitors of the residents wishes. During a review of the facility's P&P titled Resident Rights undated, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility including, privacy and confidentiality.During a review of the facility's P&P titled Residents Involved with the Criminal Justice System undated, the P&P indicated residents involved in the criminal justice system are entitled to the same rights as all other residents residing in the facility. The facility was not to impose any restrictions on justice-involved residents that violate their rights. Justice Involved Residents include residents under community supervision, including those on parole, probation, or ongoing supervision and treatment as an alternative to criminal prosecution. The facility does not admit or accept responsibility for justice-involved individuals whose terms of release and placement (as stipulated by the department of corrections or law enforcement) are contrary to the Centers for Medicare & Medicaid Services (CMS) requirements for participation. Only individuals for whom the facility can provide care and services are admitted . If admitting a particular individual compromises, the health, safety and rights of other residents, visitors and staff he or she will not be admitted .

Based on interview and record review the facility failed to:a. Ensure the Program Manager of the Behavioral Unit (PMBU) reported to the State Survey Agency (CDPH) and investigated an allegation of staff to resident sexual abuse (unwanted touch) for one out of six (Resident 35) sampled residents.b. Ensure the PMBU and the Director of Nursing (DON) reported an unusual occurrence (an unexpected or atypical event that deviates from the norm or expected pattern) of illicit drugs (substances that are illegal to manufacture, possess, sell, or use) being brought into the facility and possibly consumed by two out of six sampled residents (Resident 54 and Resident 79).c. Ensure the DON reported Resident 44's injury of unknown origin to CDPH and local law enforcement.Findings:a. During a review of Resident 35's admission Record (Face sheet), the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of schizophrenia (a chronic brain disorder characterized by psychosis (hallucinations [hearing things not based in reality] and delusions [believing things not based in reality], disorganized thinking, and reduced emotional expression), unspecified mood disorder (affect your persistent emotional state).During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 6/17/2026, the MDS indicated Resident 35 was cognitively intact (an individual has sufficient judgment, planning, organization, and self-control to manage the normal demands of their environment without assistance).During an interview on 7/8/2026 at 2:10 p.m., Resident 35 stated roughly two weeks ago (unknown exact date), Primary Counselor (PC) 2 touched her on her leg inappropriately and she did not like how PC 2 spoke to her as a woman. Resident 35 stated PC 3 and the PMBU were all aware of what happened with PC 2.During an interview with the PMBU on 7/8/2026 at 4:11 p.m., the PMBU stated at the end of PC 2's employment she became aware PC 2 was trying to provide comfort to Resident 35 and touched Resident 35 on her upper leg towards the knee. The PMBU stated she could not recall if she reported the incident to the facility administrator (ADMIN). The PMBU stated the incident was not reported to the State Survey Agency or local law enforcement, but it should have been because it was important for resident safety and it was the law.During an interview on 7/9/2026 at 9:20 a.m., with the Administrator (ADMIN), the ADMIN stated the PMBU and PC 3 were suspended for failing to notify and report the allegation of abuse by PC 2 to Resident 35. The ADMIN stated she did not know about the allegation of abuse and it was a complete shock. b. During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia (such as hallucinations or delusions) with those of a mood disorder), psychoactive substance dependence (a state where an individual's body or mind requires a psychoactive substance (like alcohol, opioids, or nicotine) to function normally), and stimulant dependence.During a review of Resident 79's MDS dated [DATE], the MDS indicated Resident 79 was cognitively intact.During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, opioid dependence (a physical adaptation where the body requires the drug to function normally and avoid withdrawal), and other stimulant dependence.During a review of Resident 54's Psychiatry Progress Note dated 5/13/2026, the Psychiatric Progress Note indicated per facility staff report (unknown staff) Resident 54 was found to be intoxicated on 5/8/2026. Resident 54 admitted to using ecstasy aka molly and reportedly provided his EBT card to another resident to procure the substance.During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54 was cognitively intact.During an interview on 7/8/2026 at 4:11 p.m., the PMBU stated in May 2026 (exact date not disclosed), a resident (unknown) reported to staff that drugs (unknown substance) had been smuggled into the facility and there was increased anxiety noted for some of the residents (unknown). The PMBU stated this was a very unusual incident for the facility. During an interview on 7/10/2026 at 11:25 a.m., with the Director of Nursing (DON), the DON stated on 5/8/2026 she was notified by a charge nurse that Resident 54 was acting different. They suspected drug use and after investigation they identified six possible residents involved in the drug incident (unknown). The DON stated she was aware of the drug incident at time of occurrence and it was not a usual thing that happens in the facility, but it was not reported to the State Survey Agency, and they should follow the facility policy on reporting unusual occurrence.During a review of the facility policy and procedure (P&P) titled Unusual Occurrence Reporting revised 8/27/2021, the P&P indicated unusual occurrences were to be reported to the State Agency within 24 hours by telephone and then confirmed in writing. c. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), schizophrenia, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44 had intact cognitive functioning. The MDS indicated Resident 44 was independent for self-care abilities such as eating, hygiene, dressing and putting on footwear.During a review of Resident 44's change in condition (any sudden or major deviation from a person's baseline physical, mental, or functional health) evaluation note, dated 6/14/2026, the change in condition evaluation note indicated Resident 44's had a laceration in the oral cavity, oral cavity bleeding with laceration laceration (deep, ripped cut or gash caused by a hard blow or blunt impact) to the left upper inner lip. During an interview on 7/9/2026 at 4:17 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 44 was observed with blood to the mouth and that it can be considered as injury of unknown origin.During an interview on 7/10/2026 at 10:29 a.m., with the DON, the DON stated she was aware of Resident 44's injury of unknown origin and Resident 44 now had a scab on the lips with light swelling.During an interview on 7/10/2026 at 11:19 a.m., with the ADMIN, the ADMIN stated that all staff should be able to report allegations of abuse, suspicions of abuse, or injury of unknown origin. The ADMIN stated the timeframe to report abuse was within two hours of being aware of the allegation of abuse, suspicions of abuse or injury of unknown origin. The ADMIN stated the staff should have reported Resident 44's injury, as an allegation of abuse or the likes to law enforcement agency, ombudsman, and CDPH.During a review of the facility's P&P titled Abuse Prohibition Policy and Procedure dated 2/23/2021, the P&P indicated:1. Suspected abuse needs to be reported to ADMIN right away in accordance with state law. The P&P indicated the facility was to report allegations of abuse no later than two hours after the allegation was made to the State Survey Agency and local law enforcement. 2. Injuries of unknown source are defined as an injury with both of the following conditions such as the source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. the notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of resident property within twenty-four hours if the event does not result in serious bodily injury.Cross Reference F609 and F610.

Based on interview and record review, the facility failed to include The Office of Diversion and Reentry ([ODR] long-term, supportive care for justice-involved individuals who are medically fragile, have severe cognitive impairments, or are deemed Incompetent to Stand Trial [defendant cannot understand criminal proceedings or assist in defense due to mental disorder or developmental disability]) Program in the facility assessment (a facility-wide evaluation conducted and documented to indicate the resources, and staffing the facility needs to provide the necessary care for their residents daily) for ninety five out of ninety-five residents.This failure had the potential to result in delays in care and services.Findings: During an interview on 7/8/2026 at 4:11 p.m. with the Program Director of the Behavioral Unit (PMBU), the PMBU stated that the facility works with the ODR Program. During a concurrent interview and record review on 7/9/2026 at 8:43 a.m., with the Administrator (Admin), the Facility Assessment Tool, updated 6/5/2026, was reviewed. The Administrator confirmed and stated the ODR program was not incorporated in the facility assessment. The Admin stated resources needed for residents in the ODR program needed to be reflected in the facility assessment to ensure the facility had adequately trained staff, and goods to provide the needed care for residents. During a review of the Facility Assessment Tool, the tool indicated that the facility must conduct a comprehensive assessment to determine the resources necessary for resident care during day-to-day operations. This assessment supports safe and effective care guides and ensures compliance with applicable regulations.

Based on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, thereby affecting 95 out of 95 residents, failed to identify and implement corrective action to the systemic problems identified:Primary Counselor (PC) 3, Director of Nursing (DON), and Program Manager of the Behavioral Unit (PMBU)'s failure to report and investigate allegations of abuse and unusual occurrences to the California Department of public Health (CDPH).There were implemented facility practices (visitation, smoke break, provision of snacks, medication administration, grievance resolution) that violates residents' rights.These failures equated with substandard quality of care, violated the resident's rights and placed the residents at risk of not receiving the quality treatment necessary to ensure residents lived at their highest practicable well-being.Findings: During an interview on 7/10/2026 at 12:37 p.m., with the Administrator (Admin), the Admin stated the following systemic issues identified were not identified by the QAA committee:The Director of Nursing (DON), and Program Manager of Behavioral Unit (PMBU) failed to report and investigate abuse and unusual occurrences to the California Department of public Health (CDPH) and local law enforcement.There were facility practices (visitation, smoke break, provision of snacks, medication administration, grievance resolution) that violate residents' rights. During a record review of the facility's Quality Assurance and Performance Improvement Plan, 2026, the plan indicated the QAA committee will take a proactive approach to continually improve the way they care for residents where residents feel secured valued and cared for. The facility will identify and address system gaps and breakdowns, do a root cause analysis and implement actions plan to resolve these issues. Cross Reference: F550, F563, F565, F 585, F609, F610, F835

Based on observation, interview, and record review, the facility failed to honor residents' rights for three out of 23 sampled residents (Resident 35, Resident 69, and Resident 93). As a result of this deficient practice Resident's Rights and dignity were violated for Resident 35, Resident 69, and Resident 93. Findings: a. During a review of Resident 69's admission Record (Face sheet), the admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses of schizophrenia (a chronic brain disorder characterized by psychosis (hallucinations [hearing things not based in reality] and delusions [believing things not based in reality], disorganized thinking, and reduced emotional expression) and anxiety disorder (an emotion characterized by feelings of tension, worried thoughts, and physical changes like a rapid heartbeat). During a review of Resident 69's Minimum Data Set (MDS, a resident assessment tool) dated 5/13/2026, the MDS indicated Resident 69 was cognitively intact (an individual has sufficient judgment, planning, organization, and self-control to manage the normal demands of their environment without assistance). The MDS indicated it was very important for Resident 69 to take care of her personal belongings, to go outside to get fresh air when the weather was good, and somewhat important to be able to use the telephone in private. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of schizophrenia, unspecified mood disorder (affect your persistent emotional state), and other stimulant use (a mental health condition characterized by the repeated, uncontrollable use of stimulant (psychoactive substances that speed up the central nervous system and bodily functions) drugs, which continues despite significant negative consequences on a person's life, health, and relationships). During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35 was cognitively intact. The MDS indicated it was very important for Resident 35 to take care of her personal belongings, have snacks between meals, go outside to get fresh air when the weather was good, and to be able to use the telephone in private. During an interview on 7/8/2026 at 2:10 p.m., with Resident 35, Resident 35 stated residents in the behavioral unit were not allowed to keep their personal phones with them. Resident 35 stated staff allowed residents to use their own phones for only 30 minutes per day in the counselor's office, under supervision. Resident 35 stated residents on the behavioral unit were not allowed to keep snacks in their room and family members were not allowed to bring bulk snacks into the facility for the residents. Resident 35 stated if they wanted snacks, the residents had to purchase snacks from the Canteen (facility store), but the snacks were expensive and it cost one dollar for a small bag of chips. Resident 35 stated she felt as though the residents on the behavioral unit did not get enough outside time because they only got two smoke breaks a day, (while the rest of the residents throughout the facility got 6 smoke breaks a day), and three fresh air breaks a day. Resident 35 stated she felt as though the rules were very strict, not fair, and they negatively affected her mood. During an interview on 7/10/2026 at 8:46 a.m., Resident 69 stated the facility only provided the residents with half of a sandwich prior to bed and he was a big guy so that did not fill him up. Resident 69 stated if they wanted any other snacks, they had to buy it from the facility canteen, but the snacks were expensive stating a small bag of chips was one dollar and they couldn't keep personal snacks in their room. Resident 69 complained about only having two smoke breaks daily and it was important to the residents because the smoke breaks helped them relax. Resident 69 stated they have brought concerns regarding snacks and smoke breaks to facility staff multiple times, but nothing changed. During an interview on 7/10/2026 at 9:22 a.m., the Case Manager (CM) 1 became tearful and stated she was very passionate about the behavioral unit residents because they were young and she felt as though the new rules were treating the residents like animals and as though the residents were still incarcerated (kept in prison). CM 1 stated it was not fair to impose these rules on the residents because they were not incarcerated. CM 1 stated she voiced her concerns regarding the rules to management (unknown), but they did not listen. CM 1 stated prior to these new rules being implemented, the residents were able to go out to the patio freely but now they only have three fresh air breaks on top of the two smoke breaks and the residents (unknown) are not happy about this. CM 1 stated the changes were due to not having enough staff to watch the residents out on the patio. CM 1 stated the behavioral unit residents should have more smoke breaks because the other residents in the facility got six smoke breaks daily. CM 1 stated there were different rules for the behavioral unit residents compared to the rest of the residents that reside in the facility. CM 1 stated the facility does not let the residents keep snacks in their rooms and the canteen was open to purchase snacks three times a week (Tuesday, Thursday, and Saturday). During an interview and concurrent record review on 7/10/2026 at 11:25 a.m., with the Director of Nursing (DON), the California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities was reviewed. The DON stated the residents residing on the behavioral unit were considered skilled nursing facility (SNF) residents, and they all had resident's rights. The DON stated there was different rules imposed on the behavioral unit residents based on the resident population. The DON reviewed the California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities given to all of the facility's residents upon admission and stated the Resident [NAME] of Rights indicated the facility ensured the following rights were not violated for residents in the facility: ability to voice grievances and recommend changes in policies and services, be free from discrimination, to be treated with consideration, respect and full recognition of individuality, including privacy in treatment and in care of personal needs, to associate and communicate privately with persons of the patient's choice, to retain and use personal clothing and possessions, to be allowed privacy for visits with family and friends, and to have reasonable access to telephones and to make and receive confidential calls. The DON stated on the behavioral unit the counselors keep the resident's phones locked in the counselor's office and the residents were only able to use the phones at certain times of the day (30 minutes in the morning and 30 minutes in the evening), in the counselor's office with staff present. The DON stated the different rules implemented on the behavioral unit infringe on the residents' rights and the potential outcome of treating the behavioral unit residents differently was discrimination. The DON stated the residents on the behavioral unit were admitted straight from jail and came to the facility to finish their sentence, but they were not still in jail, they were admitted to the facility to complete a program. The DON stated residents on the SNF side were allowed to keep snacks in their room but not on the behavioral unit and on the behavioral unit family could only bring in pre-packaged foods. b. During a review of Resident 93's admission Record, the admission Record indicated the facility admitted Resident 93 on 6/8/2026 with diagnoses including schizophrenia and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 93's MDS, dated [DATE], the MDS indicated Resident 93's cognition (ability to learn, reason, remember, understand, and make decisions) was intact and was independent for eating, oral hygiene, toileting hygiene, bathing, and dressing. During an observation on 7/9/2026 at 9:12 a.m., in the station 2 nursing station, licensed vocational nurse (LVN ) 5 administered seven oral medications to Resident 93 through the station 2 nursing station window. During an interview on 7/9/2026 at 9:20 a.m., in the hallway with Resident 93, Resident 93 stated the nurse usually administers their medications from behind a counter, through the window. Resident 93 stated they preferred the nurses to give them medications in the rooms. During an interview on 7/9/2026 at 9:23 a.m., LVN 5, LVN 5 stated they (LVN 5) frequently administered oral medications through the station 2 nursing station window. During an interview on 7/9/2026 at 1:18 p.m., with LVN 6, LVN 6 stated it was important to always administer medications in the residents' room to provide privacy for the residents. During a review of the facility's P&P, titled Medication administration – general guidelines, dated October 2017, the P&P indicated fore residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR is flagged. After completing the medication pass, the nurse returns to the missed resident to administer medications. During a review of the facility's P&P, titled Dignity, undated, the P&P indicated resident goals, choices, preferences, values and beliefs are respected and honored to the extent possible.staff protect confidential clinical information.staff promote, maintain, and protect resident privacy. During a review of the facility's Policy and Procedure (P&P) titled Resident's Personal Property dated 8/25/2021, the P&P indicated the residents had the right to retain his/ her personal belongings and preserve the resident's individuality and dignity. During a review of the facility's P&P titled Food Brought by Family/ Visitors dated 8/25/2021, the P&P indicated the residents were provided with an option of having food prepared by the resident's family brought into the facility. During a review of the facility's P&P titled Dignity undated, the P&P indicated the facility was to always treat all residents with dignity and respect. Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person or entity associated with the facility. Residents' private property are always respected. Staff are to treat cognitively impaired residents with dignity and sensitivity and address the underlying motives or root cause for behavior and not challenge or contradict the residents' beliefs or statements. During a review of the facility's P&P titled Resident Rights undated, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility including, privacy and confidentiality, voice grievances, a dignified existence, and to be treated with respect, kindness, and dignity. During a review of the facility's P&P titled Residents Involved with the Criminal Justice System undated, the P&P indicated residents involved in the criminal justice system are entitled to the same rights as all other residents residing in the facility. The facility was not to impose any restrictions on justice-involved residents that violate their rights. Justice Involved Residents include residents under community supervision, including those on parole, probation, or ongoing supervision and treatment as an alternative to criminal prosecution. The facility does not admit or accept responsibility for justice-involved individuals whose terms of release and placement (as stipulated by the department of corrections or law enforcement) are contrary to the Centers for Medicare & Medicaid Services (CMS) requirements for participation. Only individuals for whom the facility can provide care and services are admitted . If admitting a particular individual compromises, the health, safety and rights of other residents, visitors and staff he or she will not be admitted .

Based on interview and record review, the facility failed to provide a follow up resolution for one of seven residents who attended the resident council meeting (Resident 36) for the grievances filed from previous resident council meetings for:Increased smoke breaks and increased use of phone time throughout each day, on 5/13/2026 andIncreased number of snacks on throughout each day 6/26/2026. This deficient practice resulted in violating the resident council and Resident 36's right to voice grievances and receive a response leaving the resident council and Resident 36 feeling unheard and frustrated.Findings:During a review of Resident 36's admission Record, the admission Record indicated the facility admitted Resident 36 on 3/13/2026 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (persistent and excessive worry that interferes with daily activities), and depression (prolonged sadness and loss of interest in activities of daily living).During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 6/17/2026, the MDS indicated Resident 36's cognition (ability to learn, reason, remember, understand, and make decisions) was intact and was independent for eating, oral hygiene, toileting hygiene, bathing, and dressing. During an interview on 7/8/2026 at 2:16 p.m., with Resident 36 during the Resident Council Meeting in the Station 3 dining room, Resident 36 stated the residents have requested for more smoke breaks, more snacks, and more phone time. Resident 36 stated the facility had not given a resolution.During an interview on 7/9/2026 at 9:12 a.m., in the hallway with Resident 36, Resident 36 stated they told me it is part of the regulations that we have two smoke breaks a day. Resident 36 stated the residents do not feel heard; we are frustrated and stressed.During a concurrent interview and record review on 7/10/2026 at 3:41 p.m., with the Social Services Director (SSD), the Resident Council Response Form dated 5/13/2026 and the Resident Council Concern Response form dated 6/23/2026 were reviewed. The SSD stated the Resident Council Response Form dated 5/13/2026 indicated the Resident Council requested more smoke breaks and more phone time. The SSD stated the Resident Council Response Form dated 6/23/2026 indicated the Resident Council requested for more snacks. The SSD stated both Resident Council Response Forms did not indicate that a resolution was presented to the resident council regarding their concerns. The SSD stated there is no documentation that indicated the facility addressed the smoke breaks or the phone time. The SSD stated the facility should respond to grievances and concerns within three to five days. The SSD stated it is the residents' right to file a grievance or concern and receive a resolution.During an interview on 7/10/2026 at 4:01 p.m., with the Director of Nursing (DON), the DON stated it was the resident's right to receive a resolution to their grievance.During a review of the facility's policy and procedure (P&P), titled Residents Rights, undated, the P&P indicated residents have the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal and have the facility respond to their grievances.During a review of the facility's P&P, titled Grievance/Concern, dated 8/5/2021, the P&P indicated all residents and /or their representatives may voice grievances/concerns and recommendations for changes. Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident or resident representative. Social services personnel will serve as resident advocates in the grievance/concern process.the department manager will.notify the person filing the grievance of resolution and/or status within 72 hours and provide written resolution for civil rights grievances.

Based on observation, interview, and record review the facility failed to provide assess and implement resident centered trauma informed care for: a. One out of six sampled residents (Resident 35) who was a victim of sexual abuse b. One of six sampled residents (Resident 9) by failing to assess and identify Resident 9's Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) triggers, determine the severity of potential re traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again), and provide trauma informed care. c. One of six sampled residents (Resident 59) who was identified on admission to be a victim of physical abuse. As a result of these deficient practices Resident 9, Resident 35, and Resident 59 were at risk of re-traumatization, and psychosocial decline. Findings: a. During a review of Resident 35's admission Record (Face sheet), the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of schizophrenia (a chronic brain disorder characterized by psychosis (hallucinations [hearing things not based in reality] and delusions [believing things not based in reality], disorganized thinking, and reduced emotional expression), unspecified mood disorder (affect your persistent emotional state), and other stimulant use (a mental health condition characterized by the repeated, uncontrollable use of stimulant (psychoactive substances that speed up the central nervous system and bodily functions) drugs, which continues despite significant negative consequences on a person's life, health, and relationships). During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 6/17/2026, the MDS indicated Resident 35 was cognitively intact (an individual has sufficient judgment, planning, organization, and self-control to manage the normal demands of their environment without assistance). During a review of Primary Counselor (PC) 2's employee file document titled, Notice to Employee as to Change in Relationship dated 6/16/2026, the document indicated PC 2 was discharged from employment on 6/16/2026 for violation of policy. During an interview on 7/8/2026 at 2:10 p.m., Resident 35 stated roughly two weeks ago (unknown exact date), PC 2 was fired after he touched her on her leg inappropriately and she did not like how PC 2 spoke to her as a woman. Resident 35 stated the day PC 2 touched her leg inappropriately they were in the counselor's office and she was able to smell liquor from under PC 2's face mask and PC 2 was stumbling when walking. Resident 35 stated she became loud and upset and told PC 2, do not ever fucking touch me again. Resident 35 stated PC 3, Clinical therapist (CT) 1, and the Program Manager of the Behavioral Unit (PMBU) were all aware of what happened with PC 2. During an interview with the PMBU on 7/8/2026 at 4:11 p.m., the PMBU stated at the end of PC 2's employment she became aware PC 2 was trying to provide comfort to Resident 35 and touched Resident 35 on her upper leg towards the knee. The PMBU stated she talked to PC 2 and told him it was inappropriate to touch a resident and most of their residents do not like being touched at all. The PMBU stated she never spoke to Resident 35 about the situation but had PC 3 who had witnessed the incident talk to Resident 35. The PMBU stated unwanted touch from staff to residents should never happen and it could be considered sexual abuse. During an interview on 7/9/2026 at 10:17 a.m., with PC 3, PC 3 stated she was in the counselor's office the day of the incident between PC 2 and Resident 35 and witnessed PC 2 reach out and touch Resident 35 on the thigh. PC 3 stated the moments leading up to the touching incident PC 3 had secretly texted the PMBU to inform her that PC 2 was not acting right and he was stumbling with blood shot eyes, so she felt he was drunk or hungover. PC 3 stated PC 2 was trying to speak to Resident 35, but she would not respond to him. PC 3 stated she heard PC 2 say terms of endearment such as sweetie to Resident 35. PC 3 stated she told PC 2 to stop talking to Resident 35 because she did not want to speak to him and PC 2 was persistent and kept trying to make Resident 35 speak to him and when PC 2 called Resident 35 sweetie, PC 3 turned around to see what was going on and that was when she witnessed PC 2 touch Resident 35 on her thigh. PC 3 stated right after that, the PMBU walked into the counselor's office and escorted PC 2 out of the building, but she could not tell the PMBU about the leg touching until one to two hours after the incident. PC 3 stated the PMBU asked PC 3 to speak to Resident 35 about the incident so she did and Resident 35 confirmed PC 2 touched her on the thigh and Resident 35 felt disgusted by PC 2, she did not consider him a counselor, questioned why he was being persistent with her, and did not want him talking to her again. PC 3 stated she believed the incident was sexual abuse due to unwanted touching and she felt it was weird and inappropriate that PC 2 touched Resident 35 on the thigh. During an interview on 7/9/2026 at 10:55 a.m., with CT 1, CT 1 stated days after the incident (unknown exact date), Resident 35 informed him that PC 2 had touched her (Resident 35) on the leg, but it was already after PC 2 was permanently removed from the facility. CT 1 stated Resident 35 had previously disclosed during one of their group sessions that she was sexually abused by a man and CT 1 was afraid the touching by PC 2 may trigger Resident 35's sexual abuse trauma. CT 1 stated when Resident 35 first came to the facility she was very guarded (uses emotional self-protection to prevent vulnerability) and guarded towards male staff but CT 1 was able to work with Resident 35 to break down her wall so he was afraid she would lose progress due to this situation. CT 1 stated Resident 35 reported feeling uncomfortable due to the situation. During an interview on 7/9/2026 at 2:45 p.m., Resident 35 stated she felt as though PC 2 was using his power against her to take advantage of a mentally ill person. Resident 35 reported having trouble with male staff and she was not used to being in places with male authority because she has history of sexual abuse. During an interview on 7/10/2026 at 11:35 a.m., the Director of Nursing (DON) stated if past trauma was identified at any time during the facility stay the staff were to notify her so they could initiate person centered care. The DON stated it was important to care plan and identify the resident's triggers to ensure care is individualized and triggers are minimized. The DON read the Psychiatric Progress note from 6/16/2026 and acknowledged the Psychiatric Intake Note indicated Resident 35 did have a history of past trauma from sexual abuse. The DON stated an individualized care plan should have been created for Resident 35's past trauma but it was not done. b. During a review of Resident 9's admission record, the admission record indicated Resident 9 had been admitted to the facility on [DATE] with diagnoses including PTSD, paranoid schizophrenia (a chronic mental health condition characterized by intense, unfounded suspicions and false beliefs that others were plotting against or trying to harm the individual), anxiety disorder (constantly feeling worried and nervous), and mood disorder (a category of mental health conditions primarily characterized by a persistent disturbance in a person's emotional state). During a review of Resident 9's Psychiatry (the branch of medicine focused on diagnosing, treating, and preventing mental, emotional, and behavioral disorders) Intake Note (PIN) dated 1/6/2026, the PIN indicated that Resident 9 had impaired (diminished in function, ability, or condition) judgment and poor decision making. During a review of Resident 9's Minimum Data Set (MDS—a resident assessment tool) dated 4/10/2026, the MDS indicated Resident 9 required no assistance and was independent with eating, showering, hygiene, bed mobility, and transfer. During an interview on 7/7/2026 at 2:42 p.m., with Resident 9 in her room, Resident 9 stated she had been unhoused for a long time and had been in and out of jail multiple times. Resident 9 stated these past experiences on the street and in jail contributed to her PTSD. Resident 9 stated loud noises and sudden approaches triggered her trauma, and she would experience nightmares, anxiety, and crying. During a concurrent interview and record review on 7/9/2026 at 9:28 a.m., with Registered Nurse Supervisor (RNS) 2, Resident 9's Trauma Questionnaire, dated 1/6/2026 was reviewed. The Trauma Questionnaire indicated Resident 9 had stated she did not recall the past trauma and that there were no documented PTSD triggers or severity of re traumatization. RNS 2 stated the staff should have contacted a family member or a psychiatrist to obtain more information regarding PTSD triggers and the severity of the trauma if Resident 9 could not recall. During a concurrent interview and record review on 7/9/2026 at 10:44 a.m., with the Social Service Director (SSD), Resident 9's Social History & Program Initial Assessment, dated 1/6/2026, was reviewed. The Social History & Program Initial Assessment indicated Resident 9 had been diagnosed with PTSD and a mood disorder. The Social History & Program Initial Assessment indicated there was no documentation regarding possible causes of the PTSD, triggers, or the severity of re traumatization. The SSD stated she had not been aware of Resident 9's PTSD triggers, such as sudden approaches and loud noises, because Resident 9 had not mentioned them to her. The SSD stated it was important to identify PTSD triggers and the potential severity of re traumatization to prevent recurrent events and psychosocial decline. During a concurrent interview and record review on 7/9/2026 at 3:08 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 9's Care Plan (CP) titled Resident 9 reported past experience of trauma as evidenced by diagnosis of PTSD, revised 1/12/2026, was reviewed. The CP goal indicated Resident 9 would identify stressors and report them to staff. The CP intervention indicated that staff should encourage Resident 9 to identify personal trauma and triggers and take steps to eliminate or minimize them. The MDSC stated the CP did not identify Resident 9's specific triggers and the interventions were very generic rather than resident specific. The MDSC stated that without a resident centered care plan for PTSD, Resident 9 was at risk of experiencing re traumatization due to the lack of individualized interventions. During an interview on 7/10/2026 at 11:18 a.m., with the Director of Nursing (DON), the DON stated when a resident with PTSD as part of their diagnosis was admitted to the facility, the SSD should have assessed the resident for triggers and past history to prevent re traumatization. The DON stated it was important to recognize the root causes of a resident's distress, prevent secondary trauma, and effectively de escalate (to reduce the intensity, magnitude, or severity of a conflict or dangerous situation) situations through accurate assessment and care planning. c. During a review of Resident 59's admission Record, the admission Record indicated the facility admitted Resident 59 on 1/6/2026 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and major depressive disorder. During a review of Resident 59's Minimum Data Set (MDS – a resident assessment tool), dated 4/14/2026, the MDS indicated Resident 59's cognition (ability to learn, reason, remember, understand, and make decisions) was intact and was independent for eating, oral hygiene, toileting hygiene, bathing, and dressing. During a concurrent interview and record review on 7/10/2026 at 3:32 p.m., with the Social Services Director (SSD), Resident 59's Social History & Program Initial assessment dated [DATE] and care plans were reviewed. Resident 59's Social History & Program assessment dated [DATE] indicated Resident 59 had experienced physical abuse from their family and in 2025 was hit with a brick, pepper sprayed, and hit with a bottle. The SSD stated a care plan should have been initiated to address Resident 59's trauma. The SSD stated there was no care plan that addressed Resident 59's experience with abuse or trauma. During a review of the facility's Policy and Procedure (P&P) titled, Trauma Informed Care, dated 8/20/2022, the P&P indicated, Policy Explanation and Compliance Guidelines: 2. A trauma questionnaire will be completed by Social Services/Designee upon admission, re admission, significant change of condition related to trauma, and annually. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event. An interdisciplinary trauma informed care plan will be initiated if a positive response on the Trauma Questionnaire indicates a need for specialized care planning and interventions . 5. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include but are not limited to: a. Experiencing a lack of privacy or confinement in a crowded or small space. b. Exposure to loud noises, or bright/flashing lights. c. Certain sights, such as objects that are associated with their abuser. d. Sounds, smells, and physical touch. e. Care giver of the opposite sex.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as follows:A. Dietary Aide (DA) 1 and DA 2 failed to demonstrate how to check the sanitization concentration level in the red bucket using the correct test strip and accurately read the result.This failure had the potential to result in reduced effective sanitization, increasing the risk of pathogen (germ) exposureB. Dietary [NAME] (DCK) 1 and DA 2 failed to place melted margarin as fortified (adding vitamins, minerals, and extra calories to foods to improve their nutrient status) food item for Resident 88 and failed to verbalize fortified food items during trayline (an assembly line system used in nursing homes and institutional food services to prepare and assemble patient or resident meal trays).This failure had the potential for Resident 88 to lose weight due to not receiving the prescribed fortified diet.Findings:A. During a concurrent observation and interview on 7/7/2023 at 8:53 a.m., with DA 1, DA 1 brought a test strip intended for the dishwasher sanitization concentration level and attempted to use it to check the sanitization level in the red bucket. DA 1 used the incorrect test strip and dipped it into the red bucket but was unable to determine whether the reading was within an acceptable range. The District Dietary Manager (DDM) instructed DA 1 to obtain the correct test strip. DA 1 returned with the correct strip, dipped it into the red bucket for a few seconds, withdrew it, and again was unable to read and interpret the result. The DDM directed DA 1 to dip the strip and wait 10 seconds before removing it. The DDM read the result as 272 parts per million (ppm) and asked DA 1 whether that value was within the acceptable range. DA 1 stated they were not sure. DA 1 then attempted to retrieve the dishwasher test strip again to test the red bucket, and the DDM stopped DA 1. DA 1stated she was not sure what to do and she felt very nervous.During a concurrent observation and interview on 7/7/2026 at 9:07 a.m., with DA 2, DA 2 brought the correct testing strips for two additional red buckets. DA 2 dipped the strips into both buckets at the same time for a few seconds and was unable to determine whether the results were within an acceptable range. The DDM instructed DA 2 to try again and wait 10 seconds before reading the strips. DA 2 stated that both strips indicated 700 ppm, but DA 2 was not sure whether this was within the acceptable range. DA 2 stated that did not know what type of sanitizing solution was in the red buckets or what the required sanitization concentration level should be.During an interview on 7/7/2026 at 9:13 a.m., with the DDM, the DDM stated he realized both DA 1 and DA 2 could not correctly perform or read the results of the sanitizing test strips. The DDM stated it was important for staff to know what type of sanitizing solution was being used and to know the acceptable concentration range. He stated if the sanitizing solution level was not within the required range, it would not effectively kill germs.During a review of the facility's Policy and Procedure (P&P) titled, Sink and Surface Cleaner Sanitizer Test Strips How-To Guide, dated 2020, the P&P indicated, How to use the test strip: 1. Withdraw a test strip from the canister. 2. Dip test strip for five seconds into the test solution and shake off excess solution. 3. Compare colors after 10 seconds with colors on the test strip canister to determine the concentration. The test strip will only work with Sink and Surface Cleaner Sanitizer and cannot be used with other products. The approved active range of DDBSA is 272 - 700 ppm.B. During a review of Resident 88's admission record, the admission record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), schizophrenia (a mental illness that is characterized by disturbances in thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and extrapyramidal and movement disorder(involuntary muscle movements and altered muscle tone).During a review of Resident 88's History and Physical (H&P), dated 6/1/2026, the H&P indicated, Resident 88 had no capacity (ability) to understand and make decisions.During a review of Resident 88's Minimum Data Set (MDS-a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 88 required dependent assistance (Helper does all of the effort) from two or more staff for shower, oral hygiene, toilet hygiene, lower body dressing, maximal assistance (Helper does more than half the effort) from one staff for transfer, upper body dressing, moderate assistance (Helper does less than half the effort) from one staff for bed mobility, and supervision or touching assistance (Helper sets up or cleans up) from one staff for eating.During a review of Resident 88's Order Summary Report (OSR) , dated on 7/9/2026, the OSR indicated fortified diet with easy to chew texture and thin consistency liquid was ordered on 5/27/2026.During a review of Resident 88's Care Plan Report (CPR) titled, Resident is at nutritional risk with poor food intake, revised 3/26/2026, the CPR Goal indicated Resident 88 would consume 75 to 100 percent of at least three meals every day by target date of 9/28/2026. The CPR Interventions indicated, provide diet as ordered.During a concurrent observation and interview on 7/7/2026 at 12:09 p.m., with DCK 1 and DA 2 during trayline, DA 2 read the meal ticket (also known as a tray card, a slip of paper listing a resident's name, room number, allergies, and diet orders) for Resident 88 out loud for DCK 1 to prepare the lunch tray. Resident 88's meal ticket indicated a fortified diet with easy to chew texture and thin liquids. The meal ticket listed roast beef with gravy, rice pilaf, Italian blend vegetables, roll, butterscotch square, beverage, and melted margarine. DA 2 did not read fortified diet out loud, and DCK 1 did not place melted margarine on Resident 88's lunch tray. DA 2 placed the tray into the lunch cart. DA 2 stated that she did not realize she had failed to mention the fortified diet or include the melted margarine. DA 2 stated she did not know what the fortified food item was for Resident 88. DCK 1 could not state what fortified food items should have been provided for Resident 88 as well.During an interview on 7/7/2026 at 12:25 p.m., with the Dietary Supervisor (DS), the DS stated staff should have known what a fortified food item consisted off, and should have followed the meal ticket and diet order correctly to prevent unintended weight loss.During a concurrent interview and record review at 7/7/2026 at 3:49 p.m., with the DS, DA 1 and DA 2's Competency Evaluation, dated 4/16/2026 and 4/17/2026, were reviewed. The Competency Evaluation indicated that no competency had been completed on performing and reading the sanitization concentration level using the correct test strip. The evaluations also indicated that no competency had been completed on identifying fortified food items. The DS stated that they should have included those competencies to ensure DA 1 and DA 2 understood the required skills.During a concurrent interview and record review at 7/7/2026 at 3:49 p.m., with the DS, DA 1 and DA 2's Competency Evaluation, dated 4/16/2026 and 4/17/2026 were reviewed. The Competency Evaluation indicated that no competency had been completed on performing and reading the sanitization concentration level using the correct test strip. The Competency Evaluation indicated no competency had been completed to identify fortified food items. The DS stated they should have included those competencies to ensure DA 1 and DA 2 understood the required skills.During a concurrent interview and record review at 7/7/2026 at 3:49 p.m., with the DS, DCK 1's Competency Evaluation, dated 4/16/2026 was reviewed. The Competency Evaluation indicated no competency had been completed to identify fortified food items. The DS stated they should have included those competencies to ensure DCK 1 understood the required skills.During a phone interview on 7/10/2026 at 10:44 a.m., the Registered Dietitian (RD) stated staff should have known how to use the testing strips for the red bucket sanitizer and should have known the effective sanitization range. The RD stated that staff should have been able to identify fortified food items, such as melted margarine, and should have ensured they were placed according to the menu to prevent weight loss.During a review of the facility's Policy and Procedure (P&P) titled, HPSI FORTIFIED/HIGH CALORIE DIET, revised 1/2022, the P&P indicated, Intended Use: This diet is used when additional amounts of protein and/or calories are needed. This diet is also used to help prevent weight loss and tissue waste. Recommendations: 2 This diet includes Fortification of two menu items per day with ingredients such as evaporated milk, butter and sugar. These recipes provide 16 grams of additional protein and approximately 750 additional calories per day . 4. Additional items may be added to the menu based on the individual protein and calorie needs of the resident.During a review of the facility's P&P titled, Menu for Week 1, dated, 7/7/2026, the P&P indicated, Melted Margarine one ounce need to be added for Fortified diet for lunch.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 92 out of 95 total residents in the facility by failing to1. Ensure French toast and tortillas were properly dated2. Discard expired eggs and French toast in the refrigerator.This failure had the potential to affect residents and to result in pathogen (germ) exposure, and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications and hospitalization.Findings:During a concurrent observation and interview on 7/7/2026, at 8:35 a.m., with Dietary [NAME] (DCK) 1, in refrigerator #1, there were food items that were not properly dated and discarded when expired as follows:a. Unopened French toast in a bag with Receiving Date (RD- the day of delivery) of 6/5/2026, and no Used By (UB- the strict safety deadline after which a perishable food product or medication should no longer be consumed) date.b. Opened and used tortillas in a zip lock bag with RD of 6/23/2026, Open Date (OD) of 7/5/2026, and no UB date.c. Opened carton of eggs with some already used with RD of 5/28/2026, OD of 6/1/2026, and UB date of 6/20/2026.DCK 1 stated all food items should have been labeled with a RD when delivered from the vendor and a UB date. DCK 1 stated it was the responsibility of all dietary staff to check food items for proper labeling, dating, storage, and sealing. DCK 1 stated these practices were important to ensure food items remained in good condition (not spoiled) because residents consumed them. DCK 1 stated, once the food items were opened, they had a different shelf life (the length of time for which an item remains usable, fit for consumption). DCK 1 stated staff should have referred to the facility's Dry Goods Storage Guidelines (including refrigeration guidelines) to determine shelf life after opening and to apply the appropriate Open Date (OD) and UB date. DCK 1 stated unopened French toast or bread had a one week shelf life if not frozen, even when stored in the refrigerator, and stated they were not sure why the French toast had not been discarded. DCK 1 stated an opened package of tortillas had a one week shelf life and, although there was no specific guideline for tortillas, staff treated the tortillas as a type of bread and followed the same guideline. DCK 1 stated whole eggs had a three to five week shelf life and the eggs observed were expired and should have been discarded. During a review of the facility's Policy and Procedure (P&P) titled, Dry Storage Guidelines, undated, the P&P indicated that bread had a shelf life of five to seven days after opening and that there was no guideline for tortillas.During a review of the facility's P&P titled, Food Storage and Labeling Guide, undated, the P&P indicated that eggs in the shell had a shelf life of three to five weeks.During an interview on 7/7/2026 at 9:18 a.m., with the Dietary Supervisor (DS), the DS stated all food items should have been dated and dietary staff should have followed the Dry Storage Guidelines and the Food Storage and Labeling Guide to ensure the safety of perishable items requiring refrigeration. The DS stated opened food items had different UB dates once they were opened and used. The DS stated all expired items past their UB date should have been discarded immediately for safety. The DS stated the facility did not have a separate policy or guideline for refrigerated food items and that those guidelines were included in the Dry Storage Guidelines.During a phone interview on 7/10/2026 at 10:44 a.m., with the Registered Dietitian (RD), the RD stated, all food items should be dated and expired food should be thrown away to prevent foodborne illness.During a review of the facility's P&P titled, Food Receiving and Storage, dated 11/2022, the P&P indicated, Refrigerated/Frozen Storage: 1. All Foods stored in the refrigerator or freezer are covered, labeled, and dated ( used by date) .7. Refrigerated foods are labeled, dated and monitored so they are used by their used by date, frozen, or discarded.During a review of the facility's P&P titled, Receiving, dated 2/2023, the P&P indicated, Policy Statement: Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Procedures: 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.

Based on interview and record review, the facility failed to implement a water management plan (comprehensive plan aimed to prevent waterborne illnesses by controlling germs in the water) by monitoring and documenting control measures (actions taken to eliminate or reduce the likelihood or severity of exposure to a hazard) and limits (a specific, measurable, and quantitative range for a particular parameter that indicates when a water system is operating acceptably), and by conducting water testing regularly.This failure had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors.Findings:During a concurrent interview and record review on 7/10/2026 at 1:24 p.m., with the Maintenance Director (MD), the facility's Water Management Plan Binder (WMPB), dated 6/1/2026 was reviewed. The WMPB indicated control measures and limits should be monitored and documented as follows: Water heater flow assessment and temperature - monthly Laminar flow aerator (a faucet attachment that shapes water into a crystal-clear, non-splashing, and non-aerated stream without mixing air into the water) cleaning and inspection - quarterly Backflow preventer (valve) check - biannually Disinfectant (a strong chemical used to kill harmful germs) free chlorine residual level checks - weekly Eyewash station operation and flushing validation - weeklyThe WMPB indicated there were no annual Legionella (a type of bacteria that can cause a severe form of lung infection) testing results for 2023,2024,2025 and the last testing was completed in 2022. The MD stated that water temperatures were documented in a log, but the remaining control measures and limits were not monitored or documented. The MD stated that monitoring these control measures was important to prevent Legionella in the water system, and without consistent monitoring, documentation, and testing, early interventions and detection would not be effective.During an interview on 7/10/2026 at 3:51 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated that all control limits and measures should be monitored and documented. The IPN stated that water testing for Legionella should be conducted at least annually to ensure water quality and identify the presence of Legionella. The IPN stated that they did not know why annual testing had not been completed since 2023. The IPN stated that maintaining water quality was essential to protect vulnerable residents from Legionella.During an interview on 7/10/2026 at 4:10 p.m., with the Director of Nursing (DON), the DON stated that the water management program was designed to prevent Legionella and should be followed as written. The DON stated that all control measures and limits must be monitored and documented, and that water testing should be conducted at least annually as part of the monitoring process. The DON stated that these measures were preventive practices intended to protect vulnerable residents.During a review of the facility's Policy and Procedure (P&P) titled, Legionella Water Management Program, revised 9/2022, the P&P indicated, Policy Statement: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation: 3. The purpose of the water management program is to identify areas in the water system where Legionnaire's disease .7. The identification of situations that can lead to Legionella growth, such as .e. water temperature fluctuations, h. inadequate disinfection. M. when control limits are not met and /or control measures are not effective .8. The water management program is reviewed at least once a year if any the control limits are consistently not met and there are any disease cases associated with the water system.During a review of the facility's P&P titled, Water Management Plan, revised 6/1/2026, the P&P indicated, General Requirements: Control Measures-Determine locations where control measures must be applied and maintained in order to stay within established control limits. Monitoring-Establish procedures for monitoring whether control measures are operating within established limits. Documentation-establish documentation and communication procedures for all activities of the program .Periodic sampling at least quarterly for Legionella is recommended to demonstrate that the biocidal control is effective for the organism.

Based on interview and record review, the facility failed to notify the physician of an allegation of abuse for one of six sampled residents (Resident 35). As a result of this deficient practice there was potential for Resident 35's psychosocial needs to go unmet and a delay in care. Findings: a. During a review of Resident 35's admission Record (Face sheet), the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of schizophrenia (a chronic brain disorder characterized by psychosis (hallucinations [hearing things not based in reality] and delusions [believing things not based in reality], disorganized thinking, and reduced emotional expression), unspecified mood disorder (affect your persistent emotional state), and other stimulant use (a mental health condition characterized by the repeated, uncontrollable use of stimulant (psychoactive substances that speed up the central nervous system and bodily functions) drugs, which continues despite significant negative consequences on a person's life, health, and relationships).During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 6/17/2026, the MDS indicated Resident 35 was cognitively intact (an individual has sufficient judgment, planning, organization, and self-control to manage the normal demands of their environment without assistance).During a review of Primary Counselor (PC) 2's employee file document titled, Notice to Employee as to Change in Relationship dated 6/16/2026, the document indicated PC 2 was discharged from employment on 6/16/2026 for violation of policy.During an interview on 7/8/2026 at 2:10 p.m., with Resident 35, Resident 35 stated roughly two weeks ago (unknown exact date), PC 2 was fired after he touched her on her leg inappropriately and she did not like how PC 2 spoke to her as a woman. Resident 35 stated the day PC 2 touched her leg inappropriately they were in the counselor's office and she was able to smell liquor from under PC 2's face mask and PC 2 was stumbling when walking. Resident 35 stated she became loud and upset and told PC 2, do not ever fucking touch me again. Resident 35 stated PC 3, Clinical therapist (CT) 1, and the Program Manager of the Behavioral Unit (PMBU) were all aware of what happened with PC 2.During an interview with the PMBU on 7/8/2026 at 4:11 p.m., the PMBU stated at the end of PC 2's employment she became aware PC 2 was trying to provide comfort to Resident 35 and touched Resident 35 on her upper leg towards the knee. The PMBU stated she talked to PC 2 and told him it was inappropriate to touch a resident and most of their residents do not like being touched at all. The PMBU stated she never spoke to Resident 35 about the situation but had PC 3 who had witnessed the incident talk to Resident 35. The PMBU stated unwanted touch from staff to residents should never happen and it could be considered sexual abuse. The PMBU stated PC 3 informed her that Resident 35 stated she did not like being touched by PC 2 and she did not want PC 2 touching her anymore. TDuring a review of Resident 35's Investigation Statement taken on 7/8/2026 at 5:20 p.m., the statement indicated Resident 35 alleged PC 2 told her, [NAME] it is going to be okay while he rubbed her leg up and down and she felt like there was a pervert in the room. Resident 35 alleged PC 2 was intoxicated, dirty, and inappropriate.During an interview on 7/9/2026 at 9:20 a.m., with the Administrator (Admin), the Admin stated the PMBU and PC 3 were suspended for failing to notify and report the allegation of abuse by PC 2 to Resident 35. The ADMIN stated she did not know about the allegation of abuse and it was a complete shock. During an interview on 7/9/2026 at 10:17 a.m., with PC 3, PC3 stated she was in the counselor's office the day of the incident between PC 2 and Resident 35 and witnessed PC 2 reach out and touch Resident 35 on the thigh. PC 3 stated the moments leading up to the touching incident PC 3 had secretly texted the PMBU to inform her that PC 2 was not acting right and he was stumbling with blood shot eyes, so she felt he was drunk or hungover. PC 3 stated PC 2 was trying to speak to Resident 35, but she would not respond to him. PC 3 stated she heard PC 2 say terms of endearment such as sweetie to Resident 35. PC 3 stated she told PC 2 to stop talking to Resident 35 because she did not want to speak to him and PC 2 was persistent and kept trying to make Resident 35 speak to him and when PC 2 called Resident 35 sweetie, PC 3 turned around to see what was going on and that was when she witnessed PC 2 touch Resident 35 on her thigh. PC 3 stated right after that, the PMBU walked into the counselor's office and escorted PC 2 out of the building, but she could not tell the PMBU about the leg touching until one to two hours after the incident. PC 3 stated the PMBU asked PC 3 to speak to Resident 35 about the incident so she did and Resident 35 confirmed PC 2 touched her on the thigh and Resident 35 felt disgusted by PC 2, she did not consider him a counselor, questioned why he was being persistent with her, and did not want him talking to her again. PC 3 stated she believed the incident was sexual abuse due to unwanted touching and she felt it was weird and inappropriate that PC 2 touched Resident 35 on the thigh.During an interview on 7/9/2026 at 2:45 p.m., Resident 35 stated she felt as though PC 2 was using his power against her to take advantage of a mentally ill person. Resident 35 reported having trouble with male staff and she was not used to being in places with male authority because she has history of sexual abuse.During an interview on 7/10/2026 at 11:25 a.m., the Director of Nursing (DON) stated the allegation of abuse by PC 2 to Resident 35 should have been reported to her right away, a change of condition (COC) assessment should have been done and psychosocial follow up visits should have been conducted to ensure the resident felt safe. The DON stated a COC assessment was not done, and the physician was not notified at the time of incident because she was not aware of the incident. The DON stated it was important to notify the physician and initiate a COC because the residents may suffer adverse effects from the incident and new physician's orders may be needed. The DON stated necessary care may not be implemented and delay of care may occur.During a review of the facility's Policy and Procedure (P&P) titled Change in Condition: Notification of dated 8/25/2021, the P&P indicated the resident's physician should be notified immediately when there was a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to file a grievance for one of six sampled residents (Resident 35) regarding an allegation of abuse by staff member (Primary Counselor [PC] 2).As a result of this deficient practice, Resident 35's concern was not addressed promptly placing Resident 35 at risk for psychosocial decline. Findings:a. During a review of Resident 35's admission Record (Face sheet), the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of schizophrenia (a chronic brain disorder characterized by psychosis (hallucinations [hearing things not based in reality] and delusions [believing things not based in reality], disorganized thinking, and reduced emotional expression), unspecified mood disorder (affect your persistent emotional state), and other stimulant use (a mental health condition characterized by the repeated, uncontrollable use of stimulant (psychoactive substances that speed up the central nervous system and bodily functions) drugs, which continues despite significant negative consequences on a person's life, health, and relationships). During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 6/17/2026, the MDS indicated Resident 35 was cognitively intact (an individual has sufficient judgment, planning, organization, and self-control to manage the normal demands of their environment without assistance).During an interview on 7/8/2026 at 2:10 p.m., Resident 35 stated roughly two weeks ago (unknown exact date), PC 2 was fired after he touched her on her leg inappropriately and she did not like how PC 2 spoke to her as a woman. Resident 35 stated the day PC 2 touched her leg inappropriately they were in the counselor's office and she was able to smell liquor from under PC 2's face mask and PC 2 was stumbling when walking. Resident 35 stated she became loud and upset and told PC 2, do not ever fucking touch me again. Resident 35 stated PC 3, Clinical therapist (CT) 1, and the Program Manager of the Behavioral Unit (PMBU) were all aware of what happened with PC 2. Resident 35 stated she made a grievance that day with staff (unknown), they had her fill out a paper and she signed it. During an interview with the PMBU on 7/8/2026 at 4:11 p.m., the PMBU stated at the end of PC 2's employment she became aware that PC 2 was trying to provide comfort to Resident 35 and touched Resident 35 on her upper leg towards the knee. The PMBU stated she talked to PC 2 and told him it was inappropriate to touch a resident and most of their residents do not like being touched at all. The PMBU stated she never spoke to Resident 35 about the situation but had PC 3 who had witnessed the incident talk to Resident 35. The PMBU stated unwanted touch from staff to residents should never happen and it could be considered sexual abuse. The PMBU stated PC 3 informed her that Resident 35 stated she did not like being touched by PC 2 and she did not want PC 2 touching her anymore.During a review of Resident 35's Investigation Statement taken on 7/8/2026 at 5:20 p.m., the statement indicated Resident 35 alleged PC 2 told her, [NAME] it is going to be okay while he rubbed her leg up and down and she felt like there was a pervert in the room. Resident 35 alleged PC 2 was intoxicated, dirty, and inappropriateDuring an interview on 7/9/2026 at 10:17 a.m., PC 3 stated she was in the counselor's office the day of the incident between PC 2 and Resident 35 and witnessed PC 2 reach out and touch Resident 35 on the thigh. PC 3 stated the moments leading up to the touching incident PC 3 had secretly texted the PMBU to inform her that PC 2 was not acting right and he was stumbling with blood shot eyes, so she felt he was drunk or hungover. PC 3 stated PC 2 was trying to speak to Resident 35, but she would not respond to him. PC 3 stated she heard PC 2 say terms of endearment such as sweetie to Resident 35. PC 3 stated she told PC 2 to stop talking to Resident 35 because she did not want to speak to him and PC 2 was persistent and kept trying to make Resident 35 speak to him and when PC 2 called Resident 35 sweetie, PC 3 turned around to see what was going on and that was when she witnessed PC 2 touch Resident 35 on her thigh. PC 3 stated right after that, the PMBU walked into the counselor's office and escorted PC 2 out of the building, but she could not tell the PMBU about the leg touching until one to two hours after the incident. PC 3 stated the PMBU asked PC 3 to speak to Resident 35 about the incident so she did and Resident 35 confirmed PC 2 touched her on the thigh and Resident 35 felt disgusted by PC 2, she did not consider him a counselor, questioned why he was being persistent with her, and did not want him talking to her again. PC 3 stated she believed the incident was sexual abuse due to unwanted touching and she felt it was weird and inappropriate that PC 2 touched Resident 35 on the thigh. PC 3 stated she helped Resident 35 with grievance by writing down Resident 35's thoughts on a grievance form and Resident 35 signed it. PC 3 stated she placed Resident 35's grievance on the PMBU's desk per her request and she was not sure what happened to it after that.During an interview on 7/10/2026 at 11:25 a.m., with the Director of Nursing (DON), the DON stated it was the resident's right to voice grievances and all grievances should be logged. The DON stated if a grievance is not properly filed the facility may not be able to address the resident's concern correctly.During an interview and concurrent record review on 7/10/2026 at 2:03 p.m., with the SSD stated, the Grievance Logs for May 2026 and June 2026 were reviewed. The SSD stated there was no grievance filed for Resident 35 during the months of May 2026 and June 2026. The SSD stated all grievances should be logged and if another manager received a grievance they should give it to the SSD because she was the grievance officer. The SSD stated grievances were important so the facility could identify and address concerns and identify potential abuse. During a review of the facility's policy and procedure (P&P) titled Grievance/ Concern dated 8/25/2021, the P&P indicated the resident had a right to file a grievance orally or in writing. The grievance was to be initiated by the staff receiving the concern and documented on the grievance log. Immediate action was to be taken to prevent further violations of any resident rights while the alleged violation was being investigated and the abuse policy would be followed.

Based on interview, and record review, the facility failed to ensure a rolling stool (a mobile seating device featuring a padded seat, a lift for adjustable height, and 360 degree swivel casters) was not left in the facility's dining/activity room where it posed a safety hazard to residents due to the rolling mechanism of the chair, for one out of three residents (Resident 1). This deficient practice resulted in Resident 1 losing her balance and falling while attempting to sit on a rolling stool. Resident 1 complained of pain to her right hip and left rib area and was transferred to a General Acute Care Hospital (GACH) where she was assessed with multiple right rib fractures (broken bones). This deficient practice had the potential to cause harm to other residents who were in the area where a rolling stool was left unattended. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included multiple fractures of the ribs on the right side and paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational, and persistent distrust, suspicion, and fear of others, along with auditory hallucinations [the perception of sounds, such as voices, music, or noises, in the absence of any external stimulus] and delusions [fixed, false beliefs firmly held despite clear, contradictory evidence]). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 1's cognition (the ability to think and reason) was moderately impaired. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance [where constant, light physical contact with a patient to provide stabilization and prevent falls, without lifting or supporting their weight] as resident completes activity, provided throughout the activity or intermittently) with walking greater than 10 feet and when sitting to standing. 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) dated 2/8/2026, and timed at 4:30 p.m., the SBAR indicated Resident 1 sustained an unwitnessed fall in the activity room, and was lying on her left side. The SBAR indicated Resident 1 verbalized she had pain to both her right hip and left rib area. During a review of Resident 1's Physician's Orders, dated 2/8/2026, the Physician's Orders indicated to transfer Resident 1 to the GACH for a suspected fall with suspected injury. During a review of the facility's Five-Day Summary, dated 2/10/2026, the Five-Day Summary indicated on 2/8/2026, at approximately 4:30 p.m., Resident 1 independently ambulated (walked) into the activity room, where Certified Nursing Assistant (CNA) 1 was present. The Five-Day Summary indicated at the time of the incident CNA 1 was assisting another resident and briefly turned away when Resident 1 attempted to sit on a rolling stool, which rolled from underneath her (Resident 1) causing her to fall on to her left side. During a review of the GACH's Information Sheet dated 2/8/2026, the GACH's Information Sheet indicated Resident 1 arrived to the GACH on 2/8/2026, at 8:50 p.m. During a review of Resident 1's GACH Computed Tomography Scan ([CT Scan] a procedure that produces detailed images of bones, organs, and soft tissues), dated 2/9/2026 and timed at 10:34 p.m., the CT Scan indicated Resident 1 had right-sided rib fractures. During a review of Resident 1's GACH History of Present Illness (HPI), dated 2/9/2026, the HPI indicated Resident 1 presented to the emergency department (ED) after a mechanical fall (a fall caused by an external environmental factor) from losing her balance. The HPI indicated the CT scan of Resident 1's chest showed right side rib fractures, and the plan was to observe Resident 1, control her pain, provide prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease) to prevent a deep vein thrombosis ([DVT], a serious condition where a blood clot forms in a deep vein, usually in the legs, causing symptoms like swelling, pain, warmth, and redness, and the clot can break loose and travel to the lungs, being potentially fatal), and to have her evaluated by physical therapy ([PT] the treatment of disease, injury, or physical conditions by methods such as massage, heat treatment, and exercise rather than by drugs or surgery). During an interview on 2/25/2026 at 11:55 a.m., the Director of Nursing (DON) stated there was a care plan created for Resident 1 related to a fall she sustained in 6/2025, but it had been resolved due to Resident 1 meeting her goals. The DON stated Resident 1 was steady on her feet and there had been no other care plan created prior to her current fall on 2/9/2026. The DON stated Resident 1 was still at risk for falls due to her use of psychotropic medications (a class of prescription drugs designed to affect the mind, emotions, and behavior by altering the chemical balance of neurotransmitters in the brain). During an interview on 2/25/2026 at 3:24 p.m., the Administrator (ADM) stated the rolling stool was from the rehabilitation/therapy room and should not have been in the activity/dining room because it was not safe and posed a safety risk to residents. The ADM stated she was not able to identify who left the rolling stool in the dining/activity room. During an interview on 2/25/2026, at 3:30 p.m., CNA 1 stated on 2/8/2026 sometime before dinner (5 p.m.), she was in the dining room/activity room supervising residents while they watched television. CNA 1 stated she witnessed Resident 1 walk into the dining room and got water from the water station. CNA 1 stated she was assisting another resident, and when she turned around, she witnessed Resident 1 fall and land on her left side as a rolling stool rolled away from her (Resident 1). CNA 1 stated she did not see the rolling stool in the dining/activity room prior to it rolling away from Resident 1 and thought it must have been pushed under a table and Resident 1 pulled it out to sit on it. During a review of the facility's Policy and Procedure (P/P), titled, Hazardous Areas, Devices and Equipment dated 7/2017, the P/P indicated hazardous areas and objects in the resident environment, such as furniture that is unstable, will be identified and addressed.

Based on observation, interview and record review, the facility failed to ensure the Housekeeper (HK 1) did not run over the resident ' s foot with the laundry cart (a large, blue, storage device with wheels used to deliver residents ' clothing and clean linens in bulk) for one of two sampled residents (Resident 1). Resident 1 sustained left foot fracture. The facility failed to: 1. Ensure Housekeeper (HK 1) did not overfill a laundry cart (a large, blue, storage device with wheels used to deliver residents ' clothing and clean linens in bulk) with clean linen and clothing preventing HK1 to have a clear view when transporting the laundry cart around the facility. On 7/20/2024 HK 1 run over Resident 1 left foot with a laundry cart while transporting it to Station 2. 2. Ensure HK 1 followed the facility policy and procedure titled, Laundry Initiative Module 2: the Six-Step Laundry Process which indicated when delivering clean linen, the clean linen must not be stacked higher than the rim or top shelf of the linen cart and nothing shall be stacked on top of the cart or covering. As a result of this deficient practices Resident 1 sustained a fracture (broken bone) of the left medial (middle) cuneiform (bone in the mid foot) on 7/20/2024 at 7:00 a.m. Resident 1 was sent to a general acute care hospital (GACH) for an evaluation of the left foot fracture. Resident 1 once independent in ambulation (walking) became a wheelchair dependent for mobility after sustaining a left foot injury. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a problem in the way the body regulates and uses sugar as a fuel), unspecified nondisplaced (the bone typically stays aligned in an acceptable position for healing) fracture of neck of right humerus (upper arm bone), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), and generalized anxiety disorder (extremely worried or nervous-even when there is little or no reason to worry about them). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 6/12/2024, the MDS indicated Resident 1 ' s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were intact (not affected). The MDS indicated Resident 1 did not use any assistive devices for ambulation. The MDS indicated Resident 1 was able to walk 150 feet ([ft] a unit of measurement of length) with supervision or touching assistance (staff provides verbal cues and/or touching/steadying but the resident completes the activity). During a review of Resident 1 ' s Health Status Note dated 7/20/2024, the Health Status Note indicated the activity staff informed Licensed Vocational Nurse (LVN 1) Resident 1 was complaining of the left foot pain. The Registered Nurse (RN 1) and LVN 1 then assessed Resident 1 and noted Resident 1 had swelling on the left foot and she was not able to bear any weight on the left foot. Resident 1 informed nursing staff she was hit from behind by the big blue linen bucket by HK 1, while ambulating (walking) towards the double doors near the activities room. Resident 1 informed RN 1 and LVN 1 she did not tell anyone about the incident, because HK1 apologized and believed it was an accident. A STAT (immediate) x-ray (picture of the inside structures of the body), ice pack for left foot, and Motrin (medication for pain) was ordered on 7/20/2024 by Resident 1 ' s physician (MD 1). During a review of Resident 1 ' s Change of Condition ([COC] - documentation of a resident ' s sudden change from regular state of being) evaluation dated 7/20/2024, the COC evaluation indicated MD 1 was notified of Resident 1 ' s accident on 7/20/2024 at 12:45 p.m. During a review of Resident 1 ' s care plan initiated on 7/20/2024, focusing on Resident has left foot pain with swelling due to Resident 1 stating, she was bumped into from behind by the big blue laundry bucket, the care plan indicted the goal for Resident 1 was to have pain improving. The car plan interventions included for Resident 1 to wear a controlled ankle movement ([CAM] foot brace that limits ankle and foot movement) boot on the left foot at all times, except when sitting or lying, non-weight bearing (cannot put any weight on that part of the body) on the left foot and remind Resident 1 not to have weight bearing on the left foot. During a review of Resident 1 ' s Radiology (x-ray) Results Report, the Radiology Results Report indicated an x-ray of Resident 1 ' s left foot was done on 7/20/2024 at 2:24 p.m., and the results were reported to the facility on [DATE] at 1:05 p.m. The x-ray report result was as follows: no definite fracture identified; radiologist suggested to obtain additional x-ray views of the foot for further evaluation. During a review of Resident 1 ' s Health Status Note on 7/21/2024, the Health Status Note indicated MD 1 was informed of Resident 1 ' s left foot x-ray results and ordered for Resident 1 to be transferred to the GACH for evaluation of left foot fracture. During a review of Resident 1 ' s GACH emergency room (ER) After Visit Summary, dated 7/21/2024, the ER ' s After-Visit Summary indicated Resident 1 was seen in the ER for foot pain and was diagnosed with a fracture of the left cuneiform bone and was to follow up with an orthopedic (bone doctor) physician in 3 days. Resident 1 was discharged back to the facility on the same day she was seen in the ER, 7/21/2024. The ER ' s After Visit Summary indicated cuneiform fractures could be caused by dropping a heavy object on the foot and could be treated by wearing a boot or brace for several weeks. During a review of Resident 1 ' s care plan initiated on 7/21/2024, focusing on Resident has actual pain and discomfort related to incident on 7/20/2024, facility staff accidently ran over her foot with a laundry cart, the care plan indicated the goals for Resident 1 included achieving an acceptable level of pain control. The care plan interventions included obtaining a STAT x-ray, assisting Resident 1 to a position of comfort, utilizing pillows for positioning, and medicating Resident 1 as ordered for pain. During a review of Resident 1 ' s After Visit Summary 1, from her orthopedic physician visit dated 7/29/2024, the After Visit Summary 1 indicated Resident 1 was to always wear the CAM boot except when sitting or lying, needed to be non-weight bearing (on the left foot) for four to six weeks, and would need to go back to the orthopedic physician in six weeks for a repeat x-ray. During a review of Resident 1 ' s Physician ' s Orders Summary Report, the Physician ' s Orders Summary Report indicated an order dated 7/29/2024 for no weight bearing on the left foot. During an observation on 8/5/2024 at 12:35 p.m., a blue laundry cart was parked in the hallway in front of the laundry room. The laundry cart was piled high with clean linens in plastic bags and covered with a white blanket. The approximate height of the laundry cart, including the clean linens was over 5 ft tall. When standing behind it, the laundry cart obstructs the view of the hallway ahead. During an observation and concurrent interview on 8/5/2024 at 12:40 p.m., Resident 1 was sitting at the bedside eating lunch with her foot in a black orthopedic boot. Resident 1 stated that on the day she got injured she was walking toward the double doors on her unit when HK 1 came walking down the hall with the large blue laundry cart piled high with clothing and hit her from behind and ran over her left foot with the laundry cart. Resident 1 stated after HK 1 ran over her foot with the laundry cart, Resident 1 walked to her room to lay down in bed because the pain was excruciating, and she wanted to forget about it. Resident 1 stated she went back to her room, so she did not cry in front of everyone because of the pain and did not tell anyone about it because it was an accident, Resident 1 stated that a little while later HK 1 came to her room and apologized for running over her foot. Resident 1 stated she was able to walk before the accident but now she needed to use a wheelchair to move around in the facility. During an interview on 8/5/2024 at 1:04 p.m., LVN 1 stated Resident 1 was able to walk with a steady gait prior to getting her foot ran over by the laundry cart but now they had to provide her with a wheelchair because she had orders not to bear any weight on the left foot. During an interview on 8/5/2024 at 1:08 p.m., Activities Staff (ACT 1) stated Resident 1 attended activities on 7/20/2024 for a coffee social and around 11 a.m., Resident 1 asked for help back to her room which was unusual for her. ACT 1 asked Resident 1 why she needed help back to her room because she is usually ambulatory without assistance. ACT 1 stated Resident 1 informed her she could not walk because she had a bump on her left foot. ACT 1 stated she called LVN 1 over for help and LVN 1 assessed Resident 1 ' s foot with RN 1 and placed Resident 1 in a wheelchair and took her to her room. During an interview on 8/5/2024 at 2:47 p.m., LVN 1 stated that before lunch time (between 11 a.m. and 12 p.m.) on 7/20/2024, ACT 1 informed her that something was wrong with Resident 1 ' s left foot. LVN 1 stated she removed Resident 1 ' s shoes and noted the resident ' s left foot was visibly swollen on the dorsal (top) part. LVN 1 stated Resident 1 stated that her left foot was ran over by a laundry cart that had stacks of clothes in it. LVN 1 stated Resident 1 ' s MD 1 was informed of what had happened to Resident 1 and that her left foot was swollen and tender to the touch. LVN 1 stated Resident 1 verbalized her left foot hurt a lot. During an interview on 8/5/2024 at 3:36 p.m., HK1 did not speak a commonly used language (English) and a housekeeping supervisor (HKS) was translating the interview with HK1. The HK1 stated she was pushing the blue laundry cart into Station 2 from through the double doors and she did not see Resident 1 but heard ouch! HK1 stated she stopped the cart, walked around the cart, and saw Resident 1 there. HK 1 stated Resident 1 told her she (HK1) hit her with the laundry cart. HK1 stated she asked Resident 1 if she was okay and she said yes, she was okay. HK 1 stated she did not see Resident 1 walking in the hallway because the laundry cart was full of clean clothing, and it blocked her view. HK 1 stated the incident occurred around 7 a.m. on 7/20/2024. During an observation and concurrent interview on 8/6/2024 at 8:14 a.m., the blue laundry cart was parked in the hallway by the laundry room, the laundry cart was piled high with residents clothing in plastic bags on hangers and the plastic bags of clothes were covered by a white blanket. HK 1 was standing next to the blue laundry cart and the laundry cart and HK 1 was approximately the same height (HK 1 stated she was 5 ft tall). HK 1 with the scheduler (SCH) as a translator stated the blue laundry cart was the same laundry cart that she was pushing when she hit Resident 1. HK 1 stated the day of the accident, the laundry cart was piled high with clothing as it was during the observation. HK 1 acknowledged the laundry cart was piled too high and was blocking her visual field. During an interview on 8/6/2024 at 11:15 a.m., the Director of Rehabilitation ([DOR] - specializes in techniques to restore muscle function and movement) reviewed Resident 1 ' s Rehabilitation Evaluations from Physical Therapy (PT) and stated Resident 1 was previously discharged from PT Rehabilitation in February 2024 and was not using any assistive devices during that time and was able to walk 150 ft with hardly any assistance. The DOR stated Resident 1 had a high level of function at the time of discharge (2/2024) from Rehabilitation (rehab). The DOR stated Resident 1 was reevaluated for rehab services again on 7/23/2024 by PT and Occupational Therapy (OT) after her accident and now required a wheelchair and non-weight bearing on the left foot due to her injury. The DOR stated Resident 1 had a functional (ability to move and use a joint to perform activities of daily living) decline due to the left foot injury. During an interview on 8/6/2024 at 11:40 a.m., Resident 1 stated she was 5 ft 2 inches tall. Resident 1 stated she was feeling antsy from being stuck in her wheelchair because she likes to walk around. Resident 1 stated she was having a hard time propelling the wheelchair with her arms because she had an old right shoulder injury. Resident 1 stated she was stuck in her room since the accident unless staff pushed her around in the wheelchair. During an interview on 8/6/2024 at 12:06 p.m., the Director of Staff Development (DSD) stated to ensure resident safety, staff are to look around the carts when they are pushing them and not have the carts stacked too high, blocking their visual field. The DSD stated if the laundry cart was piled too high there was not a clear view, and someone could get hit with the cart. The DSD stated the accident between HK 1 and Resident 1 could have been prevented if HK 1 had a clear view and was able to see Resident 1. During an interview on 8/6/2024 at 12:37 p.m., the HKS stated HK 1 should have informed the charge nurse on duty or any nursing staff immediately about the accident, even if she thought Resident 1 was okay. The HKS stated the laundry carts should not be filled above the top of the cart. During an interview on 8/6/2024 at 2:15 p.m., the Director of Nursing (DON) stated Resident 1 was ambulatory prior to this incident and was now wearing a CAM boot and would be non-weight bearing for 4-6 weeks. During a review of the facility ' s P/P titled Laundry Initiative Module 2: the Six-Step Laundry Process revised 8/2024, the P/P indicated, when delivering clean linen, the clean linen must not be stacked higher than the rim or top shelf of the linen cart and nothing shall be stacked on top of the cart or covering.

Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for two of eight sampled residents (Resident 61 and Resident 102) with limited range of motion ([ROM] full movement potential of a joint {where two bones meet}) and mobility by failing to: 1. Monitor and assess Resident 61's ROM in each joint of both arms and legs during the quarterly Rehab Screening (brief assessment of a resident's abilities) from 11/5/2021 to 6/12/2022 in accordance with the facility's policy titled, Resident Mobility and Range of Motion, which indicated the facility will identify the resident's ROM of the joints as part of the resident's comprehensive assessment. 2. Provide Resident 61 with passive range of motion ([PROM] a movement of joint through the ROM with no effort from the person) to the left arm from 2/2/2022 to 6/11/2022, as ordered by Resident 61's physician on 3/26/2019, and in accordance with the Resident 61's request documented in Resident 61's Rehab Screening, dated 2/2/2022. 3. Monitor and assess Resident 61's ROM in each joint of both arms and legs quarterly from 9/2/2022 to 4/2/2024 in accordance with the facility policy titled, Resident Mobility and Range of Motion after Resident 61's discharge from Occupational Therapy ([OT] profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) on 9/2/2022. 4. Perform PROM exercises on 6/25/2024 to Resident 61 left elbow, wrist, hand, and ankle and the right leg in accordance with the physician's orders, dated 1/23/2024, to provide PROM to the left arm and both legs as tolerated. 5. Monitor and assess Resident 102's ROM in each joint of both arms and legs during Resident 102's quarterly Rehab Screening, dated 4/5/2024. These failures resulted in Resident 61 developing ROM limitations in the left elbow, forearm, and wrist on 6/12/2022, causing Resident 61 to develop contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) in the left elbow, forearm, and wrist, experience pain with movement of the left arm, and prevented Resident 61 from participating in activities of daily living ([ADL], tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), including dressing in normal clothes and getting out of bed. These failure also had the potential for Resident 61 to develop ROM limitations in both legs and Resident 102 to experience a decline in ROM in both arms and both legs without detection and intervention. Findings: a. During a review of Resident 61's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction (brain damage due to a loss of oxygen to the area) due to embolism (blood vessel blockage) of the right middle cerebral artery (largest of the major blood vessels in the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), hypertensive (abnormally high blood pressure) heart disease, type 2 diabetes mellitus (high blood sugar), and major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning). During a review of Resident 61's OT Evaluation and Plan of Treatment, dated 3/22/2019, the OT Evaluation indicated Resident 61's ROM in the right arm was within functional limits ([WFL] sufficient movement without significant limitation) and the left arm was impaired. The OT Evaluation indicated Resident 61's left arm ROM impairments included left shoulder flexion (lifting the arm upward) 30 to 90 degrees (30-90 degrees, normal 0-180 degrees), left elbow flexion (bending the elbow) 40-140 degrees (normal 0-150 degrees), left wrist (unspecified ROM), and left-hand ring finger and small finger had flexion (bending) contractures. The OT Evaluation indicated Resident 61 had limited strength in both arms with weakness in the left arm. Resident 61's OT Plan of Treatment indicated an OT Evaluation only (no OT intervention) with recommendations for Resident 61 to receive a Restorative Nursing Aide ([RNA] a certified nursing aide program that helps residents to maintain their function and joint mobility) program to provide PROM to the left shoulder, elbow, and hand, five times per week. During a review of Resident 61's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 3/22/2019, the PT Evaluation indicated Resident 61's both legs were WFL except for left ankle stiffness. Resident 61's PT Plan of Treatment indicated a PT evaluation only. During a review of Resident 61's Physician's Orders, dated 3/26/2019, the Physician's Orders indicated for the RNA to provide PROM to the resident's left arm in all available planes (movement side-to-side, front, and back, or rotational), five times per week as tolerated. Another physician's order, dated 3/26/2019, indicated for the RNA to provide Resident 61 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to both legs and sit to stand transfers with one siderail use, five times per week as tolerated. During a review of Resident 61's physician's orders, dated 10/29/2021, the physician orders indicated for the RNA to provide PROM to the resident's left leg, five times per week as tolerated. During a review of Resident 61's Rehab Screening, dated 11/5/2021, the Rehab Screening indicated Resident 61's ROM in the right arm and right leg were WFL. The Rehab Screening indicated Resident 61's ROM in the left arm and left leg were impaired (unspecified). During a review of Resident 61's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/9/2021, the MDS indicated Resident 61 had intact cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 61 had ROM limitations in one arm and one leg. During a review of Resident 61's Rehab Screening, dated 2/2/2022, and 5/2/2022 the Rehab Screening indicated Resident 61's ROM in the right arm and right leg were WFL. The Rehab Screening indicated Resident 61's ROM in the left arm and left leg were impaired (unspecified). The Rehab Screening indicated Resident 61 had left-sided hemiplegia with noted hypertonicity (increased tightness in the muscles). The Rehab Screening indicated Resident 61 verbalized a wish to continue with the RNA program for PROM to both arms and both legs. The Rehab Screening indicated Resident 61 was receiving RNA for PROM to the left arm and left leg, five times per week as tolerated. During a review of Resident 61's Documentation Survey Report (record of nursing assistant tasks) for RNA, dated for the month of 2/2022, 3/2022, and 4/2022, the Documentation Survey Report indicated Resident 61 received RNA for PROM to the left leg, five times per week as tolerated. The Documentation Survey Report did not include documentation from 2/2022 thru 4/2022 RNA for PROM to the left arm as ordered by Resident 61's physician (3/26/2019) and as indicated in the Rehab Screening, dated 2/2/2022. During a review of Resident 61's Documentation Survey Report (record of nursing assistant tasks) for RNA, dated for the months 5/2022 and 6/2022, the Documentation Survey Report indicated Resident 61 received RNA for PROM to the left leg, five times per week as tolerated. The Documentation Survey Report did not include documentation from 5/2022 thru 6/2022 RNA for PROM to the left arm as ordered by Resident 61's physician (3/26/2019) and indicated in the Rehab Screenings, dated 2/2/2022 and 5/2/2022. During a review of Resident 61's Rehab Screening, dated 6/12/2022, the Rehab Screening indicated Resident 61 required an OT Evaluation. During a review of Resident 61's OT Evaluation and Plan of Treatment, dated 6/12/2022, the OT Evaluation indicated Resident 61's ROM in the right arm was WFL but Resident 61's left arm ROM was impaired. The OT Evaluation indicated Resident 61's left arm ROM impairments included shoulder flexion 0-80 degrees, shoulder abduction (lifting the arm up and away from the body) 0-45 degrees (normal 0-180 degrees), elbow positioned in extension (straightened elbow) with 10 degrees of motion, wrist positioned in flexion (bent downward) to 90 degrees, wrist extension (bending the wrist upward) to neutral (wrist straightens but unable to bend further upward), the forearm positioned in increased pronation (rotation of the forearm that results in the palm facing downward), and the left-hand middle, ring, and small fingers were positioned in flexion. The OT Plan of Treatment included to provide therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), therapeutic activities (tasks that improve the ability to perform ADLs), self-care management training, and orthotic (also known as a splint, material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) management and training, five times per week for 30 days. During a review on Resident 61's PT Evaluation and Plan of Treatment, dated 6/11/2022, the PT Evaluation indicated Resident 61's ROM in the right leg, left hip, and left knee were WFL. The PT Evaluation indicated Resident 61's left ankle dorsiflexion (bending the ankle toward the body, normal 0-20 degrees) was impaired and positioned in 10 degrees of plantarflexion (ankle bent away from the body). The PT Plan of Treatment included therapeutic exercise, neuromuscular reeducation, and therapeutic activities five times per week. During a review of Resident 61's OT Discharge Summary, dated 7/29/2022, the OT Discharge Summary indicated Resident 61 tolerated wearing the left-hand wrist, hand, finger orthosis ([WHFO], material secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures) for five hours daily and the RNA (unknown) demonstrated 100 percent (%) good return demonstration of the left arm PROM exercises with prolonged stretch to maintain joint mobility, good hygiene, and prevent contractures. The OT Discharge Summary indicated recommendations for the RNA to provide Resident 61 with AAROM to the right arm, PROM to the left arm, and application of the left-hand WHFO for four to six hours, seven days a week as tolerated. During a review of Resident 61's PT Discharge Summary, dated 7/29/2022, the PT Discharge Summary indicated Resident 61 tolerated wearing pressure relief ankle-foot orthosis ([PRAFO] a device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) to the left ankle for two hours five times per week. The PT Discharge Summary indicated recommendations for the RNA to provide Resident 61 with PROM of both legs and to apply the left ankle PRAFO as tolerated with skin checks, five times per week as tolerated. During a review of Resident 61's Physician's Orders, dated 7/29/2022, the physician's orders indicated the order for the RNA to perform AAROM to Resident 61's right arm, PROM to Resident 61's left arm, and to apply the left-hand WFHO for four to six hours as tolerated, seven days per week. Another physician's orders, dated 7/29/2022, indicated the order for the RNA to perform PROM to both of Resident 61's legs and to apply the left ankle PRAFO, five times per week as tolerated. During a review of Resident 61's PT Evaluation and Plan of Treatment, dated 8/19/2022, the PT Evaluation indicated Resident 61's ROM in the right leg was WFL but impaired on the left hip, knee, and ankle. The PT Evaluation indicated the ROM in Resident 61's left leg included left hip flexion 0-60 (bending the leg at the hip joint toward the body, normal 0-120), left knee fixed (immovable) into extension (straightening out the knee, normal 0-135 degrees), and the left ankle was positioned in 10 degrees of plantarflexion. During a review of Resident 61's OT Evaluation and Plan of Treatment, dated 8/20/2022, the OT Evaluation indicated Resident 61's ROM in the right arm was WFL but Resident 61's ROM in the left arm was impaired. The OT Evaluation and Plan of Treatment indicated Resident 61's left arm ROM impairments included shoulder flexion 0-70 degrees, shoulder abduction 0-45 degrees, elbow positioned in extension with 10 degrees of motion, wrist positioned in flexion to 90 degrees, wrist extension to neutral, the forearm positioned in increased pronation, and left-hand middle, ring, and small fingers were positioned in flexion. The OT Plan of Treatment included to provide therapeutic exercises, neuromuscular reeducation, therapeutic activities, and orthotic management and training, four times per week for two weeks. During a review of Resident 61's PT Discharge Summary, dated 8/25/2022, the PT Discharge Summary indicated Resident 61 tolerated wearing the left ankle PRAFO for two hours five times a week. The PT Discharge Summary indicated recommendations for the RNA to provide Resident 61 with PROM of both legs and to apply the left ankle PRAFO as tolerated with skin checks, five times per week as tolerated. During a review of Resident 61's Physician's Orders, dated 8/25/2022, the physician's orders indicated the order for the RNA to provide Resident 61 with PROM to both legs and to apply the left ankle PRAFO for two hours with skin checks, five times per week. During a review of Resident 61's OT Discharge Summary, dated 9/2/2022, the OT Discharge Summary indicated Resident 61 tolerated wearing the left-hand WHFO for four-and-a half hours (4.5 hours) and the RNA (unknown) demonstrated 100% good return demonstration of applying and removing Resident 61's left-hand WHFO. The OT Discharge recommendations included for the RNA to perform PROM to Resident 61's left arm and apply the left-hand WHFO for four to six hours, seven times per week. During a review of Resident 61's Physician Orders, dated 9/15/2022, the physician orders indicated for the RNA to provide PROM to Resident 61's left arm and to apply the left-hand WHFO for four to six hours, seven times per week as tolerated. During a review of Resident 61's Rehab Screening, dated 10/24/2022, 1/18/2023, 4/18/2023, 7/13/2023, and 10/12/2023, the Rehab Screen indicated Resident 61's ROM in the right arm and right leg were WFL and Resident 61's ROM in the left arm and left leg were impaired (unspecified). The Rehab Screenings indicated for Resident 61 to continue with the RNA program for the left arm and left leg exercises and application of the left-hand WHFO and left ankle PRAFO. During a review of Resident 61's Progress Note for Rehab Screening, dated 1/10/2024, the Progress Note for Rehab Screening indicated Resident 61's ROM in the right arm and right leg were WFL and Resident 61's ROM in the left arm and left leg were impaired (unspecified). The Progress Note indicated to continue with the established RNA program of left arm and left leg PROM exercises and application of the left hand WHFO and left ankle PRAFO. During a review of Resident 61's Physician's Order, dated 1/23/2024, the Physician's Order indicated there was an order for the RNA to perform PROM to both legs and apply the left ankle PRAFO for two hours, five times per week as tolerated. The physician's order, dated 1/23/2024, also indicated for the RNA to provide Resident 61 with PROM to the left arm and apply the left hand WHFO for four to six hours, seven days per week as tolerated. During a review of Resident 61's Progress Note for Rehab Screening, dated 4/2/2024, the Progress Note for Rehab Screening indicated Resident 61's ROM in the right arm and right leg were WFL and Resident 61's ROM in the left arm and left leg were impaired (unspecified). The Progress Note for Rehab Screening indicated Resident 61 did not have any significant decline with mobility, ADLs, and ROM (from the last Rehab Screening on 1/10/2024) and to continue with RNA. During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 had clear speech, expressed ideas, and wants, understood verbal content, and had intact cognition. The MDS indicated Resident 61 had ROM limitations in one arm and one leg and was dependent on staff for showering/bathing, upper body dressing, lower body dressing, rolling to either side in bed, and tub/shower transfers. The MDS indicated chair/bed-to-chair transfers were not attempted with Resident 61 due to medical condition or safety concerns. During a review of Resident 61's Restorative Administration Record (record of RNA tasks) for 6/2024, the Restorative Administration Record indicated the RNA provided Resident 61 with PROM to both legs and applied the left ankle PRAFO, five times per week for two hours. The Restorative Administration Record also indicated the RNA provided PROM to the left arm and applied the left-hand WHFO for four to six hours, seven times per week. During an interview on 6/24/2024 at 9:14 a.m. with the Director of Rehabilitation (DOR), the DOR stated the Rehab Screening (in general) were completed on admission, quarterly, after a fall, after a change in the resident's condition, and from RNA referrals. The DOR stated the Rehab Screening monitored whether a resident had any declines in ROM, development of contractures, and decline in levels of assistance. The DOR stated the Rehab Screening indicated whether the extremity (arm and leg) was impaired. The DOR stated the Rehab Screening did not include a measurement of the resident's ROM at each joint. During a concurrent observation and interview on 6/24/2024 at 11:14 a.m. with Resident 61 in the room, Resident 61 was observed in bed and had active movement in the right arm. Resident 61 stated being unable to move the left side of the body and felt pain when Resident 61 tried to move the left side. Resident 61 stated the staff did not provide any ROM exercises (unknown length of time). During a concurrent observation and interview on 6/24/2024 at 1:34 p.m. in Resident 61's room, the resident was observed being awake in bed and wearing a hospital gown. Resident 61 stated he was unable to move the left arm and left leg since admission to the facility and did not receive exercises to arm and leg every day (unknown length of time). During a concurrent observation and interview on 6/25/2024 at 8:57 a.m. with Restorative Nursing Aide (RNA 1) in Resident 61's room, the resident was observed in bed awake and requested to receive pain medication prior to RNA exercises. Resident 61 stated he was having the left arm and the left leg pain level 10 out of 10 on a pain scale rating from zero to ten (a pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). During an observation on 6/25/2024 at 11:06 a.m. with RNA 1 in Resident 61's room, the resident was observed in bed, awake in a hospital gown with the left arm positioned directly on the left side of Resident 61's body. Resident 61's left shoulder was rotated toward the body, the left elbow was in an extended position, the forearm was excessively rotated inward in a position that made the left-hand palm face away from Resident 61's body, the wrist was bent downward in a 90-degree position, and the left-hand middle, ring, and small fingers had a claw-like appearance. RNA 1 was observed standing on the left side of Resident 61's bed and performing ROM exercises to the left arm, including shoulder flexion and shoulder abduction (lifting the arm up and away from the body). RNA 1 was observed not performing any ROM exercises to Resident 61's left elbow, forearm, wrist, and hand. Resident 61's left leg was observed straight on the bed and the left ankle was bent away from the body. RNA 1 was observed performing ROM exercises to Resident 61's left leg, including ROM into hip flexion with the knee extended and hip abduction (moving the leg away from the body) with the knee extended. RNA 1 was observed attempting to bend Resident 61's left knee but Resident 61 immediately complained of pain. Resident 61 agreed to allow RNA 1 to continue with ROM exercises to the left knee despite the pain. RNA 1 was observed not performing any ROM exercises to Resident 61's left ankle. Resident 61 declined to wear the left-hand WHFO and left ankle PRAFO splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). RNA 1 stated the last time Resident 61 wore both splints was on 6/21/2024. During an interview on 6/25/2024 at 11:14 a.m. RNA 1 stated he provided Resident 61 with PROM exercises to the left shoulder. RNA 1 stated PROM was not provided to Resident 61's left elbow, wrist, and hand because Resident 61 cannot bend at those joints. RNA 1 stated he forgot to perform PROM to the left ankle. During an interview on 6/25/2024 at 1:17 p.m., RNA 1 stated he usually provided Resident 61 with PROM exercises to the left shoulder, hip, knee, and ankle but forgot to perform PROM of the left ankle on 6/25/2024. RNA 1 stated Resident 61 refused the application of the left-hand WHFO and left ankle PRAFO splints on 6/25/2024. During a concurrent interview and record review on 6/25/2024 at 1:39 p.m. with RNA 1, Resident 61's Restorative Administration Record for the month of 6/2024 was reviewed. The Restorative Administration Record for Resident 61 indicated for the RNA to provide PROM to both legs. RNA 1 stated he did not provide PROM to Resident 61's right leg today (6/25/2024) because he (RNA 1) felt nervous. During an observation on 6/26/2024 at 8:35 a.m. in Resident 61's room, the resident was observed in bed, awake in a hospital gown, and asked to be turned to the left side. The Director of Nursing (DON) and Central Supply (CS) came to Resident 61's bedside to assist Resident 61 with turning toward the left. Resident 61 asked the DON and CS to be careful with the left arm due to pain. During an interview on 6/26/2024 at 9:37 a.m. a CS stated she was also a CNA. CS stated Resident 61 was repositioned to turn toward the left side and had pain in the left arm because of the left arm contracture. During a concurrent interview and record review on 6/26/2024 at 10:00 a.m. with the DOR, Resident 61's OT Evaluation, dated 3/22/2019, was reviewed. The DOR stated Resident 61 was admitted to the facility on [DATE] and received an OT Evaluation on 3/22/2019. The DOR reviewed Resident 61's OT Evaluation and stated Resident 61's ROM in the right arm was WFL which meant Resident 61 could use right arm functionally without limitations. The DOR stated Resident 61's ROM in the left shoulder was 30-90 degrees which meant Resident 61's left arm could be lifted to shoulder height. The DOR stated Resident 61's left elbow ROM was 40-140 degrees which meant Resident 61's left elbow could not completely straighten but could bend completely. The DOR stated Resident 61's left-hand ring finger and small finger were contracted into flexion. The DOR stated Resident 61 could partially move the left arm. The DOR stated Resident 61 did not receive OT therapy and was referred to the RNA program for PROM exercises to the left shoulder, elbow, and hand, five times per week. During a concurrent interview and record review on 6/26/2024 at 10:55 a.m. with the DOR, Resident 61's OT Evaluation, dated 6/12/2022, was reviewed. The DOR reviewed Resident 61's OT Evaluation, dated 6/12/2022, and stated Resident 61 was found to have a decline in ROM. The DOR stated Resident 61's right arm ROM was WFL but had impaired ROM in the left arm. The DOR stated Resident 61's left shoulder ROM included shoulder flexion 0-80 degrees and shoulder abduction 0-45 degrees. The DOR stated Resident 61's left elbow was positioned in complete extension, could bend 10 degrees, but could not completely bend. The DOR stated Resident 61's left forearm was positioned in increased pronation but stated Resident 61's OT Evaluation did not include ROM measurements of the left forearm. The DOR stated Resident 61's left wrist was positioned in 90 degrees of flexion but could extend the wrist to neutral. The DOR stated Resident 61's ROM in the left thumb and index finger were WFL but stated Resident 61's middle, ring, and small fingers were in bent positions. During a concurrent interview and record review on 6/26/2024 at 11:16 a.m. with the DOR, Resident 61's OT Discharge Summary, dated 7/29/2022, was reviewed. The DOR stated the OT Discharge Summary indicated Resident 61 wore a left-hand WHFO for five hours and the RNA (unknown) demonstrated 100 % competence in performing Resident 61's left arm ROM exercises. The OT Discharge recommendations included RNA for PROM of the left arm and application of the left-hand WHFO splint for four to six hours. The DOR stated the PROM exercises the RNA should be performing with Resident 61 included shoulder flexion and extension (returning the arm downward), shoulder abduction and adduction (returning the arm downward to the side of the body), elbow flexion and extension, wrist flexion and extension (bending the wrist upward), forearm supination (rotating the forearm that results in the palm facing upward), and finger flexion and extension. During a concurrent interview and record review on 6/26/2024 at 12:23 p.m. with the DOR, Resident 61's OT Evaluation, dated 8/20/2022, and OT Discharge Summary, dated 9/2/2022, was reviewed. The DOR stated Resident 61's left arm ROM on 8/20/2022 did not change from the OT Evaluation, dated 6/12/2022. The DOR stated Resident 61's OT Discharge Summary, dated 9/2/2022, indicated Resident 61 wore the left-hand WHFO for 4.5 hours and the RNA (unknown) demonstrated 100% competence in applying the left-hand WHFO. The DOR stated Resident 61's OT Discharge recommendations included for RNA to provide PROM to the left arm and the application of the left hand WHFO for four to six hours, seven times per week. During a concurrent interview and record review on 6/26/2024 at 12:48 p.m. with the DOR, Resident 61's physician's orders, dated 1/23/2024, for RNA were reviewed. The DOR stated Resident 61's physician's orders indicated the order for the RNA to provide PROM to both legs, PROM to the left arm, and application of the left-arm WHFO and left ankle PRAFO. During a concurrent interview and record review on 6/26/2024 at 1:20 p.m. with the DOR, Resident 61's quarterly Rehab Screening, dated 11/5/2021, 2/2/2022, 5/2/2022, 6/12/2022, 8/1/2022, 10/24/2022, 1/18/2023, 4/18/2023, 5/31/2023, 7/13/2023, 10/12/2023, 1/10/2024, and 4/2/2024, were reviewed. The DOR stated Resident 61's Rehab Screening did not include ROM measurements because measuring a resident's ROM was an assessment and not a part of the screening. The DOR stated the RNAs provided ROM exercises to the residents (in general) and will verbally inform the DOR during weekly meetings whether the resident had a change in ROM and whether the resident did not tolerate wearing the splints. The DOR stated the quarterly Rehab Screening (in general) indicated whether a resident had an impairment in the arms and legs but did not indicate which joint was impaired and the severity of the impairment. During a concurrent observation and interview on 6/26/2024 at 1:37 p.m. with the DOR, in Resident 61's room, the resident was in bed wearing a hospital gown with the left arm positioned on the side of the body. Resident 61's left shoulder was rotated toward the body, the left elbow was in an extended position, the forearm was excessively rotated inward in a position that made the left-hand palm face away from Resident 61's body, the wrist was bent downward in a 90-degree position, and the left-hand middle, ring, and small fingers had a claw-like appearance. Resident 61 stated feeling pain throughout the left arm. Resident 61 allowed the DOR to move the left arm. The DOR stated Resident 61's ROM for left shoulder flexion was 0-70 degrees, left shoulder abduction was 0-45 degrees, left elbow ROM was 170-180 degrees, the left wrist moved from a flexed position to neutral, and the left thumb and index fingers were WFL. The DOR attempted to rotate Resident 61's left forearm into supination but Resident 61 immediately screamed in pain. The DOR stated Resident 61's left forearm ROM had a decline in ROM since the DOR could usually move the left forearm to neutral (rotating the forearm that results in the palm facing the body). The DOR stated the RNAs should be performing PROM to Resident 61's left shoulder, elbow, forearm, wrist, and hand prior to applying the left-hand WHFO. During an interview on 6/26/2024 at 1:45 p.m. the DOR stated the purpose of performing PROM to Resident 61's left arm was to maintain ROM, joint mobility, and prevent contractures. The DOR stated Resident 61's complaint of pain in the left arm and screaming in pain during forearm supination indicated Resident 61's left arm has not been moved (exercised). The DOR stated Resident 61's left arm experienced a ROM decline and increased pain. During a concurrent observation and interview on 6/27/2024 at 1:20 p.m. with Resident 61 in the bedroom, Resident 61 was in bed, awake in a hospital gown with the left arm positioned directly to the side of Resident 61's body. Resident 61 stated the left arm had some pain at rest that sharply increased when someone touched or moved the left arm for exercises. Resident 61 stated he wanted and encouraged the facility staff to perform left arm exercises (in general) but did not remember anyone performing any exercises to the left arm. Resident 61 stated he did not remember when or how long the left arm had a twisted appearance but stated it did not happen overnight. During an interview on 6/27/2024 at 1:42 p.m. a Certified Nursing Assistant (CNA 5) in Resident 61's room, CNA 5 stated Resident 61 was dressed in a hospital gown because Resident 61 had pain in the left arm, preventing Resident 61 from putting on a shirt. CNA 5 stated Resident 61 did not like to get out of bed because Resident 61 felt pain throughout the body. Resident 61 stated the left arm pain prevented Resident 61 from getting dressed and getting out of bed. During a concurrent interview and record review on 6/27/2024 at 5:16 p.m. with the DON and DOR, Resident 61's Census List, OT Evaluation, dated 3/22/2019, Rehab Screening, dated 2/2/2022 and 5/2/2022, Documentation Survey Report for RNA for 2/2022, 3/2022, 4/2022, 5/2022, and 6/2022, and OT Evaluation, dated 6/12/2022, were reviewed. The DON and DOR reviewed Resident 61's Census List and stated Resident 61 never left the facility after admission on 3/21/2019. The DON and DOR reviewed Resident 61's OT Evaluation, dated 3/22/2019, which indicated Resident 61's ROM in the right arm was WFL but had impaired ROM in Resident 61's left shoulder, left elbow into extension but could bend completely, and left ring finger and small finger. The DON and DOR reviewed Resident 61's Rehab Screening, dated 2/2/2022. The DON stated the Rehab Screening, dated 2/2/2022, indicated the ROM in Resident 61's left arm and left leg were impaired but did not indicate which joints were impaired and the severity of the impairments. The DON stated Resident 61's Rehab Screening, dated 2/2/2022, indicated Resident 61 wanted an RNA program for ROM to both arms and both legs. The DON and DOR reviewed Resident 61's Documentation Survey Report for RNA from 2/2022 to 5/2022. The DOR stated Resident 61 did not receive PROM to the left arm from 2/2022 to 5/2022. The DOR and DON reviewed Resident 61's Rehab Screen, dated 5/2/2022. The DON stated the Rehab Screening, dated 5/2/2022, indicated the ROM in Resident 61's left arm and left leg were impaired but did not indicate which j [TRUNCATED]

Based on interview and record review, the facility failed to ensure, residents, assessed at risk for falls, did not have a fall, for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 3) did not leave Resident 1 unsupervised when Resident 1 was sitting at the edge of the bed. 2. Ensure CNA 3 followed the facility's policy and procedure (P&P) titled Answering the Call Light which indicated to call another staff for help by using the call light for assistance. CNA 3 left Resident 1 sitting at the edge of her bed unattended and went to the resident's restroom to get some gloves. 3. Ensure staff followed Resident 1's care plan titled Resident at risk for fall related to poor safety awareness, cognitive (ability to think, understand, learn, and remember) loss, and visual limitation which indicated staff will assist Resident 1 getting in and out of bed, and perform frequent visual checks. The deficient practices resulted in an unavoidable fall on 5/4/2024 and Resident 1 sustained a right inferior pubic ramus fracture (crack or break in the pelvis [basin-shaped complex of bones that connect the trunk and the legs]). Resident 1 was hospitalized at the General Acute Care hospital (GACH) for orthopedic ([ortho] field of medicine specialize in injuries of the muscles, bones, joints, ligaments, and tendons) evaluation and management from 5/4/2024 and discharged back to the facility on [DATE]. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), osteoporosis (condition in which bones become weak and brittle), dementia (loss of memory, language, problem-solving and other thinking abilities) and difficulty in walking. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 2/9/2024, indicated Resident 1's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required maximal assistance (helper gets more than half the effort) from staff for upper body dressing, lower body dressing and personal hygiene and moderate assistance (helper does less than half the effort) on oral hygiene, toileting hygiene, toileting, and showering. The MDS indicated Resident 1 required moderate assistance walking 150 feet. The MDS indicated Resident 1 used walker for assistance in moving. The MDS indicated Resident 1 was incontinent (inability to control bladder and bowel functions) of urine and bowel. The MDS also indicated Resident 1 had a history of falls with injuries. A review of Resident 1's care plan titled Resident at risk for fall related to poor safety awareness, cognitive loss, and visual limitation dated 1/24/2024 indicated Resident 1 will minimize episode of falls through the next review date of 5/17/2024. The Care Plan indicated interventions including fall mat (a rectangular floor pads with inner surface made of foam or other cushiony materials used to provide a softer place for the resident to land when falling especially if the resident falls from the bed) while resident in bed, provide extensive assistance to the resident with getting in and out of bed, and frequent visual check. A review of Resident 1's care plan titled Resident at risk for ADL Self-care performance deficit related to impaired function and mobility, cognition, diagnosis of dementia, and depression (persistent feeling of sadness and loss of interest in activities) dated 3/23/18, indicated staff will assist Resident 1 with activities of daily living ([ADLs] daily self-care activities) as needed. A review of Nursing Progress Note dated 5/4/24 timed at 11:15 a.m., indicated Resident 1 fell on [DATE] at 11:06 a.m., due to Resident 1 not asking for assistance. The Nursing Progress Note indicated Resident 1 complained of a pain level of 10 out of 10, on a zero to ten pain rating scale (where 0 indicates no pain and 10 was worse possible pain) to the right side of her head, right arm, and right leg. The Nursing Progress Note indicated Resident 1 was observed with facial grimacing (distort face in an expression usually of pain) and holding the right side of her ribcage (bones in the chest). The Nursing Progress Note indicated 911 (a phone number used to contact emergency services) was called and the resident was transferred to the GACH on 5/4/2023 at 12:15 p.m. A review of Resident 1's 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) note dated 5/4/24 timed at 11:30 a.m., indicated on 5/4/24 at around 11:06 a.m., Resident 1 was observed on the floor by the foot of the bed towards the left side. The IDT note indicated Resident 1's roommate witnessed the fall and stated Resident 1 was sitting at the edge of the bed, reached to her walker with one hand and when Resident 1 grabbed the walker, she lost her balance and fell backwards. A review of Resident 1's GACH History and Physical indicated Resident 1's Computed Tomography ([CT] an imaging test used to detect internal injuries) of the chest, abdomen, and pelvis on 5/4/2024 at 7:27 p.m. indicated a right inferior pubic ramus fracture. A review of Resident 1's GACH report titled Medicine for Discharge Summary under 48 hours, dated 5/6/2024, indicated Resident 1 was admitted for further orthopedic ([ortho] field of medicine specialize in injuries of the muscles, bones, joints, ligaments, and tendons) evaluation and management from 5/4/2024 and discharged back to the facility on [DATE]. The report indicated based on Resident 1's imaging results, the ortho did not recommend surgical intervention, the resident's pubic rami fracture will be treated conservatively. The report indicated recommendations including weightbearing (amount of weight a resident put on an injured body part) as tolerated to right lower extremity, elevate and ice right hip as needed, always use assistive devices with ambulation, Lovenox (medication to prevent blood clots), for 2 weeks after discharge, and follow-up with ortho as outpatient in 3 to 4 weeks, for repeat imaging and to discuss advancing weight bearing. During an interview on 5/16/24 at 12: 20 p.m., Resident 1 stated one day, she slipped and fell in her room. The resident could not remember the date and time. During an interview on 5/16/2024 at 1:15 p.m., with the Director of Nursing (DON) in Resident 1's room, the DON stated Resident 1 had history of multiple falls. The DON stated Resident 1 had a fall in 1/2024 (cannot remember the exact date). The DON stated prior to Resident 1's fall on 5/4/2024, Resident 1 used a rollator walker (a device used to walk with wheels and a seat) where she sat but was discontinued after the resident fell on [DATE]. The DON stated Resident 1 needed assistance form staff on getting up from a sitting position, and ambulating (walking). The DON stated CNA 3 should not have left Resident 1 sitting at the foot of the bed unattended. The DON stated Resident 1's fall was avoidable if CNA 3 did not leave Resident 1 unattended on 5/4/2024. During an interview on 5/16/24 at 2:20 p.m., with CNA 1, CNA 1 stated she was in another room when she heard a loud noise coming from Resident 1's room. CNA 1 stated when she entered Resident 1's room, Resident 1 was on the floor. CNA 1 stated Housekeeper 1 and CNA 3 got the resident up and took Resident 1 to the dining room. CNA 1 stated Resident 1 was sitting in the dining room when she started complaining of headache and the resident was observed with a big bump on the right side of her head. During an interview on 5/21/24 at 12:40 p.m., with CNA 3 stated on 5/4/24 at around 11 a.m., when she entered Resident 1's room, Resident 1 was sitting up at the foot of the bed. CNA 3 stated she asked Housekeeper 1 to watch and talk to Resident 1 while she went to the bathroom to grab a pair of gloves. CNA 3 stated when she left Resident 1, Resident 1 got up to walk with her rollator walker and fell . CNA 3 stated Resident 1 slipped, fell , and hit her head. CNA 3 stated she should not have left Resident 1 unattended while sitting at the foot of the bed and ready to get up. CNA 3 stated she should have asked another staff to get her a pair of gloves and not leave Resident 1. CNA 3 stated she should have assisted Resident 1 to a wheelchair to ensure her safety. CNA 3 stated Resident 1 fell on the left side of her bed and hit her head on the bedside table. CNA 3 stated she (CNA 1) came in after she heard a noise coming from Resident 1's room. CNA 3 stated Resident 1 complained of headache, LVN (unknown) was notified and 911 was called. CNA 3 stated an ambulance arrived and took Resident 1 to GACH on 5/4/2024 around 12 p.m. CNA 3 stated Resident 1's fall was avoidable if she did not leave her unattended. CNA 3 stated Resident 1 should have had a wheelchair instead of a rollator walker to prevent further falls. During an interview on 5/21/24 at 12:44 p.m., with Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) 1, OT 1 stated Resident 1 required a one-person assistance to get in and out of the bed and going to the bathroom. OT 1 stated CNA and licensed staff were instructed not to leave Resident 1 by herself as she was a high risk for fall. A review of facility's policy and procedures (P&P) titled Falls Management dated 5/26/2021, indicated residents will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. A review of facility's P&P titled Answering the Call Light revised on 9/2022, indicated If assistance is needed when you (staff) enter the room, summon help by using the call signal.

Based on interview and record review, the facility failed to ensure a resident, who experienced a change of condition (COC), was continuously monitored/assessed and transferred to a General Acute Care Hospital (GACH) during a window of time when interventions to prevent a major stroke and/or reduce damage to the brain would have been effective, for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's status was continuously assessed and monitored after the resident had a COC, as ordered by the physician on [DATE]. 2. Assess and recognize sooner than seven hours after Resident 1's COC that the intervention of providing IV fluids to Resident 1 was not effective, preventing a timely transfer of Resident 1 to the GACH during a window of time when interventions to prevent a major stroke and/or reduce damage to the brain would have been effective. This deficient practice resulted in Resident 1 being unmonitored for over seven hours and in delay of Resident 1's evaluation and treatment. Resident 1 was transferred to a GACH over seven hours after the resident's initial COC at the facility and was admitted to the GACH's intensive care unit ([ICU] a unit in the hospital that provides the critical care and life support for acutely ill and injured patients), where he was intubated (insertion of a tube either through the mouth or nose into the airway to aid with breathing, deliver anesthesia or medications) for eight days. Resident 1 was diagnosed with an acute cerebral vascular accident ([CVA] a disruption of blood to the cells in the brain [stroke]) and was deemed outside of the treatment window (within three hours of having a stroke, or for some eligible patients, up to 4.5 hours after the onset of a stroke) for treatment using tissue plasminogen activator ([tPA] a drug often used to treat CVA, when given in a timely matter can reduce damage to the brain by restoring blood flow to brains regions affected by a stroke). Resident 1 expired on [DATE] at 1 a.m. Findings: During a review of Resident 1's Admission Record, (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (altered brain function) and chronic kidney disease ([CKD] when the kidneys are damaged and cannot filter blood). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated [DATE], the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 had clear speech, was usually understood, and had the ability to understand others. During a review of Resident 1's Change of Condition (COC) note, dated [DATE] and timed at 12:30 p.m., the COC indicated Resident 1 was usually more alert and talkative but became less responsive to staff and to stimuli (anything that triggers a physical or behavioral change). The COC indicated Resident 1 had a sudden an altered level of consciousness ([ALOC] when a patient is not as awake, alert, or able to understand or react as normal). The COC indicated Resident 1's physician was notified and an order for intravenous ([IV] a method of putting drugs or other substance through a needle or tube inserted into a vein) fluids was obtained. During a review of Resident 1's Progress Notes (PN), dated [DATE] and timed at 12:30 p.m., the PN indicated Resident 1's physician was notified that Resident 1 was less responsive to staff and to stimuli, would not open his eyes, his mucous membranes appeared dry, there was visible skin tenting (when the skin is pinched and it stays up in a tent shape once you let it go, people who are dehydrated may experience this) and Resident 1 had only urinated twice since midnight ([DATE]). The PN indicated Resident 1's vital signs ([v/s] measurements of the body's most basic functions, the main ones being; temperature, pulse rate, breathing rate and blood pressure) were as follows: 1. Blood pressure was ,d+[DATE] millimeters of mercury ([mm Hg] a unit of measurement, normal range less than ,d+[DATE] for a male over 65). 2. Heart rate 73 beats per minute ([bpm] normal range 60- 100 bpm). 3. Respirations 18 breaths per minute ([bpm] normal range ,d+[DATE] bpm). 4. Temperature was 97.7 degrees Fahrenheit ([F] scale for measuring temperature, normal range 97.8 F-99.1 F). 5. Blood sugar was 126 milligrams per deciliter ([mg/dl] a unit of measurement; amount of glucose (sugar) in the blood]) normal range ,d+[DATE] mg/dl). During a review of PN dated [DATE] and timed at 12:30 p.m., the PN indicated Resident 1's physician ordered Resident 1 to receive 2000 milliliters [(ml) unit of liquid measurement) of Normal Saline ([NS] a mixture of sodium [salt]) chloride and water) 0.9% at the rate of 100 ml/per hour and to continue monitoring. At 2 p.m., (one hour and thirty minutes after Resident 1's initial COC assessment) the PN indicated Resident 1's IV was removed due to Resident 1's activity, the resident responded to physical stimuli and was able to open both his eyes with a focused stare. During a review of Resident 1's electronic Medication Administration Record (eMAR) note, dated [DATE] and timed at 3:16 p.m., the eMAR indicated to monitor and document every shift, and report to the physician (MD) Resident 1's signs and symptoms of dehydration including tenting skin, new onset of confusion, dizziness on sitting and standing, increased pulse, headache, fatigue, weakness and dizziness. The eMAR note indicated an endorsement was made to the incoming evening shift nurse indicating Resident 1 was extremely fatigued (tired), responsive but could not keep his eyes open and Resident 1's physician ordered IV hydration. A review of Resident 1's PNs dated [DATE], indicated there were no additional assessments of Resident 1's v/s, urinary status, skin, lips, mucous membranes, or the resident's cognitive status. During a review of Resident 1's eMAR, dated [DATE] and timed at 7:54 p.m., (seven hours and 25 minutes after Resident 1's initial COC assessment) the eMAR indicated Resident 1 was not verbally responsive at this time. Resident 1's eMAR notes and PNs indicated there was no documentation of another assessment or continued monitoring after Resident 1's initial COC at 12:30 p.m. During a review of Resident 1's Health Status Note (HSN), dated [DATE] and timed at 8:45 p.m., (eight hours and 15 minutes after Resident 1's initial COC assessment), the HSN indicated Resident 1 remained in a sleeping state and was not easy to arouse. The HSN indicated due to Resident 1's continued altered status, Resident 1's physician instructed staff to transfer Resident 1 to a GACH for further evaluation. During a review of Resident 1's Physician's Orders (PO), dated [DATE], the PO indicated to transfer Resident 1 via 911 for further evaluation. During a review of the GACH's Emergency Department (ED) notes, dated [DATE], the GACH's ED notes indicated Resident 1 arrived at the ED at 9:05 p.m., and was intubated upon arrival to protect his airway. During a review of the ED's Physical Exam (PE), the PE indicated Resident 1's Glasgow Coma Scale ([GCS] a clinical scale used to reliably measure a person's level of consciousness after a brain injury, severe=8 or less, moderate=,d+[DATE], mild=,d+[DATE]) was a 6, his pupils were pinpoint (indicates a problem with your health), he was only moving his left upper extremity, bilateral lower extremities and he had right sided facial droop. During a review of GACH's History of Present Illness (HPI), the HPI indicated Resident 1 was not a candidate for tPA as he was outside the window for treatment. As confirmed during a neurology consult and by a neuro-interventionalist (a doctor who specializes in treatments of the brain, neck, and spine). During a review of the GACH's Computed Tomography ([CT] a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) report dated [DATE] and timed at 9:22 p.m., the CT report indicated Resident 1 suffered a left middle carotid artery ([MCA] a major artery that supplies blood to the brain) occlusion (complete or partial blockage of a blood vessel). During a review of Resident 1's GACH Discharge Summary (DS) dated [DATE] and timed at 5:37 p.m., the DS indicated intervention was not deemed appropriate for Resident 1 as it would not provide any meaningful benefit to quality of life, as his prognosis was already grim given the large size of infarct (blockage in blood supply). The DS indicated Resident 1's family was made aware and came to the decision to initiate comfort care (care to control pain and other symptoms so the patient can be as comfortable as possible). The DS indicated Resident 1 passed away on [DATE]. During a telephone interview with Resident 1's Responsible Party (RP) on [DATE] at 2:38 p.m., the RP stated she was present when Resident 1 had a COC ([DATE]). The RP stated, at approximately 11:30 a.m., she was talking to Resident 1 when the resident suddenly stopped talking. The RP stated she left Resident 1 and found a nurse and reported what happened, and that nurse grabbed another nurse to check on Resident 1. The RP stated the nurse told her Resident 1 looked dehydrated, they called Resident 1's physician and obtained an order to start Resident 1 on IV fluids. The RP stated she left the facility and returned at approximately 7:30 p.m., the same day and when she went to see Resident 1 she found the resident in the same condition as the resident was at 11:30 a.m. The RP stated she went to get a nurse and asked why Resident 1 was still in the same condition, the nurse checked Resident 1 and stated Resident 1 needed to be transferred out immediately. The RP stated the GACH told her Resident 1 had suffered a major stroke. During an interview with Registered Nurse 1 (RN 1) on [DATE] at 4:01 p.m., RN 1 stated when a resident has a sudden change of consciousness it is important call 911 as soon as possible. If it is a possible stroke, time becomes an important factor when treating the stroke. During an interview with the Director of Nursing (DON) on [DATE] at 2:06 p.m., the DON stated if a resident has a COC, we call the MD to report the resident's status and obtain orders as needed. The DON stated we continue to monitor the resident to see if the interventions that were implemented worked. The DON stated the resident's COC is reported to the oncoming nurses during their huddle, so incoming nurses will continue to monitor the resident. The DON stated if a resident is known to be verbal, suddenly stops talking and only responds to painful stimuli, we need to escalate the situation and call 911 immediately. The DON stated she was unaware of Resident 1's COC until later that evening. The DON stated when she assessed Resident 1, Resident 1 was not responding verbally but was able to move, he was able to squeeze my hands but was very weak. During an interview with Licensed Vocational Nurse 4 (LVN 4) on [DATE] at 3:43 p.m., LVN 4 stated at the beginning of shift, a report is given about all residents who had COCs during the outgoing shift, so the incoming shift knows to monitor and document any changes and/or if the interventions are working for the resident. LVN 4 stated any residents with COCs need to be monitored closely. During an interview with LVN 5 on [DATE] at 11:20 a.m., LVN 5 stated it is important to continue monitoring residents with any COC and to document any findings weather there is a change or not. During a phone interview with RN 2 on [DATE] at 2:52 p.m., RN 2 stated she reported her findings to Resident 1's physician after assessing Resident 1. RN 2 stated when she assessed Resident 1 there was nothing indicating a stroke, so she thought he had an infection or was dehydrated. RN 2 stated, Resident 1 was moving around a lot and was very active. RN 2 stated she did not remember if she reported that Resident 1 could not speak to Resident 1's physicians or if she endorsed his status to the incoming shift. During a review of the facility's LVN Job Description (JD), dated ,d+[DATE], the JD indicated that qualifications include being knowledgeable of nursing/medical practices and procedures. Safety concerns are identified, and appropriate actions are taken to maintain a safe environment including recognizing emergency situations and appropriate action is instituted in a timely matter. During a review of the facility's RN Supervisor JD, dated ,d+[DATE], the JD indicated the RN's responsibilities included performing assessments and identifying changes in resident's physical or psychological condition. During a review of the facility's Policy and Procedure (P&P), titled Change of Condition, Resident, revised ,d+[DATE], the P&P indicated it is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective matter. In the event of a life-threatening situation or serious injury, the charge nurse may elect to contact emergency personnel services to assist with care and possible transport to an acute hospital. The staff will continue to monitor and document resident's condition at a minimum of every shift for 72 hours and as needed, until the acute episode has subsided, and the resident is stable. According to The National Institute of Neurological Disorders and Stroke, https://www.ninds.nih.gov/health-information/public-education/know-stroke/patients-and-caregivers. Ischemic strokes, the most common type, can be treated with the drug t-PA, which dissolves blood clots obstructing blood flow to the brain. The window of opportunity to start treatment is three hours, but patients need to get to the hospital within 60 minutes to be evaluated and receive treatment.

Based on observation, interview and record review, the facility failed to ensure a certified nursing assistant (CNA 1), used the assistance of another staff member when transferring the resident, with a mechanical lift from the bed to a chair to prevent the resident from sustaining a fall with injuries for one of three sample residents (Resident 1). The facility failed to: 1. Ensure CNA 1 used the assistance of another staff member to transfer Resident 1 from bed to a chair utilizing a mechanical lift as indicated in Resident's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 1/1/2023. 2. Ensure the nursing staff followed Resident 1's care plan titled Activities of Daily Living (ADL) Self Care Performance Deficit related to amputation . and provided Resident 1 with two staff total assistance during the resident's transfers from bed to a chair. 3. Ensure a minimum of two staff members used a mechanical lift to transfer Resident 1 from a bed to chair to reduce the risk of residents' injury per facility's policy titled Lifting Residents by Use of Mechanical Device. 4. Ensure CNA 1 followed the facility's policy titled Standards of Certified Nursing Assistant Practice, which stipulated that CNAs must assist one another in caring for residents when lifting, transferring and/or turning a resident. 5. Ensure CNA 1 followed the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, which stipulated if the resident cannot stand alone, two persons (one on each side) should use a mechanical lift to move the resident. This deficient practice resulted in Resident 1 sliding out of the mechanical lift approximately 3.0 feet onto the floor, and sustaining fractures of the 10th, 11th and 12th left ribs. Resident 1 also suffered emotional distress due to the fall. Resident 1 was transferred to a General Acute Care Hospital (GACH) for emergent care due to complaints of pain on the left chest area. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots), end staged renal disease (ESRD- permanent kidney failure that requires a regular course of dialysis [mechanical way of removing waste products and toxins the kidneys are no longer able to filter] or a kidney transplant), cerebral vascular disease ([CVD] interruption in the flow of blood to the brain, causing damage or death to brain tissue) with hemiplegia (severe weakness of one side of the body that can impact upper, lower limbs and facial muscles) and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). A review of the MDS, dated [DATE], indicated Resident 1's cognitive (mental process by which knowledge is acquired, including perception, intuition, and reasoning) skills for daily decision making were intact. The MDS indicated Resident 1 depended on total assistance from two staff members during all transfers from one surface to another, including to or from bed, chair, wheelchair, and standing position. A review of Resident 1's care plan (CP) titled Activities of Daily Living (ADL) dated 6/20/2022, indicated Resident 1 had an ADL Self Care Performance Deficit related to (r/t) amputation (surgical removal of part of the body) of left leg below knee. One of the CP's listed goals for Resident 1 was to improve current level of function in transfers. One of the interventions was to provide Resident 1 with a total assistance from staff with transfers. During a concurrent observation and interview on 2/6/2023 at 11:14 a.m., Resident 1 was observed sitting in his wheelchair by his bed. Resident 1 was alert, and oriented to name, time, and place. Resident 1 stated, he remembered the fall incident on 1/17/2023. Resident 1 stated, CNA 1 did not place the sling from the mechanical lift on him correctly to prevent him from sliding out of the sling. Resident 1 stated, he told CNA 1that if CNA 1 did not cross the leg straps (of the sling), he (Resident 1) would slide out of the sling. Resident 1 stated, CNA1 did not respond and ignored his comment. Resident 1 stated that after he was lifted approximately three feet, he began to slide out of the sling onto the floor. Resident 1 stated he fell on the left side of his back. Resident 1 stated that after he fell , CNA 1 left the room without saying a word. Resident 1 stated he felt sad and felt left out. Resident 1 stated he felt pain on his back and neck. During an interview on 2/2/2023 at 12:40 p.m., the Director of Nursing (DON) stated she was notified by CNA 2 that Resident 1 was lying on the floor. DON stated she immediately assessed Resident 1, and did not observe any swelling or bruises on his body. DON stated she notified Resident 1's physician and received an order to transfer Resident 1 to the GACH immediately. DON stated CNA1 should have asked for assistance from other staff to transfer Residents 1 because two people physical assistance was required to transfer the resident with a mechanical lift to ensure the resident's safety. A review of Resident 1's Nurses Progress Note (NPN), dated 1/17/2023 and timed at 9:33 a.m., indicated Resident 1 was laying on the floor on his back with his head toward the window. The NPN indicated Resident 1 complained of pain to neck and back area and the resident stated he slipped out of the sling. The NPN indicated the Emergency Medical Service [(EMS)- emergency response personnel)] was called and Resident 1 was kept in a comfortable position on the floor. Resident 1 was then transported by EMS on a gurney to GACH for further evaluation. A review of Resident 1's Vital Signs Record, after his fall, dated 1/17/2023 at 09:30 a.m., indicated blood pressure was 161/67 mmHg (a normal blood pressure level is less than 120/80 mmHg) and pain level rated 6 out of 10 on a pain scale (numerical scale, 0 being no pain, and 10 being the worst possible pain). A review of Resident 1's Physician's Order Summary Report (POSR) with an order dated 1/17/2023 at 4:55 p.m., indicated an order to transfer Resident 1 to a GACH. A review of Resident 1's Emergency Department (ED) Notes and History and Physical (H&P) from the GACH dated 1/17/2023 at 10:25 a.m., indicated Resident 1 reported falling onto his left flank (area of body between the ribs and the hip). The H&P indicated Resident 1 presented to ED as status post (after) fall, slip out of mechanical lift during transfer from bed to a chair. The H&P stated, Resident 1 was currently complaining of a left flank and left upper/middle back pain. During a review of Resident 1's GACH's ED note dated 1/17/2023, at 1:11 p.m., the ED note indicated Resident 1 was admitted to the Telemetry unit (unit in a hospital where patients are constantly monitored with electronic equipment) and diagnosed with multiple rib fractures (break in bone) on the left side. During a review of Resident 1's Computerized Tomography [(CT) procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) scan of abdomen and pelvis report dated 1/17/2023 at 11:42 a.m., the report indicated a fracture of the posterior (back position) and posterolateral (outside portion of the back) 10th, 11th and 12th left ribs, not significantly displaced. Compression deformity (occurs when the fractured vertebra (one of the bony or cartilaginous [made of connective tissue] collapses shortening and tilting the vertebra forward) of the first lumbar [(L1) the first of the vertebrae connected from the rib cage to the hip bone] segments composing the spinal column [part of the body that carries signals that control the body's movements and convey sensations]). During a review of Resident 1's GACH's Discharge Summary Note (DSN) dated 1/18/2023, the DSN indicated Resident 1 was discharged to the skilled nursing facility on 1/18/2023 at 10:11 p.m. The DSN indicated Resident 1 was discharged in stable condition. A review of Resident 1's POSR, dated 1/19/2023 indicated an order for orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) physician consultation for the lumbar spine (L1) compression deformity and posterolateral 10th -12th left rib fracture. A review of Resident 1's POSR, dated 1/26/2023, indicated an order for physical therapy ([PT] therapy focused on improving the residents' ability to move their body) services every day, five times a week, for 30 days for therapy exercise and therapy activity. The POSR indicated an order for occupational therapy ([OT] therapy focused on improving the residents' ability to perform activities of daily living). On 2/3/2023 at 11:35 a.m., and 12:30 p.m., this surveyor attempted to contact CNA 1 for an interview However, CNA 1 did not respond. During an interview on 2/2/2023 at 1:35 p.m., CNA 3 stated Resident 1 preferred the mechanical lift when staff transferred him from the bed to a wheelchair. CNA 3 stated Resident 1 required two people to assist him with transfer and CNA 1 should have asked another person to assist transferring Resident 1 to ensure resident 's safety. During an interview on 2/2/2023 at 12:40 p.m., the DON stated she was covering for the Director of Staff Development (DSD) on 1/17/2023, and CNA 1 was from a registry (an agency that provides temporary staff as needed). The DON stated, she went over registry staff orientation with CNA 1 including use of mechanical lifts. The DON stated, she did not give further training on how to use the mechanical lift step by step to CNA 1 because CNA1 stated he already knew how to use it and that he had used the mechanical lift before. During a review of the facility's policy and procedure (P/P) titled, Lifting Residents by Use of Mechanical Device. Revised 11/2012, the P/P indicated a minimum of two staff members should be used to reduce the risk of residents' injury. During a review of the facility's P/P titled, Standards of Certified Nursing Assistant Practice, revised 11/2012, the P/P indicated CNA's will assist one another in caring for residents when lifting, transferring and/or turning a resident. During a review of the facility's P/P titled, Moving a Resident, Bed to Chair/Chair to Bed, revised 11/2012, the P/P indicated if the resident cannot stand alone, two persons (one on each side) should lock arms with the resident, gently stand and turn the resident and sit him/her in the chair or use mechanical lift or sit to stand lift.

Based on observations, interviews, and record reviews, the facility failed to store and prepare food under sanitary conditions in one (1) of 1 kitchen, by failing to: A. Ensure six (6) of 6 residents (Residents 32, 94, 196, 12, 75, and 31) who were served and ate over-easy eggs (egg gets fried on both sides, but it's not cooked for very long on the second side, so the yolk remains runny and uncooked) were cooked from pasteurized eggs (eggs that have gone through pasteurization, a process that kills germs in foods and drinks) and that all eggs served were cooked to a minimum of 145 degrees Fahrenheit (temperature scale) for at least 15 seconds. B. Ensure 1 of 1 ice machine was clean. C. Ensure 1 of 1 dietary staff did not enter the kitchen with personal belongings. The deficient practice of serving undercooked, unpasteurized eggs to residents had the potential for the transmission of Salmonella (a germ that may cause diarrhea, fever, and stomach cramps, leading to hospitalization and death). The deficient practice of failing to ensure the ice machine was clean and failing to ensure the dietary staff did not enter the kitchen with personal belongings had the potential for the transmission of illness, which can possibly lead to hospitalization and even death. On 10/14/2021, at 4:14 PM, an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was declared in the presence of the Administrator (Admin), Director of Nursing (DON), and the Registered Dietician (RD). Residents 32, 94, 196, 12, 75, and 31 were served over-easy eggs that were cooked from unpasteurized eggs on 10/14/2021. The facility did not check the eggs for temperature to ensure they reached a minimum of 145 degrees Fahrenheit for at least 15 seconds prior to serving them to the residents. On 10/15/2021, the facility submitted an acceptable Plan of Action (POA). After the POA was verified through observation, interview, and record review, the IJ situation was removed on 10/15/21 at 2:29 PM. The POA included the following: 1. The facility discarded the unpasteurized eggs on 10/14/2021. 2. On 10/14/2021 and 10/15/2021 dietary staff was educated on using pasteurized shell eggs only and checking the temperature prior to serving the eggs to the residents. 3. The facility identified three (3) other residents who were served undercooked unpasteurized eggs the morning of 10/15/2021. 4. For the 6 affected residents (Residents 32, 94, 196, 12, 75, and 31) a change of condition (COC, a sudden clinically important deviation from the resident's baseline in physical, cognitive, behavioral, or functional domains) was initiated on 10/14/2021. The facility also started a COC for the 3 other identified residents on 10/15/2021. According to the COC, the 6 affected residents and the 3 facility identified residents will be monitored for nausea, vomiting, abdominal cramps, diarrhea, fever, chills, headache, and blood in the stool for 72 hours. The physicians and family/ responsible parties for each resident were also notified. 5. The facility will only purchase pasteurized shell eggs from an approved vendor. No other shell eggs will be used in facility. The Alternative Menu Tickets received from the residents will be kept in a log for 90 days. 6. The Dietary Manager and/or RD will review weekly purchasing to ensure all shell eggs purchased are pasteurized. The Dietary Manager will monitor the tray line for compliance. The RD will do weekly monitoring of the tray line for compliance. Compliance of the purchases of pasteurized eggs will be reported to the Administrator. 7. The Administrator or designee will trend any findings, and results of the trends to be reviewed by the Quality Assessment and Assurance Committee (committees established for the purpose of improving the safety and quality of health services) for their review and recommendations for the next three months. Findings: A. During a review of Resident 32's Face Sheet (admission record), dated 10/15/2021, the Face Sheet the facility admitted Resident 32 on 2/8/2021 with diagnoses including: [CONDITION(S)] (abnormal heartbeat), protein-calorie malnutrition (state of inadequate intake of food), and [CONDITION(S)] (condition in which there is a lack of enough healthy red blood cells to carry adequate oxygen to the body). During a review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/20/2021, the MDS indicated Resident 32 had the ability to express ideas and wants and had the ability to understand others. Resident 32 had intact cognitive skills (the core skills your brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS also indicated that Resident 32 needed supervision in eating, Resident 32 required one-person physical assist with activities of daily living (ADLs, tasks of everyday life, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet). During a review of Resident 94's Face Sheet, dated 10/15/2021, the Face Sheet indicated the facility admitted Resident 94 on 9/26/2021 with diagnoses including hypertensive [CONDITION(S)] (heart conditions caused by high blood pressure), moderate protein-calorie malnutrition, gastroesophageal reflux disease (GERD, when stomach acid frequently flows back up into the tube connecting the mouth and stomach), dysphagia (problems swallowing certain foods or liquids), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 94's MDS, dated [DATE], the MDS indicated Resident 94 had the ability to express ideas and wants and had the ability to understand others. Resident 94 had intact cognitive skills for daily decision making. The MDS also indicated that Resident 94 needed set up supervision in eating, Resident 94 required one-person physical assist with ADLs. During a review of Resident 196's Face Sheet, dated 10/15/2021, the Face Sheet indicated the facility admitted Resident 196 on 10/6/2021 with diagnoses including essential hypertension (high blood pressure that does not have a known secondary cause), [CONDITION(S)] (disorder that results in high levels of fats circulating in the blood), GERD, dysphagia, and [CONDITION(S)] (serious mental disorder in which people interpret reality abnormally). During a review of Resident 12's Face Sheet, dated 10/15/2021, the Face Sheet indicated the facility admitted Resident 12 on 5/16/2019 with diagnoses including [CONDITION(S)] (weakness or inability to move one side of the body), protein calorie malnutrition, essential hypertension, [CONDITION(S)] [CONDITION(S)] (buildup of fats in and on your artery walls [blood vessels]), and [CONDITION(S)] disorder (brain disorder that causes changes in the persons mood, energy, and ability to function). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had the ability to express ideas and wants and had the ability to understand others. Resident 12 had intact cognitive skills for daily decision making. The MDS also indicated that although Resident 12 needed set up supervision in eating, requiring one-person to two-persons physical assist with ADLs. During a review of Resident 75's Face Sheet, dated 10/15/2021, the Face Sheet indicated the facility admitted Resident 75 on 4/29/2021 with diagnoses including hypertensive [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], type 2 diabetes (an impairment in the way the body regulates and uses sugar), metabolic [CONDITION(S)] (problem in the brain caused by a chemical imbalance in the blood), and protein calorie malnutrition. During a review of Resident 75's MDS, dated [DATE], the MDS indicated Resident 75 had the ability to express ideas and wants and had the ability to understand others. Resident 75 had intact cognitive skills for daily decision making. The MDS also indicated that Resident 75 needed set up supervision in eating and in transferring, requiring one-person physical assist with ADLs. During a review of Resident 31's Face Sheet, dated 10/15/2021, the Face Sheet indicated the facility admitted Resident 31 on 5/19/2021 with diagnoses including metabolic [CONDITION(S)], type 2 diabetes, hypertensive [CONDITION(S)], [CONDITION(S)], and GERD. During a review of Resident 31's MDS, dated [DATE], the MDS indicated Resident 31 had the ability to express ideas and wants and had the ability to understand others. Resident 31 had intact cognitive skills for daily decision making. The MDS also indicated that Resident 31 needed set up supervision in eating, requiring one-person to two-persons physical assist with ADLs. During a concurrent observation and interview on 10/13/2021, at 8:45 AM, with the Dietary Manager (DM 1) and the RD, a box of white shelled eggs was observed in refrigerator 1. DM 1 and the RD stated that the eggs were not stamped with a P. The RD stated that the box the eggs were contain in, stored in refrigerator 1, did not indicate that the eggs were pasteurized. The RD stated, the box containing the eggs indicated the eggs were California Shell Egg Food Safety Compliant (CA SEFS) complaint (eggs have gone through added measures to reduce the risk of salmonella enteritis [infection of the small intestine caused by Salmonella). RD 1 stated she believed CA SEFS eggs were pasteurized. RD 1 could not verbalize how staff could identify whether an egg was pasteurized without the box it was stored in. The RD stated eggs stamped with a P indicate they were pasteurized. During a concurrent observation and interview on 10/13/2021, at 9:05 AM, with a cook (Cook 1), Cook 1 was observed demonstrating how she fried eggs. Cook 1 was observed cracking an egg into a hot skillet. When underside of the egg was cooked, Cook 1 flipped the egg to cook the other side. After plating the cooked egg, Cook 1 cut the egg with a fork, showing that the yolk was liquid and not firm. Cook 1 stated, she fried over-easy eggs for five (5) residents (could not verbalize which residents) on 10/13/2021. During a concurrent observation and interview on 10/13/2021, at 9:15 AM, with DM 1 and RD, the RD confirmed that the printing on the box of eggs indicated safe handling instructions: to prevent illness from bacteria, keep eggs refrigerated, cook eggs until yolks are firm, and cook foods containing eggs thoroughly. During a concurrent interview and record review, on 10/13/2021, at 12:22 PM with DM 1, the food invoice from the vendor (Vendor 1), dated 10/12/21, was reviewed. Vendor 1's invoice indicated the facility ordered 15 dozen EGGS-MEDIUM. DM 1 stated that the invoice did not indicate whether the eggs purchased from Vendor 1 were pasteurized. DM 1 stated that only pasteurized eggs can be purchased from venders. DM 1 stated he could not confirm that the eggs purchased from Vendor 1 on 10/12/21 were pasteurized. During an interview on 10/13/2021, at 2:56 PM with Resident 75, Resident 75 stated that she ate fried eggs on 10/12/2021 and she usually ate fried eggs three times a week. Resident 75 stated the yolks of the eggs she ate were always runny. During an interview on 10/13/2021, at 3:42 PM with the RD, the RD stated that using an unpasteurized egg for the consumption by residents of the facility posed a risk of salmonella contamination. The RD stated salmonella infection can cause diarrhea and fever. During a concurrent observation and interview, on 10/14/2021, at 7:19 AM, with Cook 2, refrigerator 1 was observed to contain white shelled eggs with no P stamped on the shells (A P stamp on an egg indicates that the egg has been pasteurized). There were also several white shelled eggs with no P stamped on the shells in a bowl of ice water on the kitchen counter by the gas range. Cook 2 stated there was no P stamped on the shelled eggs. Cook 2 stated he always obtained the eggs from the refrigerator 1 without checking if there was a P stamped on the eggshells. Cook 2 could not verbalize the importance of using pasteurized eggs or how to determine whether an egg is pasteurized or not. During a concurrent observation and interview, on 10/14/2021, at 7:21 AM, with Cook 1, Cook 2 and a dietary aide (DA 1), Cook 2 was observed frying eggs to order. Cook 2 poured melted butter over the skillet on medium to high heat. Cook 2 cracked the egg into the skillet and cooked the egg until white at the bottom was firm and the yolks were still runny. Cook 2 flipped the egg over to cook the other side. When the eggs were finished, Cook 2 placed the fried egg onto the plate and placed the plate onto the table. Cook 2 added other ordered items onto the plate and handed the plate to DA 1. DA 1 was observed grabbing the plate and putting a cover on it and putting the covered plate onto the tray. Cook 1, Cook 2 or DA 1 did not check the temperature of the fried egg during the whole process. During a concurrent observation and interview, on 10/14/2021 at 7:35 AM, with Resident 12, Resident 12 was observed consuming 2 over-easy fried eggs with liquid yolk. Resident 12 stated he ate runny fried eggs every day for breakfast. During a concurrent observation and interview, on 10/14/21, starting at 7:37 AM, with licensed vocation nurse (TX), a certified nurse assistant (CNA 8), and Resident 75, Resident 75's food service of undercooked unpasteurized egg starting from the kitchen and ending with Resident 75's food consumption was observed. DA 1 was observed reading the meal substitutions form for Resident 75 and announced loudly that Resident 75 needed fried eggs. Cook 2 then cracked a white shelled egg, with no P stamped on, over a hot skillet. Cook 2 fried the egg, plated it, and placed a strip of bacon on the plate and handed it to DA 1. DA 1 covered the plate with a lid and placed it on Resident 75's tray on Cart 5. Another dietary aide (DA 3) rolled out Cart 5 to the hallway by the dining area. Cart 5's food trays were double checked by TX. During an interview with TX, TX stated she was verifying that the trays with a printout of residents' diet orders to make sure they were accurate. After TX verified the food trays, DA 3 wheeled cart 5 to nursing station 2. A certified nurse assistant (CNA 8) was then observed picking up, delivering, and setting it up Resident 75's breakfast tray on the bedside table. During an interview with CNA 8, CNA 8 stated Resident 75 loved fried eggs every morning. During an interview with Resident 75, Resident 75 was observed eating over-easy fried eggs with liquid yolk. Resident 75 stated she loved eggs with runny yolks for breakfast. During an observation and interview on 10/14/21, at 7:40 AM, the speech therapist (ST) was observed standing to the right side of Resident 196 feeding Resident 196 breakfast which included eggs over easy with liquid yolk. Resident 196 and the ST, both verified that eggs were over-easy. ST stated he did not know whether the temperature of the egg was checked prior to serving them to Resident 196. During a concurrent observation and interview on 10/14/2021, at 8:03 AM with Resident 94, Resident 94 was observed eating breakfast. Resident 94 stated there was an over-easy egg and sausage on the plate. Resident 94 stated that he usually ate 3 over-easy eggs a day. Resident 94 was observed consuming over-easy egg with liquid yolk. During a record review of the residents' (Residents 32, 94, 196, 12, 75, and 31) meal substitution forms (document facility used to indicate resident's special food request that was not a regular menu item), for the day of 10/14/2021, indicated that Residents 32, 94, 196, 12, 75, and 31 ordered fried eggs. During a record review of the daily food temperature record, dated from 7/1/2021 through 10/13/2021, the daily food temperature record indicated there was no documented evidence that the temperature of fried eggs was checked prior to food service. There were 105 missed opportunities for the temperature check of fried eggs. During an interview on 10/14/2021, at 9:00 AM with Cook 1 and Cook 2, Cook 1 stated salmonella (bacteria) in the eggs will be killed at 165 degrees Fahrenheit. Cook 2 stated salmonella in the eggs will be killed at 170 degrees Fahrenheit. Per Cook 2, aside from the residents receiving a warm meal, the kitchen staff checks the temperature of the foods to ensure it was cooked at the appropriate temperature. Cook 1 and Cook 2 both stated that the temperatures of the fried eggs served to residents (Residents 32, 94, 196, 12, 75, and 31) today (10/14/21) were not checked before sending the food out to the residents. During a record review of the facility's policy, Food Preparation, revised September 2017, indicated only pasteurized egg products will be used for soft-cooked egg items. The policy indicated unpasteurized egg needed to be cooked to a minimum internal temperature of 145 degrees Fahrenheit for 15 seconds. The temperature for certain foods including, unpasteurized eggs will be recorded at time of service, and monitored periodically during meal services period. During a review of the Center for Clinical Standards and Quality/ Survey & Certification Group's, CMS S&C letter 14-34-NH, dated May 20, 2014, the CMS S&C letter 14-34-NH indicated, skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting salmonella enteritis. In accordance with the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) standards, skilled nursing and nursing facilities should not prepare nor serve soft-cooked, undercooked or sunny-side up eggs from unpasteurized eggs. For the elderly, a small amount of Salmonella bacteria can cause severe illness and even death. During a record review of the Egg Safety Final Rule, from the Food and Drug Administration web site (www.fda.gov), content current as of 4/6/2020, the Egg Safety Final Rule indicated egg-associated illness caused by Salmonella is a serious public health problem. Infected individuals may suffer mild to severe gastrointestinal illness, short term, or chronic arthritis, or even death. B. During an observation on 10/13/2021, at 9:29 AM, a black substance approximately 4 inches in length was noted on the plastic in the upper, inner, right corner of the interior of the ice machine. This finding was photographed. During a concurrent interview and record review, on 10/13/2021 at 9:35 AM, with the Maintenance Supervisor, the photograph taken of the interior of the ice machine was reviewed. The Maintenance Supervisor acknowledged the black substance noted on the ice machine and stated that the machine was due for cleaning on 10/14/2021. The Maintenance Supervisor stated the ice machine was cleaned twice a week but could not verbalize why the ice machine had black dirt in it. The Maintenance Supervisor stated the ice machine should be clean and cannot have a black substance. During a review of the U.S. Food and Drug Administration's 2017 Food Code, the Food Code indicated in Chapter 1 part 1-201.10, ice is defined as food. According to Chapter 4, part 602.11 (Equipment Food-Contact Surfaces and Utensils) section (E) item (4a and b), the items 4a and 4b state that the ice machines must be cleaned at a frequency specified by the manufacturer, or .at a frequency necessary to preclude accumulation of soil or mold. C. During an observation on 10/13/2021, at 11:41 AM, Dietary Aide 4 (DA 4) was observed walking in the kitchen through the clean area with two (2) bags and a jacket. DA 4 proceeded to the janitorial supply closet (where chemicals and cleaning supplies were stored) and placed personal belongings (2 bags and a jacket) in the supply closet. During an interview on 10/13/2021, at 2:50 PM, with the RD, the RD stated that the facility had a locker room for staffs' personal belongings. RD stated that personal belongings can also be placed in DMs office if needed. RD stated that staff cannot walk through kitchen with personal belongings. RD stated that cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) can occur if staff walked through kitchen with personal belongings. RD stated that cross-contamination can lead to illness of residents which can possibly lead to hospitalization and even death. The RD stated the facility does not have a policy indicating that personal items are not allowed in the kitchen, but it is the facility's expectation, to prevent the spread of illness. During a record review of the Food and Drug Administration's (FDA) Food Code 2017, chapter 6 physical facilities, the FDA's Food Code 2017 indicated, Because employees could introduce pathogens (organism that causes disease) to food by hand-to-mouth-to-food contact and because street clothing and personal belongings carry contaminants, areas designated to accommodate employees' personal needs must be carefully located. Food, food equipment and utensils, clean linens, and single-service and single use articles must not be in jeopardy of contamination from these areas. Consequently, street clothing and personal belongings must be stored in properly designated areas or rooms.

Based on observation, interview, and record review, the facility failed to implement its fall policy, IDT ((Interdisciplinary Team/ IDT) a group of health care professionals working together for a common goal for the resident) recommendations and the resident's plan of care and provide adequate monitoring and supervision for one of two sampled residents (Resident 1) with a history of multiple falls. These deficient practices resulted in Resident 1 having recurring falls, 10 within four months, requiring two transfers to a general acute care hospital (GACH), after sustaining a frontal scalp laceration (a deep cut or tear in skin or flesh) to the head, repaired with staples, antibiotics, and pain medications, and blunt head trauma with an abrasion (a wound caused by superficial damage to the skin) to the head during another fall. Findings: A review of Resident 1's Admission record Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. life), generalized muscle weakness, and unspecified psychosis (a mental disorder characterized by a disconnection from reality). A review of Resident 1's History and Physical (H/P), dated 6/29/17, indicated the resident did not have the capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 5/3/17, indicated Resident 1 had short and long-term memory problems and had moderately impaired decision-making skills requiring cues and supervision. The MDS indicated the resident required extensive assistance with a one-person physical assistance for transferring between surfaces, toilet use, personal hygiene care, and locomotion on and off the unit. The MDS indicated Resident 1 did not have a steady gait and was only able to stabilize with staff assistance when moving to and from a seated to standing position, walking, turning around, and surface to surface transfer. The MDS indicated Resident 1 was frequently incontinent (having no or insufficient voluntary control) of bowel and bladder. A review of Resident 1's Fall Scene Investigation Report, indicated on 4/5/17 at 5:17 p.m., Resident 1 had an unwitnessed fall. Resident 1 was found in front of the nursing station, lying on the floor on the right side with both hands holding her head up and both legs extended with the right foot by the wheels of the wheelchair. Prior to Resident 1's fall, the resident was standing in front of the nursing station and was talking on the phone, but lost her balance, fell , and landed on the floor. On 4/12/17 at 8:46 p.m., Resident 1 had a witnessed fall that occurred in the dining room. Resident 1 was found on the floor, lying on her right side near the wheelchair. Prior to the fall, Resident 1 was picking up something on the floor and lost her balance. On 4/28/17 at 2:50 p.m., Resident 1 had an unwitnessed fall that occurred in the dining room. Resident 1 was found on the floor, lying on her left side in a fetal position with her arms over her head. Resident 1's wheelchair was found behind a dining room table. Prior to Resident 1's fall, the resident was observed with increased agitation, ineffectively redirected, confused, and screaming in her wheelchair. A review of Resident 1's Care Plan titled, Resident had a fall in the dining room with no injury, dated 4/28/17, indicated the staff's intervention included to provide frequent visual monitoring for safety. A review of a Documentation Survey Report, for the month of 6/2017, indicated to document each time Resident 1 was provided with assistance for toilet use. According to the report, Resident 1 was provided toilet use assistance on 6/19/17 at 9:48 p.m., and 6/20/17 at 1:09 a.m., but was not always offered assistance. A review of Resident 1's Health Status Note, dated 6/20/17, and timed at 3:09 p.m., indicated on 6/20/17 at 7:15 a.m., Resident 1 was found lying on her back in the middle closet of her room. The note indicated Resident 1's feet were toward her bed and her head was one foot from the closet door. Resident 1's self-locking wheelchair was found one foot from the resident's head, with the manual brakes unlocked. According to the note, at 7 a.m. (the same day), prior to the fall, Resident 1 was seen propelling herself in the wheelchair. The note indicated according to the staff, Resident 1 was attempting to take clothes out of her closet and lost her balance when trying to open the closet door. A review of Resident 1's Fall Risk Assessment, dated 6/20/17, indicated the resident had a high risk for falls. A review of Resident 1's Assessment Summary, dated 6/20/17 at 1:52 p.m., indicated the IDT Team made recommendations to monitor the resident's whereabouts every 30 minutes, and to offer assistance. A review of Resident 1's Care Plan titled, Resident had a fall incident on 6/20/17, no noted injury. Potential for complications related to the fall, dated 6/20/17, indicated the goal was for the resident not to have complications related to a fall for the next two weeks. The staff's interventions included to anticipate the resident's needs and provide frequent monitoring every 30 minutes, and monitor the resident's whereabouts. A review of Resident 1's Documentation Survey Report, for the month of 6/2017, indicated to document each time the resident was monitored for her whereabouts every 15 minutes, and offered assistance. The report indicated Resident 1 was not monitored until 6/21/17, at 1 p.m. A review of Resident 1's Health Status Note, dated 6/21/17 and timed at 4:51 a.m., indicated on 6/21/17 at 4 a.m., the resident woke up and started yelling and screaming for no apparent reason. The note indicated Ativan (a medication used to treat anxiety disorders for short-term relief), one milligram (mg) intramuscularly ((IM), administered into a muscle), was administered to the resident. The note indicated the resident was remained agitated and would be provided with frequent visual monitoring. A review of Resident 1's Health Status Note, dated 6/21/17 timed at 5:42 p.m., indicated on 6/21/17 at 1:40 p.m., the resident was on her auto-lock wheelchair, leaned forward, and fell , hitting her head on the wall, and sustained a laceration to the middle frontal part of the scalp. The laceration with measured 4.0 centimeters (cm) in length by 0.5 cm in width, and 0.2 cm in depth. The note indicated Resident 1 was alert but lethargic after fall. The note indicated the resident was transferred to the general acute care hospital (GACH). A review of Resident 1's Trauma History and Physical (H/P) from the GACH, dated 6/21/17, and timed at 3:31 p.m., indicated Resident 1 was admitted as a trauma resident to the hospital, from a witnessed mechanical fall at the skilled nursing facility. The record indicated the resident sustained [REDACTED]. The record indicated the measurement of the resident's laceration was seven cm linear to the middle front of the scalp, and the plan was to repair the laceration. A review of Resident 1's Physician order [REDACTED]. The report indicated on 6/23/17, Risperdal (Risperidone, a medication used to treat mental and mood conditions), 0.5 mg, one tablet, twice a day for schizoaffective disorder, manifested by yelling and screaming, was ordered for the resident. A review of Resident 1's care plan titled, The Resident uses Psychotropic Medications: Seroquel, dated 3/30/17, indicated staff interventions included to monitor, report, and record to the physician, the side effects and adverse reactions of psychotropic medications such as unsteady gait, tardive dyskinesia (a condition affecting the nervous system from the side effects of antipsychotic medications), extrapyramidal symptoms ((EPS) forms of abnormal body movements, caused by side effects of antipsychotic medications), and frequent falls. A review of Resident 1's Medication Administration Record (MAR), for the month of June 2017, indicated Resident 1 was administered Risperdal 0.5 mg, one tablet, twice a day, on 6/24/17, 6/25/17, and received one dose on 6/26/17. The MAR indicated Resident 1 was administered Seroquel, 300 mg, one tablet, three times a day, on 6/24/17, 6/25/17, and received two doses on 6/26/17. A review of Resident 1's Medication Administration Record (MAR), for the month of July 2017, indicated Resident 1 was administered Risperdal 0.5 mg, one tablet, twice a day, from 7/1/17 to 7/31/17. The MAR indicated Resident 1 was administered Seroquel, 300 mg, one tablet, three times a day, from 7/1/17 to 7/31/17, both are antipsychotic medications (medications used to treat symptoms of psychosis). A review of an online drug reference with a revision date of 2/2017, indicated elderly residents with dementia-related psychosis treated with antipsychotic drugs had an increased risk for falls with injury and death. The drug reference indicated somnolence (sleepiness or drowsiness), postural hypotension (occurs when a person's blood pressure drops when suddenly standing up from a lying or sitting position), motor and sensory instability, have been reported with the use of antipsychotics, including Risperdal, which may lead to falls, and consequently, fractures (a complete or partial break in a bone), or other fall-related injuries. https://www.dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=7e117c7e-02fc-4343-92a1- 1dfc5e0&type=display. A review of an online drug reference with a revision date of 2/2017, indicated Seroquel may cause somnolence, postural hypotension, motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries https://www.dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=0584dda8-bc3c-48fe-1a90- f78e8a0&type=display. A review of Resident 1's Fall Scene Investigation Report, dated 7/4/17 at 1:47 p.m., 7/22/17 at 3:12 p.m., 8/6/17 timed at 11:45 a.m., and 8/21/17, and timed at 3:30 p.m., indicated the resident lost her balance and fell on the floor without injuries. A review of Resident 1's Fall Scene Investigation Report, dated 8/25/17 timed at 7:19 p.m., indicated the resident was found on the floor in her room (four days after her previous fall). The report indicated Resident 1 had an abrasion to the right side of her head measuring 2 cm in length by 2 cm in width (without depth) with blunt head trauma. The report indicated Resident 1 was transferred to the GACH after the fall. On 6/26/17 at 3:45 p.m., during an observation and interview, a Certified Nursing Assistant (CNA 1) stated that Resident was aggressive, confused, and sometimes fights staff. CNA 1 stated the resident uses her hands to wheel herself in the wheelchair and tries to use her feet to propel herself, but does not get anywhere while propelling. CNA 1 stated the resident was usually assisted by staff to wheel her around the hallways. Resident 1 was observed in front of the nursing station in a wheelchair, accompanied by CNA 1, Resident 1 was observed with staples (used to close opened wounds) in the middle of the resident's forehead. Resident 1 was alert upon approach, but was answering questions unrelated to the topic discussed. Resident 1 stated she did not remembered what happened to her forehead, but did recall going to the hospital. On 8/29/17 at 11:20 a.m., during an interview, CNA 2 stated Resident 1 required increased supervision and needed to be monitored frequently. CNA 2 stated Resident 1 tries to transfer independently from the bed to the wheelchair, without calling for assistance. CNA 2 stated the resident had more falls and accidents after the removal of the bed and wheelchair alarms. On 8/29/17 at 3:45 p.m., during an interview and record review, the Director of Nursing (DON) stated frequent visual checks, could by shown by documentation of the tasks on the Documentation Survey Report. DON stated she could not find any documentation to indicate Resident 1 was monitored every 30 minutes, on 6/20/17 as per the IDT recommendations and the resident's plan of care. The DON stated the facility was a restraint-free facility and the resident required more supervision than the facility could provide. On 8/30/17, at 1:24 p.m., during a telephone interview, a Registered Nurse (RN 1) stated Resident 1 was difficult to care due to her aggressive behavior. RN 1 stated the resident may require a facility that allows more restrictive measures (alarms and restraints). RN 1 stated the resident exhibits sudden angry outbursts, becomes agitated, and throws objects. RN 1 stated the resident had behaviors of independently standing up unassisted with an unsteady gait, to remove items from her cabinet or to use the telephone at the nursing station without assistance. A review of the facility's Policy and Procedures titled, Falls Management, with a revision date of 11/2012, indicated new or existing residents scoring as high risk will have interventions implemented to reduce the potential for falls outlined in their plan of care, as referred to Strategies for Fall Prevention. The policy and procedure indicated recent falls would be reviewed daily by a designated facility fall team, to evaluate cause, determine strategies as needed to prevent recurrence for each resident and revise the care plan if needed. A review of the facility's undated policy titled Fall Prevention Strategies and Interventions, indicated for the staff to add bed, chair or floor alarm, to add body or sensor pad alarm, or self-release belt alarm, and to provide 15 or 30 minute checks.