Every finding on record at Novato Healthcare Center

Based on interview and record review, the facility failed to identify an abuse allegation and implement its required abuse policies and procedures for one resident (Resident 1) of six sampled residents when:There was no documentation of an assessment for physical injuries or emotional distress on Resident 1;There was no documented notification of the physician and resident's responsible party (RP); and,There was no documented evidence of 72-hour monitoring of Resident 1 initiated by nursing.This failure decreased the facility's potential to protect Resident 1 from abuse.Findings:A review of Resident 1's admission record indicated admission to the facility on 3/12/25 with a diagnosis of cognitive communication deficit, Traumatic Subdural Hemorrhage (bleeding between the surface of the brain and its outer covering, caused by a head injury), Maxillary fracture (break in the upper jawbone), and fracture of nasal (nose) bones.A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a chronic disease when the body does not make enough insulin or is resistant to it, causing blood sugar levels to be high).During a concurrent interview and record review on 8/28/26 at 10:52 a.m. in Resident 2's room, Resident 2 stated on the evening of 8/27/26, he witnessed Resident 1 seated in a wheelchair pinned against the wall in the dining room with a dining room table in front of her. Certified Nursing Assistant 1 (CNA 1) was standing directly across the table from Resident 1 and there was no one else in the dining room. Resident 2 reported that when Resident 1 attempted to stand, CNA 1 pushed the dining room table toward Resident 1, preventing her from getting up. Resident 2 stated that he heard Resident 1 say she wanted to get up, but CNA 1 continued to push the table toward preventing her from standing. Resident 2 said he asked CNA 1 for her name, but she would not provide it. Resident 2 then took photographs with his phone and returned to his room, where he texted the Administrator (ADM) with his concern about Resident 1's safety and included the photographs he had taken. Resident 2 stated he spoke with the ADM shortly after sending the texts and was told by the ADM he would speak with Resident 2 in the morning.During an interview on 8/28/26 at 12:08 p.m. in the conference room, the ADM acknowledged he received a text message from Resident 2 on 8/27/26 at 8:48 p.m. reporting an allegation of staff-to-patient abuse involving Resident 1. The ADM stated Resident 2 had a history of making false allegations and complaints about the facility. The ADM further stated he spoke with Resident 1's assigned Licensed Nurse (LN), who informed the ADM nothing had occurred as Resident 2 had reported. Based on these factors, the ADM stated he did not feel the need to report the alleged incident to the California Department of Public Health (the Department). The ADM confirmed he was the facility's abuse coordinator and was obligated to report any and all allegations of abuse within two hours to the Department. The ADM stated he had a lapse in judgment by failing to report the allegation.A review of Resident 1's electronic medical record on 8/28/26 found no documented evidence indicating the LN performed an assessment for physical injuries or emotional distress, no evidence that the physician or family/representative were notified, and no evidence the LN initiated 72 hour monitoring.During an interview on 8/28/26 at 2:21 p.m., the Director of Nursing (DON) stated the nursing staff were expected to follow the abuse policy and their training when responding to allegations of abuse. The DON confirmed there was no documentation showing the LN performed an assessment on Resident 1, no progress note indicating notification of Resident 1's physician, family member or representative, and no evidence that 72 hour monitoring was initiated.A review of the facility's policy titled Abuse Prevention and Management, dated 6/12/24, indicated, Immediate Actions: The resident will be assessed by the licensed nurse for any physical injuries or emotional distress. Notify the physician and provide treatment as ordered, if applicable. Notify the responsible party of the incident and results of assessment findings.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health (the Department), law enforcement and the ombudsman, within two hours of their awareness of an allegation of abuse for one resident (Resident 1) when Resident 2 reported to the Administrator (ADM) that he witnessed a Certified Nursing Assistant (CNA) pin Resident 1 against a wall using a dining room table.This failure decreased the facility's potential to protect Resident 1 from ongoing abuse.Findings:During a concurrent interview and record review on 8/28/26 at 10:52 a.m. in Resident 2's room, Patient 2 stated on the evening of 8/27/26, he witnessed Resident 1 seated in a wheelchair pinned against the wall in the dining room with a dining room table in front of her. CNA 1 was standing directly across the table from Resident 1 and there was no one else in the dining room. Resident 2 reported that when Resident 1 attempted to stand, CNA 1 pushed the dining room table toward Resident 1, preventing her from getting up. Resident 2 stated that he heard Resident 1 say she wanted to get up, but CNA 1 continued to push the table toward preventing her from standing. Resident 2 said he asked CNA 1 for her name, but she would not provide it. Resident 2 then took photographs with his phone and returned to his room, where he texted the ADM with his concern about Resident 1's safety and included the photographs he had taken. Resident 2 stated he spoke with the ADM shortly after sending the texts and was told by the ADM he would speak with Resident 2 in the morning.During an interview on 8/28/26 at 12:08 p.m. in the conference room, the ADM acknowledged he received a text message from Resident 2 on 8/27/26 at 8:48 p.m. reporting an allegation of staff-to-patient abuse involving Resident 1. The ADM stated Resident 2 had a history of making false allegations and complaints about the facility. The ADM further stated he spoke with Resident 1's assigned Licensed Nurse (LN), who informed the ADM nothing had occurred as Resident 2 had reported. Based on these factors, the ADM stated he did not feel the need to report the alleged incident to the Department. The ADM confirmed he was the facility's abuse coordinator and was obligated to report any and all allegations of abuse within two hours to the Department. The ADM stated he had a lapse in judgment by failing to report the allegation.A review of the facility's policy titled Abuse Prevention and Management, dated 6/12/24, indicated, The administrator.will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 [state document used by mandated reporters known or suspected abuse of an elder or dependent adult] report to the ombudsman, law enforcement and CDPH Licensing and Certification within (2) hours.

Based on interview and record review, the Administrator (ADM) failed to protect one resident (Resident 1) from physical abuse when the ADM allowed an alleged perpetrator, Certified Nursing Assistant 1 (CNA 1), to continue working after receiving information regarding an abuse allegation and before conducting an investigation per facility policy. This failure decreased the facility's potential to protect Resident 1 from further harm.Findings:A review of Resident 1's admission record indicated admission to the facility on 3/12/25 with a diagnosis of Traumatic Subdural Hemorrhage (bleeding between the surface of the brain and its outer covering, caused by a head injury), Maxillary fracture (break in the upper jawbone) and fracture of nasal (nose) bones.A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a chronic disease when the body does not make enough insulin or is resistant to it, causing blood sugar levels to be high).A review of CNA 1's timecard on 8/27/26 indicated CNA 1 clocked in for her shift at 7:10 a.m. and punched out at 11:18 p.m. A review of the facility's staffing assignments on 8/27/26 indicated CNA 1 was assigned as supervision for the 3 p.m. - 11 p.m. shift. During a concurrent interview and record review on 8/28/26 at 10:52 a.m. in Resident 2's room, Resident 2 stated on the evening of 8/27/26, he witnessed Resident 1 seated in a wheelchair pinned against the wall in the dining room with a dining room table in front of her. CNA 1 was standing directly across the table from Resident 1 and there was no one else in the dining room. Resident 2 reported that when Resident 1 attempted to stand, CNA 1 pushed the dining room table toward Resident 1, preventing her from getting up. Resident 2 stated that he heard Resident 1 say she wanted to get up, but CNA 1 continued to push the table toward preventing her from standing. Resident 2 said he asked CNA 1 for her name, but she would not provide it. Resident 2 then took photographs with his phone and returned to his room, where he texted the ADM with his concern about Resident 1's safety and included the photographs he had taken. Resident 2 stated he spoke with the ADM shortly after sending the texts and was told by the ADM he would speak with Patient 2 in the morning.During an interview on 8/28/26 at 12:08 p.m. in the conference room, the ADM stated he received a text message from Resident 2 on the evening of 8/27/26 at 8:48 p.m. reporting allegations of abuse. The ADM stated Resident 2 had a history of making false allegations and complaints about the facility. The ADM further stated he spoke with Resident 1's Licensed Nurse (LN), who informed the ADM nothing had occurred as Resident 2 had reported. Based on these factors, the ADM stated he did not feel the need to report the alleged incident to the California Department of Public Health (CDPH), the police, or the Ombudsman, as required by facility policy and federal regulations. The ADM confirmed he was the facility's abuse coordinator and was obligated to report any and all allegations of abuse within two hours to CDPH, the police, and the Ombudsman. The ADM stated he did not suspend CNA 1 but planned to submit the abuse allegation and suspend CNA 1 after the interview. The ADM stated he had a lapse in judgment by failing to report the allegation. During an interview on 8/28/26, at 2:21 p.m., the Director of Nursing (DON) stated Resident 1 experienced a fall on 8/2/26 with a major injury. Upon Resident 1's return from the hospital, Resident 1 was placed on supervision 24 hours per day, seven days a week, for an undetermined amount of time. A review of the facility's policy titled Abuse Prevention and Management, dated 6/12/24, indicated, When the administrator.receives a report of an allegation of resident abuse, mistreatment.the administrator.will initiate an investigation immediately. The administrator.will provide for a safe environment for the resident as indicated by the situation.if the perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with facility policies.

Based on observation, interview, and record review, the facility failed to serve food at a palatable temperature and hold hot food that was ready to serve in a manner that maintained nutritional value and palatable texture. This failure affected residents' ability to receive meals consistent with their stated likes/dislikes and contributed to dissatisfaction with meal service.During a phone interview on 8/25/26 at 4:54 p.m., County Ombudsman stated she had attended multiple resident council meetings in recent months where residents had verbalized the facility food was served cold and residents' preferences were not honored, including the meeting she just attended today (8/25/26).During a kitchen observation and concurrent interview on 8/26/26 at 10:36 a.m. with [NAME] A, the steam table was loaded with multiple pans of food covered with plastic wrap. [NAME] A stated the food on the steam table was the pureed diet and minced and moist diet he had prepared for lunch. [NAME] A stated he was keeping them warm on the steam table, and as soon as the chicken in the oven was done baking, he would move all the food off the steam table and into the ovens to keep warm until 11:15 a.m. when he began plating lunch trays. During an observation on 8/26/26 at 11:07 a.m., [NAME] A pulled the pans of food out of the oven and put them back on the steam table.During an observation and concurrent interview on 8/26/26 at 1:02 p.m., [NAME] A plated the food for the last lunch tray, approximately 2.5 hours after the food was observed on the steam table ready to eat.During a test tray observation and concurrent interview on 8/26/26 at 1:18 p.m., DSM took the temperatures of the food and drinks on the tray, which were as follows:Chicken 132 degrees Fahrenheit (F) Broccoli 122 degrees FRice 128 degrees FJuice 52.9 degrees FMilk 51 degrees F The broccoli was cold and mushy, and the juice and milk were not cold. DSM stated hot foods should be 130 degrees or higher and the cold foods should be less than 40 degrees. During an interview on 8/26/26 at 2:10 p.m., Resident 1 stated he stopped eating the broccoli at the facility because it was always overcooked to the point that it disintegrated into just stems with no florets. Resident 1 stated he liked to eat broccoli that still had the tops. Resident 1 stated the food was always cold. Resident 1 stated he went out to eat once a month at a restaurant and it made him feel human again to have a hot meal. Resident 1 stated that since the facility served lunch as the main meal of the day it should always be hot. During an interview on 8/26/26 at 3:03 p.m., DSM stated that when cooked foods were held for long periods at hot temperature, they could get overcooked. DSM stated she noted the broccoli was overcooked, and she wanted the broccoli to have the floret for those residents that wanted that. DSM stated that if food is not a palatable temperature or to the residents' preferences then the residents would not enjoy their food. During a record review on 8/26/26 at 3:21 p.m., Resident Council meeting minutes dated 5/19/26 indicated, Dining & Dietary Concerns: Quality Control: Vegetable preparation concerns raised in April continue. Resident Council meeting minutes dated 6/23/26 indicated, Dietary Concerns: Sometimes meals are not brought with correct preferences. During a phone interview on 8/26/26 at 3:33 p.m., Registered Dietitian (RD) stated holding hot foods for multiple hours before serving could cause the food to get overcooked and deplete the vitamins and minerals. RD stated she got a test tray once a month at the facility and noted the food had been cold. Review of facility policy and procedure Food Temperatures, last revised 10/2/25, indicated, Acceptable Serving Temperatures: a. Food should be served promptly to maintain safe and palatable temperatures; b. Hot foods are held at 140F or higher on the steam table, cold foods are held at 41F or below at point of service. Minimize the duration of the time that food is held on the tray line prior to service to maintain food temperature and quality.

Based on observation, interview, and record review, the facility failed to serve food in a sanitary manner for a census of 171 residents when pans were stacked wet and cups were not clean. This failure had the potential to cause food borne illness in a vulnerable population, and for residents to not enjoy their food.During a phone interview on 8/25/26 at 4:54 p.m., County Ombudsman stated she had attended multiple resident council meetings in recent months where residents had verbalized they were being served food on dirty dishes, including the meeting she just attended today (8/25/26). During a kitchen observation and concurrent interview on 8/26/26 at 10:45 a.m. with Dietary Services Manager (DSM), dishes and pans were stored on shelves, DSM verified they were ready to use. Several clear plastic pans were stacked wet. DSM stated they were used to keep the drinks cold during tray line. DSM stated the pans were filled with ice and hold the juices and milks. DSM stated the pans should not be stacked wet, they should be air dried. DSM stated that when the pan were stacked wet, they would not dry. DSM took the wet pans off the shelves and asked a staff member to take them to be rewashed. A tray of coffee cups had food residue on the outside and a white residue on the inside. DSM verified the food residue on the outside and the white residue on the inside of the coffee cups. DSM stated the white residue was from the thickener they used to thicken the beverages and stated she had told the staff to wash them separately, but she needed to remind the staff. DSM asked a staff member to take the tray of cups to be rewashed. During an observation on 8/26/26 at 11:05 a.m., Dietary Aide B was at a food prep sink pulling individual containers of cranberry juice cocktail out of a bowl of water and placing them in a clear plastic pan. During a tray line observation on 8/26/26 at 11:38 a.m., Dietary Aide B pulled beverages from clear plastic pans of ice and placed them on the residents' lunch trays. During an interview on 8/26/26 at 2:10 p.m., Resident 1 stated he had been sending back dirty dishes to the kitchen, including three dirty cups he sent back this morning (8/26/26). During an interview on 8/26/26 at 3:03 p.m., DSM stated that the potential outcome to residents if the dishes were not clean was that the residents would not enjoy their food. Review of facility policy and procedure Pot and Pan Cleaning and Sanitizing, last revised 12/22/25, indicated, Invert the pots and pans and place them on a drying rack or counter. Allow the items to air dry. Do not use a towel. Review of Federal Food Code 2022, indicated, . the provisions of the Food Code provide a system of prevention and overlapping safeguards designed to minimize foodborne illness . Section titled, Equipment, Utensils, and Linens, indicated food-contact surfaces and utensils shall be clean to sight and touch and shall be air-dried after adequate draining.

Based on observation, interview, and record review, the facility failed to honor residents' food preferences for one of three sampled residents, Resident 2. This failure affected residents' ability to receive meals consistent with their stated likes/dislikes. During a phone interview on 8/25/26 at 4:54 p.m., County Ombudsman stated she had attended multiple resident council meetings in recent months where residents had verbalized the residents' preferences were not honored, including the meeting she just attended today (8/25/26).During an observation and concurrent interview on 8/26/26 at 1:15 p.m., staff were delivering lunch trays for Station 4 residents. The lunch tray for Resident 2 had a handwritten note that indicated a request for a cottage cheese and fruit plate with no oranges for lunch. The tray was noted to have a plate of cottage cheese with oranges and strawberries. Dietary Services Manager (DSM) verified the note indicated no oranges and that the cottage cheese plate had oranges on it. During an interview on 8/26/26 at 3:03 p.m., when queried, DSM stated everyone was responsible for checking tray accuracy including the cook, the two tray liners (aides who place silverware, drinks, dessert, and other items on the trays) and herself, then also nursing checked them before passing them out. DSM stated the resident who requested no oranges should not have received oranges, the tray liners and nursing staff should have captured it. During a record review on 8/26/26 at 3:21 p.m., Resident Council meeting minutes dated 6/23/26 indicated, Dietary Concerns: Sometimes meals are not brought with correct preferences. Review of facility policy Dietary Profile and Resident Preference Interview, last revised 8/28/26, indicated, The Dietary Manager will complete a Dietary Profile for residents to reflect current nutritional needs and Food Preferences. If nutritional needs or food preferences change after a Dietary Profile has been completed, these updates should be documented in the progress notes.

Based on interview and record review the facility failed to report an allegation of abuse for one resident (Resident 1) when Resident 1's Emergency Contact (EC, a trusted person designated to by notified by the facility of a resident's health status) notified the Social Service Director (SSD) of an allegation of misappropriation of Resident 1's property.This failure decreased the facility's potential to ensure the facility provided monitoring of Resident 1's psychosocial health and oversight of Resident 1's protection from further misappropriation of funds.Findings:A review of Resident 1's face sheet indicated admission to the facility on 3/23/26 with a medical history that included severe major depressive disorder with psychotic symptoms (a serious mental health condition/mental disorder in which a person has depression along with loss of touch with reality) and cognitive communication deficit.A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to identify resident care needs) dated 6/24/26, showed a Brief Interview for Mental Status (assessment of cognitive status) score of 13 which indicated Resident 1 was able to make and understand decisions independently.During an interview on 7/31/26 at 12 p.m., the Social Services Director (SSD) acknowledged she was informed by Resident 1's EC that money was taken from Resident 1's bank account. The SSD stated she reported the allegation of misappropriation of property to Adult Protective Services (APS) but was unable to state what date she reported the allegation to them. The SSD stated she was aware the allegation had been reported to the police and Ombudsman (an independent, neutral official who helps solve disputes between a resident and the facility) but did not know if the California Department of Public Health (CDPH) had been notified.A review of Resident 1's progress notes between 7/7/26 and 7/24/26 was conducted on 7/31/26. There was no documented evidence found in Resident 1's progress notes that indicated the SSD reported the allegation to the Director of Nursing (DON), Administrator (ADM), or to CDPH.During an interview on 7/31/26 at 1:29 p.m., the DON stated she and the Assistant Director of Nursing (ADON) found out about the allegation of abuse from Resident 1's EC on 7/7/26. The DON stated she reported the event to the ADM, and the ADM called the police on 7/7/26.During an interview on 7/31/26 at 3:30 p.m., the ADM stated he did not know who notified CDPH of the abuse allegation. The ADM stated the policeman who went to the facility to investigate notified him that Resident 1's allegation of abuse was already an open case.A review of the facility's policy and procedure titled Abuse Prevention and Management revised 5/30/24 indicated, .Allegations of abuse .or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately .The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practically possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours.

Based on interview and record review, the facility failed to investigate an allegation of misappropriation of resident property for one resident (Resident 1).This failure decreased the facility's potential to conduct a thorough investigation of an allegation of abuse and to protect Resident 1 from further misappropriation of funds.Findings:A review of Resident 1's face sheet indicated admission to the facility on 3/23/26 with a medical history that included severe major depressive disorder with psychotic symptoms (a serious mental health condition/mental disorder in which a person has depression along with loss of touch with reality) and cognitive communication deficit.During an interview on 7/31/26 at 1:29 p.m., the Director of Nursing (DON) confirmed Resident 1's Emergency Contact (EC, a trusted person designated to by notified by the facility of a resident's health status) notified her that money was taken from Resident 1's bank account on 7/7/26. The DON reported the event to the Administrator (ADM) who then called the police. The DON stated that the police came to the facility to investigate the allegation. A copy of the facility's own investigation of the abuse allegation and the investigation summary was requested but were not provided. The DON verified the facility had not conducted their own investigation of the allegation of abuse.During an interview on 7/31/26 at 3:30 p.m., the ADM verified he was the facility's Abuse Coordinator. The ADM stated an investigation of the abuse was conducted by the police. The ADM confirmed an investigation summary was not written nor submitted to the California Department of Public Health (CDPH).A review of the facility's policy and procedure titled, Abuse Prevention and Management, revised on 5/30/24 indicated, .When the Administrator or designated representative receives a report of an allegation of resident abuse. the Administrator or designated representative, will initiate an investigation immediately.The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime. Witnesses include but are not limited to the resident, witnesses to the incident.family, visitors, etc.While the investigation is being conducted, accused individuals may be denied access to the facility or unsupervised access to the resident.The Administrator will inform the resident.of the results of the investigation.within five (5) working days of the reported incident. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification and others that may be required by state or local laws, within five (5) working days of the reported allegation . Documents regarding allegations will be maintained for not less than 5 years.

Based on observation interviews and record review, the facility failed to ensure the required daily patient census and actual direct care service hours per patient day information was posted for 7/29/26 for a facility census of 178. The facility only displayed the estimated direct care service hours per patient day form dated, 7/30/26, and did not display actual direct care service hours provided to residents for the day prior on 7/29/26.The facility's failure to post the required daily patient census and actual direct care service hours per patient day information prevented residents, residents' representatives, staff, and members of the public from having access to current staffing information as required by law.During an interview on 7/29/26, at 11:40 a.m., the Administrator (ADM) stated the required daily census and direct care service hours per patient day (DHPPD) forms were posted by the Facility's Scheduler (FS), in the evening, before leaving the facility, and confirmed the ADM was the FS's direct supervisor.During an observation on 7/30/26 at 1:19 p.m. of the facility's designated staffing information posting location located in a hallway around the corner from the front lobby area, on a wall display cabinet behind glass, revealed the posted DHPPD form dated 7/30/26, containing a DHPPD form dated 7/30/26 displaying the estimated direct care service hours per patient day. The required DHPPD form reflecting the facility's average daily census and actual direct care service hours calculations for 7/29/26, was not displayed.During an interview on 7/30/26 at 1:24 p.m., the FS confirmed her direct supervisor was the ADM, who had instructed her to post the DHPPD form displaying the following day's daily census and estimated direct care service hours, daily, in the facility display cabinet prior to the end of shift, before leaving the facility. The FS confirmed the DHPPD form dated 7/29/26, displaying the facility's average daily census calculation and the actual direct care service hours calculation for 7/29/26, was not posted in the display cabinet. The FS said the ADM had never instructed her to post the previous day's DHPPD form containing the average daily census and actual direct care service hours calculations information at the bottom of the form, so the FS did not post that information daily.During an interview on 7/30/26 at 1:50 p.m., the director of nursing (DON) confirmed the required DHPPD form displaying the average daily census and actual direct care service hours per patient day calculations for 7/29/26, was not posted in the facility. The DON acknowledged the DHPPD form displaying the previous day's average daily census and actual direct care service hours calculations information must be posted daily.During a review of the facility's policy and procedure titled, Nursing Department - Staffing, Scheduling & Postings revised July 2018, indicated, Nurse Staffing Postings . The Facility will post the following information on a daily basis. Facility name. The current date . The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. a. Registered Nurses . b. Licensed Practical Nurses or Licensed Vocational Nurses. c. Certified Nurse Aides. d. Resident Census. B. Posting requirements. The Facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift. Data must be posted as follows . a. Clear and readable format. b. In a prominent place readily accessible to residents and visitors.

Based on interview and record review, the facility failed to provide or obtain physician ordered diagnostic services for one (1) of four (4) sampled residents (Resident 1), when a nephrology (the medical specialty focused on kidney care) consult had not been arranged within 30 days of the order date.This failure had the potential to place Resident 1 at risk for unmet clinical needs and a decline in condition.A review of Resident 1's Face Sheet (a facility demographic), dated 7/21/26, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (a condition that happens when your blood sugar (glucose) is too high), neuromuscular dysfunction of bladder (a loss of bladder control caused by brain, spinal cord, or nerve damage), and history of urinary (bladder) tract infections.A review of Resident 1's Minimum Data Set (MDS, a federally mandated clinical assessment tool used in all Medicare and Medicaid-certified nursing homes to evaluate a resident's functional abilities and healthcare needs), dated 6/1/26, indicated Resident 1 had intact cognitive function (your brain's mental processes are functioning without impairment, allowing for normal, independent everyday activities). Resident 1's active medical conditions included renal (kidney) insufficiency, renal failure or end-stage renal disease.A review of Resident 1's Order Summary Report, dated 7/21/26, indicated the facility physician ordered a nephrology referral secondary to CKD [chronic kidney disease, a long-term condition where the kidneys are damaged and gradually lose their ability to filter blood and remove waste products from the body] stage 4 on 6/12/26.During an interview on 7/21/26 at 10:15 a.m. with Resident 1, she stated she requested an appointment with a kidney doctor and a urologist but had not seen either in a year or more. She stated she was concerned about having to use a catheter to urinate (empty her bladder), and her overall condition was getting worse. Resident 1 stated this caused her anxiety about plans to leave the facility and manage her health independently in the future.During a interview on 7/22/26 at 1 p.m., evidence that a nephrology appointment had been arranged was requested but was not received.During an interview on 7/22/26 at 2 p.m. with the Social Services Director (SSD), she stated she was responsible for making appointments with outside medical providers when ordered by the facility physician. The SSD stated that unless notified by the nursing department that a referral was urgent, when becoming aware of a medical referral request, she would make the appointment within 30 days. When asked how she became aware of non-urgent referrals, the SSD stated this was usually discovered during quarterly (every three months) IDT (interdisciplinary team, refers to a coordinated group of healthcare professionals from different clinical and support specialties who work collaboratively to assess, plan, and manage the overall care of a patient or resident) meetings. During a review of facility policy and procedure titled, Referral to Outside Services, dated 6/9/26, it indicated, the Social Services Director/Designee is responsible for identifying agencies and programs that meet the needs of residents and making referrals to existing contracted providers.for community based medical appointments, a nursing designee shall assist the Director of Social Services in identifying appropriate providers and coordinating appointments.referrals require a Provider order.

Based on interviews and record reviews, the facility failed to protect one of three resident's sampled for abuse (Resident 1), right to remain free from physical abuse when Certified Nursing Assistant 1 (CNA 1), ignored Resident 1's verbalizations of pain during transfer, requests for CNA 1 to stop cleaning Resident 1, and Resident 1's tears while CNA 1 continued to provide incontinence care. This failure caused Resident 1 to experience pain, feel scared, vulnerable, and treated like an object. A review of Resident 1's admission record indicated Resident 1 was admitted in 11/25 with diagnoses of displaced right femur fracture ( a break in her right thigh bone), collapsed vertebrae in thoracic region (occurs when the bone in your mid-back breaks and squashes into a wedge shape and often causes pain, height loss, and hunched posture) , and generalized muscle weakness.A review of Resident 1's Minimum Data Set (MDS-A resident assessment tool) dated 5/16/26, indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident with a numeric range of 0-7 indicating severe cognitive impairment, 8-12 indicating moderate cognitive impairment and 13-15 indicating cognitively intact) score of 11.During an interview on 7/2/26 at 12:36 p.m. with Resident 1 in Resident 1's room, Resident 1 reported she had fragile loose skin on her upper arms and stated CNA 1 had come into the room Sunday 6/28/26 at 3:15 a.m., did not explain what she was going to do and grabbed Resident 1 by her right arm and yanked her up to sitting and then to standing. Resident 1 stated she cried out in pain multiple times and was crying tears. CNA 1 did not stop and was aggressive while cleaning Resident 1 and it hurt badly. Resident 1 stated CNA1 was dismissive and rough and was more concerned with her task than Resident 1 as a person and Resident 1 felt scared. Resident 1 continued stating there was no reason CNA 1 had to hurt her and CNA 1 should have been gentle. Resident 1 stated that CNA 1 should not be allowed to care for residents if this was how CNA 1 treated people.A review of Resident 2's admission record indicated Resident 2 was admitted in 4/25 with diagnoses of stage 4 pressure ulcer of sacral region (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone near the tailbone), and abnormal gait and mobility (deviations from a natural walking pattern, such as limping, shuffling, or imbalance).A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 15 indicating she was cognitively intact.During an interview on 7/2/26 at 2:00 p.m. with Resident 2, Resident 1's roommate at the time of the incident and currently, while in Resident 2's room, Resident 2 stated CNA 1 had come into the room on 6/28/26 at 3:15 a.m. to change Resident 1, the curtain between the two beds was drawn at this time. Resident 2 stated she could hear Resident 1 crying out stop you are hurting me at least 3 times. Resident 2 then pulled back the curtain and asked CNA 1, What are you doing, can't you hear her, she said stop, you have to be gentle. Resident 2 stated it was basic decency to stop what you are doing if it was causing another person pain.During a phone interview on 7/2/26 at 3:15 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated the charge nurse, Licensed Nurse 2 (LN 2), came and told LN 1 that Resident 1 had approached her at around 11:00 a.m. the next morning on 6/29/26, and informed LN 2 that Resident 1 never wanted CNA 1 to care for her ever again. LN 1 then went to Resident 1's room and spoke to Resident 2 who confirmed she had heard Resident 1 crying out in pain the night before when CNA 1 was cleaning Resident 1. LN 1 reported she spoke to Resident 1 later in the morning on 6/29/26 and Resident 1 was still very upset. LN 1 stated if a resident cried out in pain you should stop what you are doing, that is just being respectful. LN 1 further stated every resident had a right to be free from harm.During an interview on 7/4/26 at 10:00 a.m. with LN 2, LN 2 confirmed Resident 1 came to her the morning of 6/29/26 and reported that CNA 1 was rough and mean to her the night before on 6/28/26, and Resident 1 wished for CNA 1 to never care for her again, ever. LN 2 stated she informed LN 1 what Resident 1 had told her and LN 1 reported the incident immediately.During an interview on 7/2/26 at 2:45 p.m. with the Interim Director of Staff Development (IDSD) in her office, IDSD stated if Resident 1 was verbalizing pain she would have expected CNA 1 to stop what she was doing to Resident 1 and notify the Nurse so they could have come and assessed Resident 1.A review of Social Services Progress Notes dated 6/29/26 indicated Resident 1 had cried after the incident on 6/28/26 and explained CNA 1 handled her roughly and CNA 1's tone was curt and dismissive. Resident 1 stated the incident made her feel upset and uncomfortable.A review of Social Services Progress Notes dated 7/1/26 indicated Resident 1 expressed ongoing emotional distress related to the incident with CNA 1 and felt CNA 1 should have been reported so CNA 1 would not have the opportunity to be mean to others.A review of the Facility's Investigative Report dated 7/1/26 indicated Resident 1 stated she did not want CNA 1 to care for her anymore, never wanted to see CNA 1 in her room, and that CNA 1 was a big woman and Resident 1 did not feel she could protect herself.During an interview on 7/2/26 at 3:47 p.m. with the Director of Nursing (DON) in the conference room, DON stated she would have expected CNA 1 to first explain what she was going to do before doing it and if Resident 1 cried out in pain CNA 1 should have stopped what she was doing, made sure Resident 1 was comfortable, and then should have reported it to the nurse. DON confirmed CNA 1 was suspended following the incident until the facility investigation was completed. DON continued stating she was aware of the emotional distress the incident had caused Resident 1 and had referred Resident 1 for Psychiatric services on 6/29/26.A review of a Facility document titled, Resident Rights, revised 01/2012, indicated, Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights.A review of a Facility document titled, Abuse Prevention and Management, dated 6/12/24, indicated, Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, and physical or chemical restraint not required to treat symptoms, and/or imposed for the purpose of convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. It further indicated, Willful, as related to abuse, is defined as the individual acting deliberately ( not inadvertent or accidental) and not that the individual must have intended to inflict injury or harm.

Based on interview and record review, the facility failed to ensure Physical Therapy (PT-a healthcare specialty that uses movement, exercise, manual therapy, and patient education to reduce pain, restore physical function, and prevent injury) services were provided to seven of eleven sampled residents reviewed for PT services (Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9 ) when the facility had no current Director of Rehab (DOR), no current Physical Therapist (PT), no current Physical Therapy Assistants (PTA) to provide these services to residents with active physician orders. The affected residents did not receive their PT treatment as ordered. For two of the eleven sampled residents (Resident 6 and Resident 9) Occupational Therapy (OT - health profession that focuses on functional tasks like dressing, cooking, bathing, and cognitive problem-solving) orders were added in place of necessary PT services for these residents.This failure decreased the facility's potential to provide residents with appropriate services to maintain or improve their limitations in range of motion, strengthening, functional mobility, and increased risk of falling. This failure resulted in residents feeling frustrated and upset with the lack of progress in their physical rehabilitation. A facility document titled, Census Details Report, dated 7/2/26, was provided when a list of residents requiring any rehabilitation services was requested. The column for PT in this report was empty, indicating there were no current residents with PT services.A review of a facility document titled, Order Listing Report, dated 7/3/26, indicated there were 11 residents with active PT orders.A review of Resident 3's admission record indicated Resident 3 was admitted in 9/25 with the diagnoses of aftercare following surgical amputation (the deliberate removal of all or part of a limb or body part, performed through a bone or joint), acquired absence of right and left leg below the knee, and abnormalities of gait and mobility (difficulty walking and balancing).A review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 6/10/26, indicated Resident 3 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident with a numerical scale of 0-7 indicating severe cognitive impairment, 8-12 indicating moderate cognitive impairment, and 13-15 indicating cognitively intact) score of 15.A review of Resident 3's active PT orders, dated 6/19/26, indicated Resident 3 should have received PT 5xwk (5 times a week) for 4 weeks.A review of Resident 3's most recent PT evaluation, dated 6/19/26-7/15/26, indicated Resident 3 required skilled PT services to increase independence with walking, increase lower extremity range of motion (LE ROM) and strength, minimize falls and promote safety awareness, to return to prior level of functional abilities and safely return home. PT evaluation further indicated due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the resident is at risk for falls and further decline in function.Resident 3's current Care Plan indicated Resident 3 is at risk for decreased functional mobility without PT intervention, falls, increased deconditioning. PT was to evaluate and treat as indicated. During a concurrent observation and interview on 7/2/26 at 1:30 p.m. with Resident 3 in his room, Resident 3 had bilateral Above the knee Amputations (AKA-above-the-knee amputation), with prosthetic legs attached. Resident 3 stated his PT was renewed but he had not received any sessions since the last PT quit on 6/12/26. Resident 3 stated he really needed the PT to practice stairs and for strength training with use of new prosthetics. Resident 3 stated PT was the main reason he came to the facility, his progress had stalled, and he had no idea how long he would be without this needed therapy. A review of Resident 4's admission record indicated Resident 4 was admitted in 5/26 with the diagnoses of Displaced comminuted Fracture of the left patella (kneecap is shattered into three or more pieces that have moved out of proper alignment), difficulty walking, and osteoarthritis ( a degenerative joint disease where the protective cartilage that cushions the ends of your bones gradually wears away, causing pain, stiffness, and bone-on-bone friction in joints like the hands, knees, hips, and spine).A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had a BIMS score of 15 with no cognitive impairment.A review of Resident 4's active PT orders dated 6/19/26 indicated Resident 4 should have received PT 5xwk for 4 weeks.A review of Resident 4's most recent PT evaluation, dated 5/21-6/15/26 indicated Resident 4 presented with balance deficits, decreased functional capacity, decreased safety awareness, pain and strength impairments and in consideration of history, personal factors, and functional limitations documented in this eval, patient requires skilled PT services to increase functional activity tolerance, increase independence with gait, increased LE ROM and strength, minimize falls and promote safety awareness, in order to return to prior level of functional abilities and safely return home. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for falls and further decline in function.A review of Resident 4's current Care Plan indicated Resident 4 had impaired balance, limited mobility, limited ROM and PT/OT was to evaluate and treat as ordered. The Care Plan further indicated Resident 4 was at risk for Pressure Injury related to decreased mobility due to the fracture of her left patella.During an interview on 7/3/26 at 1:45 p.m. with Resident 4 in her room, Resident 4 stated she had not received PT for at least a few weeks, possibly one month. Resident 4 further stated her PT stopped suddenly and no facility staff came to discuss this with her. Resident 4 was concerned as she was spending more time in bed due to continued trouble walking. A review of Resident 5's admission record indicated Resident 5 was admitted in 5/26 with diagnoses of Peripheral Neuropathy (damage to the nerves outside your brain and spinal cord, it disrupts the communication network between your brain and the rest of your body, leading to symptoms like numbness, tingling, weakness, or burning pain, most commonly in the hands and feet), muscle weakness, and difficulty walking.A review of Resident 5's most recent MDS, dated [DATE], indicated Resident 5 had a BIMS score of 12 with moderate cognitive impairment.A review of Resident 5's active PT orders dated 6/4/26 indicated he should have received PT 3xwk ( 3 times a week) for 4 weeks.A review of Resident 5's most recent PT evaluation, dated 6/4/26-6/29/26, indicated Resident 5 required skilled PT services to increase independence with walking, increase LE ROM and strength, minimize falls and promote safety awareness, in order to return to prior level of functional abilities and safely return home. Due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention the patient is at risk for falls and further decline in function.A review of Resident 5's current Care Plan indicated Resident 5 had a self-care deficit related to physical deconditioning. PT/OT was to evaluate and treat as ordered as Resident 5 was at risk for decreased functional mobility, falls, and further deconditioning without PT intervention.During an interview on 7/4/26 at 11:00 a.m. with Resident 5 in his room, Resident 5 stated he had not received his PT for 1.5 weeks and wanted to go home, but there was no current PT to assess him again to see if it was safe. Resident 5 further stated he was depressed and if he was not going to receive his PT he wanted to leave. Resident 5 stated the facility had told him if he left against medical advice he would not be allowed to return and he did not want this to be a consequence in case he ever needed to return.A review of Resident 6's admission record indicated Resident 6 was admitted in 3/26 with the diagnoses of aftercare for left artificial hip joint surgery (left hip replacement), and abnormalities of gait and mobility.A review of Resident 6's MDS dated [DATE], indicated Resident 6 had a BIMS of 15 and was cognitively intact.A review of a facility document titled, Order Listing Report, dated 7/3/26, indicated Resident 6 had active orders for PT and should have received PT 3xwk for 4 weeks.A review of Resident 6's Order Summary Report, indicated the same active PT order for 3xwk and OT orders were added on 7/3/26.A review of Resident 6's most recent PT evaluation, dated 5/27-6/21/26, indicated Resident 6 required skilled PT services to increase independence with walking, increase LE ROM and strength, minimize falls and promote safety awareness, in order to perform functional mobility with reduced falls risk. Due to the documented physical impairments and associated functional deficits without skilled therapeutic intervention the resident is at risk for falls and further decline in function.A review of Resident 6's current Care Plan indicated Resident 6 had a self-care deficit related to activity intolerance and disease processes and PT/OT should continue to evaluate and treat per orders.During an interview on 7/3/26 at 12:30 p.m. with Resident 6 in the therapy room, Resident 6 stated she had just started with OT today, but she needed PT to stabilize, decrease her fall risk and increase her strength, and she had not received PT. Resident 6 stated she went to see her doctor yesterday and asked him to put in a new referral for PT to make sure Resident 6 received PT when the facility hired someone. Resident 6 further stated being without PT was upsetting because PT was the main reason she came to the facility, to get stronger and better. Resident 6 stated OT was helpful but could not replace PT.A review of Resident 7's admission record indicated Resident 7 was admitted in 3/26 with the diagnoses of Low back pain, muscle weakness, and abnormal gait and mobility.A review of Resident 7's MDS, dated [DATE], indicated he had a BIMS score of 13 with moderate cognitive impairment.A review of Resident 7's active PT orders indicated Resident 7 should have received PT 3xwk for 4 weeks. A review of Resident 7's most recent PT evaluation, dated 5/24-6/19/26, indicated Resident 7 required continued PT services in order to increase LE ROM and strength, minimize falls and promote safety awareness in order to enhance residents quality of life by an improved ability to perform functional mobility with reduced risk of falls. Due to the documented physical impairments and associated functional deficits without skilled therapeutic intervention the patient is at risk for falls and further decline in function.A review of Resident 7's current Care Plan indicated a self-care deficit related to activity intolerance and disease process and PT was to evaluate and treat as indicated.During an interview on 7/3/26 at 2:00 p.m. with Resident 7 in his room, Resident 7 stated he had not received PT in a couple of weeks as the facility did not have any PT right now. Resident 7 stated no facility staff had come to talk to him about it, he heard about the PT quitting from other residents. Resident 7 further stated he did his own exercises from what he remembered but could not keep repeating the same exercises and felt he was not progressing. A review of Resident 8's admission record indicated Resident 8 was admitted in 6/24 with diagnoses of aftercare following amputation, left AKA and right AKA.A review of Resident 8's MDS, dated [DATE], indicated she had a BIMS score of 13 with moderate cognitive impairment.A review of Resident 8's most recent PT evaluation, dated 5/10-6/5/26, indicated a frequency of 3xwk for 4 weeks and Resident 8 required continued PT services in order to increase functional activity tolerance, increase LE ROM and strength, minimize falls, promote safety awareness and develop and instruct in restorative nursing program in order to enhance patients quality of life by an approved ability to perform functional mobility with reduced risk of falls. Due to the documented physical impairments and associated functional deficits without skilled therapeutic invention the resident is at risk for falls and further decline in function. A review of a facility document titled, Order Listing Report, dated 7/3/26, indicated Resident 8 had an active PT order and should have received PT 3xwk for 4 weeks.A review of Resident 8's Order Summary Report, indicated Resident 8 had active PT orders and should have received PT 3xwk for 4 weeks. During an interview on 7/3/26 at 2:30 p.m. with Resident 8 in her room, Resident 8 stated she needed PT due to above the knee amputations. Resident 8 stated she did not know if the facility was waiting to complete a new PT evaluation when she received her new prosthetic. Resident 8 stated she had not received PT or OT in weeks. Resident 8 further stated her prosthetics required a physician's review, Resident 8 had given the form to staff two weeks ago and has not been updated. Resident 8 stated meanwhile she feels she is becoming much weaker.A review of Resident 9's admission record indicated Resident 9 was admitted in 5/26 with diagnoses of fracture of shaft of left femur ( a break in the left thigh bone), Degenerative Disc disease ( a condition where the spinal discs, the soft cushions between your vertebrae, break down over time) w back pain and extremity pain, and osteoporosis (bone disease characterized by weak, brittle bones that are highly susceptible to fractures).A review of Resident 9's MDS, dated [DATE], indicated Resident 9 had a BIMS score of 15 and was cognitively intact. A review of a facility document titled, Order Listing Report, dated 7/3/26, indicated Resident 9 had an active PT order and should have received PT 3xwk for 4 weeks.A review of Resident 9's, Order Summary Report, indicated active orders for PT for 3xwk for 4 weeks. A review of Resident 9's Order Listing Report, for active therapy orders indicated OT orders were revised as a late entry on 7/3/26.A review of Resident 9's most recent PT evaluation, dated 6/8/26-7/4/26, indicated Resident 9 should have received PT 3xwk for 4 weeks and Resident 9 required continued PT services in order to increase functional activity tolerance, increase LE ROM and strength, minimize falls and promote safety awareness in order to enhance patients quality of life by an improved ability to return to prior level of functional abilities and safely return home. Due to the documented physical impairments and associated functional deficits without skilled therapeutic intervention the patient is at risk for falls.A review of Resident 9's current Care Plan indicated PT/OT should evaluate and treat as indicated. During an interview on 7/3/26 at 3:22 p.m. with Resident 9 in the salon, Resident 9 stated she had PT 2-3 times and then it stopped suddenly. Resident 9 stated she was supposed to have received PT 5 days a week for 4 weeks because she had 5 surgeries on her left leg and 1 surgery on her right leg. Resident 9 further stated, Of course this upsets me, I mean I can't walk! If they could get someone to stay and not quit, then maybe we could all have some progress.During an interview on 7/3/26 at 11:40 a.m. with the Speech Language Pathologist (SLP) in the rehab room, SLP stated the rehab department had no director right now and the regional manager was helping when she could. SLP stated herself and the OT were the only in-house employees and the other therapists came from travel agencies. SLP further stated when the last Director of Rehab (DOR) left so did most of the travelers. SLP stated this was not the first time the facility had been without PT, this was an ongoing issue.During an interview on 7/3/26 at 12:02 p.m. with Licensed Nurse 3 (LN3), LN 3 confirmed the facility was without PT at this time and retaining staff had been an issue. LN 3 stated not having PT was concerning for residents who had come to this facility to obtain that service. LN 3 stated residents could be losing mobility and strength.During a concurrent interview and record review on 7/3/26 at 12:45 p.m. with Occupational Therapist 1(OT 1), OT 1 reviewed the Census Details Report dated 7/2/26 for residents requiring rehabilitative services. OT 1 stated she was surprised to see nothing listed under the PT column. OT 1 stated this was probably because the PT visits had been cancelled. OT 1 reviewed the list and identified resident names she knew should have had active PT orders. OT 1 confirmed the last director had left on 6/6/26, there was a temporary PTA for a short time, but she left 6/12/26. OT 1 recalled this had been the third time the facility had been without a PT or PTA. OT 1 stated the OT therapists could compensate as best they could within their scope, but OT 1 did not feel safe doing certain exercises such as stairs. OT 1 further stated if a resident required PT specifically, we should transfer them to a facility that can provide that service.During an interview on 7/3/26 at 11:30 a.m. with the Director of Nursing (DON), DON confirmed the facility was without a DOR, PT, or a PTA currently. DON stated residents were getting OT. DON agreed this was not the same service but did not know what else the facility could do at this time. The DON further stated she could not provide the PT visit notes as she did not have access to them. During a phone interview on 7/6/26 at 10:34 a.m. with the Administrator (ADM), ADM confirmed the facility did not have a DOR, PT, or PTA currently. ADM stated the facility had found a telehealth PT but did not have the PTA staff to complete the exercises with the residents. ADM confirmed residents had not received PT and this was unfortunate. ADM stated if the facility received a referral for a new resident with PT orders, they informed the referring case manager, and if the case manager still wanted the facility to accept the resident, then they did. ADM was unsure if the referring physicians were informed PT was unavailable.During a phone interview on 7/6/26 at 10:52 a.m. with the Regional Director of Rehab (RDOR), RDOR stated the facility was retaining residents that needed PT and had assigned OT to work with those residents for functional mobility. RDOR stated she was aware PT provided services OT could not, but this was the plan until the facility was able to hire somebody. RDOR stated there had been no discussion of possible transfer for residents requiring complex PT.On 7/6/26 at 11:55 a.m. the following specific facility Policies were requested and were not provided by the facility. Policy on providing Rehabilitative Services, Following Physician Orders, Maintaining Resident Mobility. These requests could not be made on the exit date as staff were not available. A review of a facility policy titled, Comprehensive Person Centered Care Planning, dated 9/2023, indicated, The Facility will provide person-centered, comprehensive, and interdisciplinary care that reflects the best practice of standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.A review of a facility policy titled, admission and Orientation of Residents, revised 10/2017, indicated, The facility will accept and retain only those residents for whom they can provide adequate care.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program when flies were observed in the facility's residential areas. This failure had the potential to negatively impact the health and wellness of the residents through the inhalation or ingestion of the flies' droppings and other body parts. Findings:During an observation on 6/17/26 at 12:22 p.m. at the facility's secured unit doorway, a fly flew into the surveyor's face upon entry and continued to buzz around the doorway area.During a concurrent observation and interview on 6/17/26 at 1225 p.m. in Resident 1's room, Resident 1 was sitting up in bed eating his cold breakfast tray. The window screen in Resident 1's room was torn, leaving a wide opening to the outside grounds. Resident 1 stated flies came in his room, and they bothered him when they buzzed around his head.During a concurrent observation and interview on 6/17/26 at 1234 p.m., Resident 2 was observed sleeping in bed. Two flies were seen flying around the room and temporarily landing on Resident 2's oxygen concentrator and bedsheets. Licensed Nurse 1 (LN 1) was brought into the room and confirmed the presence of flies. LN 1 stated the sliding door to the outside garden area is usually open. LN 1 also stated the sliding door to the outside garden area was usually open and was difficult to keep closed.During an observation on 6/17/26 at 1258 p.m. in the dining room, the surveyor observed the sliding glass door slightly open with no screen in place. Directly across from the dining room, a resident room window was open. The window screen in the room not properly seated in the window frame, leaving a corner popped out.During a concurrent observation and interview on 6/17/26 at 1:10 p.m., Certified Nursing Assistant 1 (CNA 1) stated flies did enter the facility, especially through the door leading to the garden area. The surveyor and CNA 1 observed one to two flies flying in and out of the fully open sliding glass door. CNA 1 stated it was difficult to keep the door closed because residents frequently used it to access the garden area.During a concurrent observation and interview on 6/17/26 at 1:52 p.m., the Administrator (ADM) toured the secured unit. The ADM confirmed the presence of flies in the area and noted torn and missing screens on windows and sliding doors.During an interview on 6/17/26 at 2:29 p.m., the Assistant Director of Nursing (ADON) stated flies can be harmful to residents. The ADON stated, Flies leave germs that can get in the food, and if the resident has an open wound, it can become infected or infested with maggots.A review of the facility's policy titled Pest Control, dated 1/1/12, indicated, [the] facility is free of insects.that could compromise the health, safety, and comfort of residents.Windows are screened at all times.

Based on observation, interview, and record review, nurses failed to prevent an avoidable accident for one resident (Resident 1) of four sampled residents when staff/nursing supervision did not ensure Resident 1 used her walker while walking from her room to the nurse's station.This failure had the potential to result in an injury due to Resident 1 experiencing a staff-assisted fall on 6/16/26 in the memory care unit.Findings:A review of Resident 1's face sheet indicated admission to the facility in November 2024 with diagnoses which included toxic encephalopathy (a malfunction in the brain caused by exposure to harmful substances), muscle weakness, lack of coordination, and long term and current use of anticoagulants (medication used to prevent blood from clotting which increases the risk of excessive and internal bleeding).A review of Resident 1's care plan regarding a risk for falls related to deconditioning, psychoactive drug use, dementia, poor impulse control, and muscle weakness initiated on 11/11/24 indicated, Goal.The resident will be free of falls through the review date.Interventions/ Tasks [nurses were expected to implement include] Anticipate and meet the resident's needs.Follow facility protocol.Per IDT [Interdisciplinary Team, a collaborative group of healthcare professionals that assess and manage a resident's medical, functional, and social needs] review on 6/10/25.reminded [Resident 1] to use her walker however resident is not likely to remember due to dx [diagnosis] of dementia. Staff to.anticipate resident's needs. [NAME] to be placed close to bed for visual reminder to use.The resident needs a safe environment.During a concurrent observation and interview on 6/16/26 at 1:27 p.m. in the facility's memory care unit, Resident 1 was observed walking independently without the use of any assistive device (walker). Within minutes Resident 1 was observed sitting on the floor. Two Certified Nursing Assistants (CNA 1 and CNA 2) and Floor Monitor 1 (FM 1) were then observed assisting Resident 1 get up from the floor and sat her on a chair. Licensed Nurse 1 (LN 1) was observed checking Resident 1's vital signs while she was seated in the chair.A review of Resident 1's progress note dated 6/16/26 at 1:50 p.m., written by LN 1 indicated, Resident [Resident 1] was ambulating [walking] with staff assistance from her room to a chair at the nurse station when she became unsteady and was about to fall. Immediately [sic] intervened and safely prevented the fall by providing support and assistance. no [sic] impact with the floor occurred. Vitals [sic] signs were obtained and were within normal limits.A review of Resident 1's progress notes dated 6/16/26 after 1:50 p.m. showed no documented evidence Resident 1 made contact with the floor, a licensed nurse conducted a post-fall assessment, a licensed nurse interviewed staff regarding the incident, a post-fall evaluation was completed, Resident 1's fall risk care plan was updated, and the physician, Director of Nursing (DON), and/or Administrator was notified of the fall.During an interview with LN 1 on 6/17/26 at 9:10 a.m., LN 1 stated Resident 1 had not fallen yesterday, 6/16/26.During an interview with CNA 1 on 6/17/26 at 10 a.m., CNA 1 stated she witnessed Resident 1 have an assisted fall on 6/16/26. CNA 1 stated an assisted fall was considered a fall.During an interview with CNA 2 on 6/17/26 at 10:08 a.m., CNA 2 stated she followed Resident 1 when Resident 1 walked out of her room and had to lower Resident 1 to the floor because she started falling. CNA 2 acknowledged CNA 1, FM 1, and herself, assisted Resident 1 from the floor in a sitting position to a standing position, and sat her on a chair. CNA 2 verified Resident 1 had an assisted fall.During an interview with the DON on 6/17/26, at 10:25 a.m., the DON stated an assisted fall was a fall. The DON stated if Resident 1 was found sitting on the floor, Resident 1 had a fall. The DON stated she expected LN 1 to complete a change of condition report, initiated a fall care plan, and notified the family and Resident 1's physician of the change in condition.During an interview with LN 3 on 7/3/26 at 12:59 p.m., LN 3 stated if a resident was found sitting on the floor, then the resident had a fall. LN 3 added that the charge nurse should assess the resident and initiate 72- hour charting if the fall was witnessed. LN 3 stated a change of condition report should be made and the fall should be reported to the DON, physician, and family.A review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 11/11/25, indicated, Definition of Falls. 'An event in which a person inadvertently comes to rest on the ground, floor, or lower level.'A review of the facility's P&P titled Fall Management Program revised 8/28/25 indicated, Post-Fall Assessment, Evaluation and Documentation.After any fall, the licensed nurse is responsible for confirming that the resident is safe and stable prior to continuing with post-fall protocols. The resident should be immediately assessed by the licensed nurse for changes in condition and/or injury post fall. Following a resident fall, the licensed nurse will interview staff regarding the incident and complete a Post-Fall Evaluation. Participants in the Post-Fall Evaluation will include individuals who are able to provide information related to the fall.Once the Post-Fall Evaluation is completed the licensed nurse will update the care plan with recommendations. The Post-Fall Evaluation form and documentation of the post-fall investigation will go to the IDT meeting for review and updating of the care plan, as appropriate.The licensed nurse will notify the following individuals regarding the fall as soon as possible.Resident's attending physician.DON and/or Administrator regarding.

Based on interviews and record review, the licensed nurses to notify a resident's Responsible Party (RP, a person designated to make decisions regarding care when the resident is no longer able to) of a change of condition for one resident (Resident 1) of four sampled residents, when Resident 1's RP was not notified of Resident 1's fall on 6/16/26.This failure prevented Resident 1's RP of the knowledge of Resident 1's fall and the ability to make informed decisions regarding the fall incident (e.g. request for updates pertaining to the fall, request for x-rays if needed).Findings:A review of Resident 1's face sheet indicated her RP was also her conservator (a court appointed person chosen by a judge to care for an adult who is mentally or physically disabled and incapable of caring for themself).During a concurrent observation and interview on 6/16/26 at 1:27 p.m. in the facility's memory care unit, Resident 1 was observed sitting on the floor. Two Certified Nursing Assistants (CNA 1 and CNA 2) and Floor Monitor 1 (FM 1) were observed assisting Resident 1 to get up from the floor and sat her on a chair. Licensed Nurse 1 (LN 1) was observed checking Resident 1's vital signs while she was seated in the chair.During an interview with LN 1 on 6/17/26 at 9:10 a.m., LN 1 stated Resident 1 had not fallen yesterday, 6/16/26.During an interview with CNA 1 on 6/17/26 at 10 a.m., CNA 1 stated she witnessed Resident 1 have an assisted fall on 6/16/26. CNA 1 stated an assisted fall was considered a fall.During an interview with CNA 2 on 6/17/26 at 10:08 a.m., CNA 2 stated yesterday she followed Resident 1 when Resident 1 walked out of her room and had to lower Resident 1 to the floor because she started falling. CNA 2 acknowledged CNA 1, FM 1, and herself, assisted Resident 1 from the floor in a sitting position to a standing position, and sat her on a chair. CNA 2 verified Resident 1 had an assisted fall.During an interview with the DON (Director of Nursing) on 6/17/26, at 10:25 a.m., the DON stated an assisted fall was a fall. The DON stated if Resident 1 was found sitting on the floor, Resident 1 had a fall. The DON stated she expected LN 1 to complete a change of condition report, initiated a fall care plan, and notified the family and Resident 1's physician of the change in condition.During an interview with Resident 1's RP on 7/6/26, at 9:53 a.m., the RP stated he was not informed that Resident 1 fell on 6/16/26.A review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 11/11/25, indicated, Definition of Falls. 'An event in which a person inadvertently comes to rest on the ground, floor, or lower level.'A review of the facility's P&P titled Fall Management Program revised 8/28/25 indicated, After any fall, .The licensed nurse will notify the following individuals regarding the fall as soon as possible.Resident's responsible party.A review of the facility's P&P titled, Change in Condition, dated 8/5/22 indicated, A Licensed Nurse will notify the . legal representative or an appropriate family member when there is an incident/accident involving the resident.A review of Resident 1's progress notes dated 6/16/26 at 1:50 p.m., written by LN1 indicated, Resident [Resident 1] was ambulating [walking] with staff assistance from her room to a chair at the nurse station when she became unsteady and was about to fall. Immediately [sic] intervened and safely prevented the fall by providing support and assistance. no [sic] impact with the floor occurred. Vitals [sic] signs were obtained and were within normal limits.

Based on interview and record review, the physician and licensed nurses failed to ensure informed consent was provided to one resident (Resident 2) of four sampled residents when Resident 2's informed consent documentation was incomplete and indicated a lethal dose of medication to be administered.This failure resulted in Resident 2 being administered a psychotropic medication without verification of their right to be informed of the risks, benefits, and options of alternative treatment.Findings:A review of Resident 2's hospital Discharge summary dated [DATE] indicated Resident 2 only had two physician's orders for prescribed medications which included amlodipine besylate (medication used to treat high blood pressure) and hydrochlorothiazide (medication used to treat high blood pressure). The hospital also recommended that the skilled nursing facility Resident 2 was to be admitted to avoid the use of sedatives (a substance that depresses the central nervous system, slowing brain activity to induce calmness, relaxation, or sleep) and deliriogenic (a substance or medication that can cause delirium [a sudden state of confusion characterized by disturbances in attention and awareness]) medication when possible.A review of Resident 2's face sheet indicated admission to the facility on 3/16/26 with diagnoses which included encephalopathy (a broad term for any damage or malfunction that affects the brain's structure and overall function), cerebral infarction (also known as stroke; the lack of blood flow to the brain which deprives brain tissue of oxygen and nutrients), cognitive communication deficit (difficulty with communication caused by impaired processes involving attention, memory and learning), major depressive disorder (a mental health condition characterized by persistent sadness or loss of interest that interfere with daily life), severe dementia (a progressive state of decline in mental abilities) with other behavioral disturbance, and insomnia. This document also indicated Resident 2's Responsible Party (RP, a person designated to make decisions when a resident is no longer able to for themselves) was Resident 2's daughter.A review of Resident 2's facility document titled Informed Consent Documentation signed by the physician on 3/16/26 indicated, Medical Provider's Name [Blank- no physician's name written].Medical Provider's Orders.lorazepam 25 mg [milligrams, a unit of measure] [every] 12 hrs [hours] PRN [as needed] for anxiety m/b [manifested by] irritability.If informed consent was obtained, complete the following.On [Blank- no date written] (date), I reviewed the following information regarding the medical intervention described above with the resident or responsible party.After reviewing this information with the resident\responsible party, I obtained informed consent from.[Box not checked next to] The resident.[Box not checked next to] The resident's responsible party (name) [Blank- no name documented].If no informed consent was obtained, complete the following.I have NOT disclosed the risks related to the restraint, psychotropic drug, and/or medical device to the resident based on the following reason.[Box not checked next to] Resident\Responsible Party specifically requested not to be informed.[Box not checked next to] Disclosure would seriously upset the resident and the resident would not be able to rationally weigh the risks of refusing to undergo the recommended treatment.I verified that informed consent was obtained by the physician [Box not checked next to] Yes.[Box not checked next to] No.Person who verified that physician spoke to them regarding informed consent.[Box not checked next to] Resident.[Box not checked next to] Responsible party name.[Blank- no name documented].The verification was obtained via [Box checked next to] Verbal/In person.[Box checked next to] Telephone (2nd signature required).Date [next to signature of Nurse verifying consent].3/16/23.Date [next to signature of second nurse verifying consent because verification was by telephone].3/16/24.A review of Resident 2's Medication Administration Record (MAR) dated March 2026 indicated Resident 2's first dose of 1 mg lorazepam was administered to her on 3/18/26 at 11:12 a.m. This MAR further indicated licensed nurses administered 1 mg of lorazepam a total of 10 times out of 30 opportunities in March 2026.A review of Resident 2's order summary report dated April 2026 indicated Resident 2 had physician's orders to receive: Lorazepam oral tablet 1 mg [milligram, a unit of measure] Give 1 tablet by mouth every 12 hours as needed [PRN] for anxiety for 14 days m/b [manifested by] irritability.Start Date 4/4/26.End Date 4/17/26. and Lorazepam oral tablet 1 mg Give 1 tablet by mouth every 12 hours as needed for anxiety for 90 days m/b irritability.Start Date 4/5/26.End Date.7/4/26.A review of Resident 2's MAR dated April 2026 and May 2026 indicated licensed nurses administered 1 mg of lorazepam to Resident 2:36 times out of 60 opportunities in April 2026; and,33 times out of 62 opportunities in May 2026.A review of Resident 2's physician's visit notes dated 5/25/26 at 8 a.m. indicated, Patient [Resident 2] lacks medical decision-making capacity.Daughter identified as responsible party [RP] and appropriate surrogate decision maker.In a concurrent interview and record review with the Director of Nursing (DON) on 6/17/26 at 2:20 p.m. the DON stated Resident 2's informed consent documentation for lorazepam 25 mg was invalid because Resident 2's lorazepam orders were for 1 mg. The DON was asked for a copy of Resident 2's informed consent for the 1 mg order of lorazepam. None was provided to the surveyor.A follow-up email regarding this surveyor's request for a copy of Resident 2's informed consent for 1 mg of lorazepam was sent to the facility's Medical Records Director (MDR) on 6/22/26 at 8:52 a.m. The MDR replied that the document would be emailed to the surveyor by noon on 6/22/26. No informed consent was received.In an interview with Licensed Nurse 3 (LN 3) on 7/3/26 at 12:59 p.m., LN 3 stated he was 100% sure Resident 2 had a signed informed consent form for the 1 mg order of lorazepam and acknowledged he had not checked Resident 2's informed consent prior to administering lorazepam to Resident 2. LN 3 stated Resident 2 lacked capacity so Resident 2's RP would have had to sign the consent form.In an interview with the California Department of Public Health's (CDPH) Pharmacy Consultant (PharmD) on 7/15/26 at 5:20 p.m., the PharmD stated a 25 mg dose of lorazepam was unheard of and she could not think of a place where this dose would be clinically appropriate. The PharmD further stated she expected a new consent form to have been obtained since the one on file was inaccurate to begin with regardless if the ordered dose was less than what was indicated on the consent form.A review of the drug manufacturer's guide for lorazepam revised September 2016 indicated, Elderly.patients may be more susceptible to the sedative effects of lorazepam. Therefore.the initial dosage should not exceed 2 mg.The usual range is 2 to 6 mg/day given in divided doses.but the daily dosage may vary from 1 to 10 mg/day. For anxiety, most patients require an initial dose of 2 to 3 mg/day given two times a day or three times a day.For elderly.patients, an initial dosage of 1 to 2 mg/day in divided doses is recommended.lorazepam tablets are available in the following dosage strengths.0.5 mg.1 mg.[or] 2 mg.A review of the facility's document titled Informed Consent Documentation last revised 12/8/20 indicated, Instructions: This form is to be completed by the physician, physician's assistant or nurse practitioner to document that they have obtained informed consent from the resident or a responsible party for orders that they have issued.A review of the facility's policy and procedure titled Informed Consent dated 1/30/26 indicated, If the resident lacks capacity to provide informed consent, the surrogate decision-maker will provide informed consent.It is the Healthcare Practitioner's. responsibility to obtain informed consent.The licensed nurse will confirm that the Healthcare Practitioner obtained informed consent and will document the verification in the Resident's medical record, before administering the first dose.of psychoactive medications.Documenting of the verification of informed consent may be done by.Contacting the.decision-maker.to verify that the Healthcare Practitioner obtained informed consent for the order. The licensed nurse will contact the healthcare practitioner to request the practitioner obtain the informed consent, if the licensed nurse is unable to verify that the Healthcare Practitioner obtained informed consent for the order.

Based on interview and record review, the facility failed to ensure one resident (Resident 2) of four sampled residents was free from unnecessary psychotropic medications (prescription drugs that alter brain chemistry, affecting mood, perception, thoughts, or behavior) when Resident 2 was prescribed lorazepam (a prescribed medication used to treat anxiety disorders) as needed (PRN) for 90 days.This failure decreased the facility's potential to safely administer psychotropic medications to residents.Findings:A review of Resident 2's face sheet indicated admission to the facility in March 2026 with diagnoses which included encephalopathy (a broad term for any damage or malfunction that affects the brain's structure and overall function), cerebral infarction (also known as stroke; the lack of blood flow to the brain which deprives brain tissue of oxygen and nutrients), cognitive communication deficit (difficulty with communication caused by impaired processes involving attention, memory and learning), major depressive disorder (a mental health condition characterized by persistent sadness or loss of interest that interfere with daily life), severe dementia (a progressive state of decline in mental abilities) with other behavioral disturbance, and insomnia.A review of Resident 2's facility document titled Order Details created on 4/5/26 at 6:31 a.m. by Licensed Nurse 4 (LN 4) indicated the physician communicated with LN 4 via phone to change Resident 2's lorazepam (an antianxiety chemical agent) order from as needed for 14 days to 90 days.A review of Resident 2's order summary report dated April 2026 indicated Resident 2 had a physician's order to receive Lorazepam oral tablet 1 mg [milligram, a unit of measure] Give 1 tablet by mouth every 12 hours as needed [PRN] for anxiety for 90 days m/b [manifested by] irritability.Start Date 4/5/26.End Date 7/4/26.In a concurrent interview and record review with LN 3 on 7/3/26 at 12:59 p.m., the LN 4 stated he sent Resident 2's physician a text message on 4/4/26 at 12:07 a.m. asking to restart Resident 2's lorazepam order. LN 4 stated he still had the text message he sent and read it out loud to the surveyor. LN 4 stated the physician replied to the text message which indicated Resident 2 could receive lorazepam PRN for 90 days. LN 4 stated the physician did not give a rationale and reiterated the text message only indicated the lorazepam was to be given PRN for 90 days.A review of Resident 2's Medication Administration Record (MAR) dated April 2026 indicated licensed nurses administered 1 mg of lorazepam to Resident 2 at least once per day between 4/20/26 through 5/2/26 and between 5/4/26 and 5/21/26.A review of the facility's policy and procedure titled Behavior/Psychoactive Medication Management effective date of 1/30/26 indicated, Any Psychoactive Medication ordered on an as necessary (prn) basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed a 90 day time frame.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of three sampled residents reviewed for abuse (Resident 1) when an allegation of abuse was reported to the Department outside of the two-hour timeframe.This failure to report promptly had the potential to delay regulatory oversight and impede timely protective interventions for Resident 1. A review of a facility document titled, Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 5/25/26, indicated that Resident 1 was the victim of physical abuse that resulted in a fracture (break) to the second digit (index finger) on the left hand. The date and time of the incident was documented as 5/26/26 at 8:40 a.m. The document further indicated, Patient's [Resident 1] family is alleging abuse and impropriety [behavior, actions, or remarks that are dishonest] related to an unknown occurrence [injury of unknown origin].A review of a facility document dated 5/25/26 indicated the SOC 341 was faxed to the Department on 5/25/26 at 6:02 p.m.During an interview on 6/4/26 at 11:40 a.m., Licensed Nurse 1 (LN 1) stated allegations of abuse are expected to be reported to the Department within two hours. LN 1 stated the timeliness of reporting is important to ensure that those involved are safe and that appropriate care is provided. During an interview and concurrent document review on 6/4/26 at 1:55 p.m., the Director of Nursing (DON) confirmed the SOC 341 documented that Resident 1's family alleged abuse. The DON also confirmed that the document indicated the time the incident occurred was on 5/25/26 at 8:40 a.m. and that the document was not faxed to the Department until 6:02 p.m. The DON stated if abuse was suspected then it should have been reported within the two-hour timeframe. A review of the facility's policy and procedure titled, Abuse- Reporting Investigations, revised 2018, indicated, To protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse.injuries of unknown source.are promptly reported and thoroughly investigated.The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. Administrator or designed representative will also notify.[Title of the Department] by telephone and in writing (SOC 341) within two (2) hours of initial report.A review of the facility's document titled, Registered Nurse - Job Description, no date, indicated, Report and initiate of alleged abuse or unusual occurrence as outlined within our established policies and procedures. A review of the facility's document titled, LVN (License Vocational Nurse) Staff Nurse - Job Description, no date, indicated, Reports allegations of abuse of unusual occurrence per State and Federal Regulations and facility policy.

Based on interview and record review, the facility failed to communicate postmortem care requirements for one of three sampled residents reviewed for postmortem care (Resident 2) when facility staff did not communicate Resident 2's postmortem care coordination efficiently and timely between internal facility departments and external entities.This failure resulted in a lack of clear direction and coordination with internal facility departments and external entities, which delayed Resident 2's necessary postmortem and cremation procedures. A review of Resident 2's admission record indicated he was admitted to the facility in [DATE] with medical diagnosis which included collapsed vertebra, thoracic region (when the bony block of the mid-back spine weakens and compresses into a wedge shape) and Alzheimer's (a disease characterized by a progressive decline in mental abilities). Resident 2's admission record indicated that a family member was assigned as his responsible party (RP, an individual who manages a resident's care decisions and finances). A review of Resident 2's progress notes titled, Alert Note, dated [DATE] at 2:24 p.m. indicated that Resident 2 was found unresponsive and pronounced dead at 2 p.m. The progress note also indicated that nurse staff attempted to notify Resident 2's RP and the phone number listed was no longer in service. A review of Resident 2's facility provided document titled, Skilled Nursing Visit Note [Name of hospice company], dated [DATE], indicated, Multiple attempts were made to contact patient's [Resident 2] next of kin [RP] - line is disconnected. A review of a facility document titled, Record of Death, indicated that Resident 2's date of death was [DATE]. The document also indicated that Resident 2's body was released to a mortuary on [DATE] at 5:50 p.m. A review of a facility provided email thread dated [DATE] - [DATE] included attempted communication between external entities and facility staff recipients that included the Administrator (ADM), Admissions (Admit), and Social Service (SS). The email thread indicated that communication between external entities and facility staff was initiated on [DATE]. The email thread indicated that an external entity [name of mortuary] required the facility to complete an Indigent application (a formal request used to prove a significant lack of income) for Resident 2 in order to proceed with his postmortem and cremation procedures. On [DATE], the mortuary forwarded the facility ADM and Admit an Indigent application and requested that the facility expedite the completion of the application so the decedent [Resident 2] can be properly cared for. The email thread indicated the mortuary followed up with the ADM and Admit on [DATE], [DATE], [DATE], and [DATE]. The email thread further indicated that the external entities did not receive a reply from facility staff until [DATE]. On [DATE], the Social Service Director (SSD) replied and attached an incomplete Indigent Application to the external entities. A review of a different facility provided email thread between Admit and SSD indicated the previously mentioned email thread that involved the external entities was forwarded to SSD on [DATE]. During an interview on [DATE] at 12:36 p.m., Admit stated she had no responsibilities following the death of a resident. Admit stated the mortuary phoned and emailed the facility with their request to have the Indigent application completed for Resident 2 in early [DATE]. Admit stated communication from the mortuary was directed to her and that she received the Indigent application via email on [DATE]. Admit further stated that she forwarded the application to SSD for completion on [DATE]. Admit confirmed the application was forward to SSD ten days after she received it and stated the application was not the responsibility of the Admissions department. Admit verified there was a delay in communication between the facility departments. During an interview on [DATE] at 1:05 p.m., the SSD stated she received the Indigent application from Admissions on [DATE]. The SSD stated she did not know why there was a delay in receiving the application from Admissions. The SSD further stated on [DATE] she was included on an email thread from Admit that included external entities. The SSD stated the forwarded email discussed that it was the facilities responsibility to contact the PA (Public Administrator- a legally mandated county office that manages the estates of deceased residents who pass away without a will or a known executor [person who manages a deceased person's estate]) to evaluate the case. The SSD stated to her knowledge, the PA was not contacted by facility staff until the Indigent application was submitted on [DATE]. During an interview and concurrent document review on [DATE] at 10:30 a.m., the ADM confirmed all email communication between the facility and the external entities in regard to Resident 2 and the Indigent application was provided. The ADM stated SS should had followed up on the phone calls and emails that was directed to Admissions. The ADM further stated, They [SSD and Admit] could have come together to decide how to proceed with the matter. The ADM reviewed the email thread and confirmed SS did not get involved until [DATE]. The ADM stated prior to [DATE] the matter regarding Resident 2 was not brought to his attention. The ADM confirmed based on the email thread there was a delay in getting the application to the correct facility department and having it completed. The ADM further stated there should had been better communication to get the necessary application completed in a timely manner. The ADM stated, If we didn't do it, we didn't do it and that is bad. The evidence [referenced to the email thread] is there. A review of the facility's policy and procedure (P&P) titled, 24 Hour Communication System, dated 2024, indicated, The facility will utilize a 24-hour report system as a means of communicating.important aspects of resident's care. A review of the facility's P&P titled, Identifying a Mortuary, dated 2025, indicated, If there is no family/resident representative, the facility staff will contact the Public Administrator's Office/county morgue at the time of the resident's death for mortuary arrangements-referenced on the face sheet. A review of the facility's document titled, Admissions Coordinator - Job Description, no date, indicated, Administrative.Documents all necessary information in an accurate and timely manner. Qualifications.Excellent organizational skills with a detail orientation towards documentation and follow-up. A review of the facility's document titled, Social Service Coordinator - Job Description, no date, indicated, Clinical/Administrative.Communicate needs and plan of care to.appropriate staff.

Based on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) from physical and verbal abuse when Resident 2 struck Resident 1's left arm and yelled insults at him after an accident involving both residents on 5/01/26.This failure had the potential to result in Resident 1 experiencing post-incident pain, as well as possible feelings of fear about other residents residing in the facility. A review of Resident 1's Face Sheet, dated 5/05/26, indicated he was admitted to the facility on [DATE] with diagnoses including respiratory failure (when the lungs can't get enough oxygen into the blood, making breathing difficult), dementia (decline in memory, reasoning, and communication caused by progressive brain cell damage), and depression (serious mood disorder causing persistent sadness, loss of interest, and functional impairment).A review of Resident 1's Minimum Data Set (MDS-a standardized assessment tool used in nursing homes), dated 4/26/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a short test used to check a person's memory and thinking) score of 3 of 15 points possible, indicating severe cognitive impairment.A review of Resident 2's Face Sheet, dated 5/05/26, indicated she was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (hemiparesis indicates weakness on one side of the body; hemiplegia indicates partial or total paralysis), auditory hallucinations (the perception of sounds or voices that are not actually present, often caused by mental health conditions), and dementia.A review of Resident 2's MDS, dated [DATE], indicated he had a BIMS score of 13 of 15 points possible, indicating intact cognitive functioning.A review of facility Social Services Progress Note, dated 5/1/26 at 3:26 p.m., indicated, [Resident 2] was in close proximity to [Resident 1], actively pulling her fist back from an outward motion, directed towards [Resident 1's] arm, suggesting that physical contact had just occurred. Immediately following this, [Resident 2] raised her voice and stated, you ran over my foot, you asshole. In response, [Resident 1] replied, I'm sorry, I didn't mean to indicating that the incident may have stemmed from an accidental action.A review of facility Psychosocial Progress Note, dated 5/4/26 at 5:04 p.m., indicated Resident 2, expressed her remorse for her reaction and acknowledged it was not appropriate.During an interview on 5/05/26 at 3:26 p.m. with Central Supply Staff (CSS), CSS indicated on 5/01/26 at approximately 1 p.m., while he was delivering supplies to resident areas, he saw Resident 2 hit Resident 1's upper outer arm with her fist, while yelling at him. Resident 1 immediately apologized and left the area.A review of facility policy and procedure (P & P) titled, Abuse Prevention and Management, dated 5/30/24, indicated, Abuse is defined as the willful, deliberate infliction of injury.verbal abuse is defined as any oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to resident within their hearing distance, regardless of age, ability to comprehend, or disability.physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking.the facility identifies, corrects and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur.

Based on interviews and record reviews, the facility failed to ensure one resident (Resident 1) of two sampled residents was free of a significant medication error when a double dose of insulin lispro (a fast-acting, man-made insulin (a hormone that regulates blood sugar allowing it to be used by our body as energy) used to treat diabetes) was administered by licensed nurses on the morning of 8/19/25.This failure resulted in Resident 1 having a hypoglycemic (when blood sugar level reaches a low level) episode in which she became unresponsive. Findings:A review of Resident 1's admission record indicated a diagnosis of Type 1 diabetes (a chronic condition in which the body is unable to produce an adequate amount of insulin).A review of Resident 1's Medication Administration Record (MAR) dated August 2025, indicated Resident 1 was scheduled to receive 12 units of Insulin Lispro 100 units/ml (milliliter, a unit of measurement) at 7 a.m. and 7:30 a.m. Licensed Nurse A (LN A) administered one dose of 12 units of Insulin Lispro at 6:58 a.m. on 8/19/25. LN B then administered a second dose of 12 units of Insulin Lispro at 8:22 a.m. on 8/19/25, which resulted in Resident 1 receiving two fast-acting insulin doses 1 hour and 24 minutes apart. In addition, LN B gave Resident 1 three units of insulin lispro 100 units/ml on 8/19/25 at 8:22 a.m. for a sliding scale (a set of various insulin doses administered based on the resident's glucose (sugar) reading at the time) order. The MAR indicated Resident 1 received a total of 27 units of a fast-acting insulin on the morning of 8/19/25. Based on Resident 1's blood glucose values obtained from the sliding scale orders, Resident 1's average blood glucose level in August 2025 was 192 mg/dl.A review of Resident 1's SBAR (Situation, Background, Appearance, Review) and Notify Communication Form dated 8/19/25, indicated, The change in condition, symptoms, or signs observed.hypoglycemia, unresponsiveness, altered [abnormal] level of consciousness.Blood Sugar.43.0 [gm/dl] .Resident became hypoglycemic MD [physician] gave order for glucose gel q [every] 15 min [minutes].During an interview on 9/8/25 at 3:15 p.m., LN C stated Certified Nursing Assistant D (CNA D) called his attention to check on Resident 1 on the morning of 8/19/25. LN C stated he went to Resident1's room and checked her blood sugar because CNA D said Resident 1 was not acting like her usual self. LN C stated Resident 1 was in a hypoglycemic episode when he checked Resident 1's blood sugar at 43 gm/dl. LN C stated Resident 1 usually had a high blood sugar reading and 43 gm/dl was low for her.During an interview on 9/9/25 at 12:57 p.m. CNA D stated she saw Resident 1 was shaking and was not her normal self on the morning of 8/19/25. CNA D stated she notified LN C.During an interview on 9/10/25 at 1:42 p.m., the Director of Nursing (DON) stated she verified with the Medical Records Director and found LN E entered orders for insulin into the computer for Resident 1 on 8/18/25. The DON acknowledged Resident 1 received 27 units of insulin lispro on 8/19/25. When asked if this was a medication error, the DON stated, Most possibly. When asked if the facility did a medication error report, she stated, Yes.During an interview on 9/10/25 at 2:47 p.m., LN E stated the Assistant Director of Nursing (ADON) gave her orders for insulin to enter into the computer, and she did so on 8/18/25. LN E stated she checked the insulin orders for Resident 1 but may have overlooked a discrepancy on the insulin orders.During an interview on 9/10/25 at 4:06 p.m., the ADON stated he gave orders to LN E to enter into the computer for several residents. The ADON stated he thought what happened was LN E entered the new insulin orders for Resident 1 but did not discontinue the previous insulin orders. The ADON acknowledged LN A and LN B gave insulin doses to Resident 1 which resulted in Resident 1's hypoglycemic episode on 8/19/25.During an interview on 9/12/25 at 8:56 a.m., Physician Assistant F (PA F) stated he was at the facility on the morning of 8/19/25 when Resident 1 had a hypoglycemic episode and notified the attending physician. PA F stated it was unfortunate, and it was a medication error.A review of a facility document titled, Medication Error Report Form, dated 8/19/25, indicated, . [Resident 1].Medication Involved in Error: Lispro [insulin].Dates Medication Was Administered in Error.8/19/25.Type of Error: Double dose given .Cause of Error: Transcription error.Describe Any Adverse Reaction: Hypoglycemia.Describe event .Two orders were placed for Lispro 12 units. The [LN] who placed duplicate order failed to D.C. [discontinue] the prior order.A review of a facility policy and procedure titled Medication Administration dated 8/19/25, indicated, The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner.

Based on observations, interviews, and record reviews, the facility failed to protect one resident (Resident 1) from physical abuse by Resident 2, when Resident 2 struck Resident 1 on the head with a coffee cup which shattered into small pieces. This failure resulted in Resident 1 being sent to the hospital Emergency Department (ED) for evaluation and treatment of a head injury. Findings: A review of Resident 1's Admission Record, indicated he was admitted to the facility on [DATE]. Resident 1's medical diagnoses included Major Depressive Disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and other symptoms that affect daily life) and Dementia (a progressive state of decline in mental abilities). A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 3/21/25, indicated Resident 2 had: - Medical diagnoses included which dementia, depression, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves); - A Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 8 which indicated moderate cognitive (the mental process involved in obtaining, storing, and using knowledge) impairment; and, - Physical behavioral symptoms directed towards others (e.g. hitting) and verbal behavioral symptoms directed towards others (e.g. cursing at others). A review of Resident 2's medical chart indicated the following various care plans regarding: - Resident-to-resident physical altercation (a fight), Resident 2 hit another resident on top of the head with a plastic coffee mug which was initiated on 2/28/25. - Resident 2 had physical aggression (violent behavior) by hitting staff on the head which was initiated on 3/23/25. - Resident 2 had physical aggression towards another resident, hit another resident on the head which was initiated on 4/10/25. A review of Resident 1's progress note dated 4/10/25 at 5:34 p.m. indicated, [Resident 1] was the victim of Resident-to-Resident Physical abuse and had to be sent out to the hospital for further Evaluation since he had a laceration [a deep, jagged wound] on is head. A review of Resident 1's hospital ED document titled Encounter Summary, dated 4/10/25 at 5:14 p.m., indicated, .Reason for Visit .Head Injury .Visit Diagnoses .Closed head injury without loss of consciousness [sudden, temporary loss of awareness of oneself and the surroundings] .Scalp abrasion [a type of wound characterized by the scraping away of the outer layer of skin] .Injury due to physical assault [the act of intentional harm]. A review of Resident 2's progress note dated 4/10/25 at 5:38 p.m. indicated, [Resident 2] had an unprovoked [occurred without cause] resident to resident physical altercation. [Resident 2] was sitting in the alcove [a small, recessed section of a room] drinking coffee and was sitting next to [Resident 1] .all of a sudden, [Resident 2] banged his empty cup on [Resident 1's] head hard enough to break it. [Resident 2] was screaming at [Resident 1] and staff immediately separated him .probed [to ask a series of questions to obtain information] [Resident 2] that there was something that happened earlier and [Resident 2] then said, ' oh that was because .[Resident 1] was trying to hold my shirt.' .Reminded [Resident 2] that is the third incident . During an interview on 4/25/25 at 1:45 p.m., Certified Nursing Assistant A (CNA A) stated he witnessed Resident 2 hit Resident 1 in the head without warning and broke his coffee cup on Resident 1's head when both residents were sitting close to each other at the nurse's station. CNA A stated Resident 1 was bleeding from the head. CNA A stated he witnessed a similar incident in the past where Resident 2 broke his coffee cup on another resident's head. CNA A stated he called Licensed Nurse B (LN B) after he had placed himself between Resident 1 and Resident 2 to separate them. During a concurrent observation and interview on 4/25/25 at 2:43 p.m., LN B stated the incident between Resident 1 and Resident 2 happened on 4/10/25 at around 9 a.m. LN B stated there was a CNA assigned to look after Resident 2 because Resident 2 was previously involved in a similar incident, where he broke his coffee cup on another resident's head. LN B stated she applied a gauze (a thin fabric typically applied to wounds to absorb fluid and provide protection to the wound) to Residents 2's head because he got a scrape that was bleeding profusely. LN B stated she called and received orders from Resident 1's physician to transfer him to the ED for evaluation. LN B showed this Surveyor the blue, hard plastic coffee cup was used by Resident 2 that had broken into multiple small pieces. During a concurrent observation of Resident 2 in the facility's Memory Care Unit (an area of the facility provides care to residents with Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia) and interview on 4/25/25 at 3:05 p.m., Resident 2 was observed seated with residents to his left and right side. Resident 2 then independently walked toward this Surveyor without the use of an assistive device (a device used to assist a person to walk or move). Resident 2 was asked if he had hurt another resident using his coffee cup he stated, Yes, I did [because] he was ' pawing' [to touch or handle clumsily] the front of my shirt. During an interview on 4/28/25 at 1:52 p.m., CNA C stated early on 4/10/25, CNA A took Resident 1 back to his room because he was annoying other residents. CNA C stated at around 9 a.m., Resident 1 came out of his room, sat beside Resident 2 and started watching television. CNA C stated he was walking toward Resident 1 to get his coffee cup when Resident 2 suddenly and without any provocation, hit Resident 1 on the head with a plastic coffee cup. CNA C compared the sound of the impact from the coffee cup to somebody using a hammer. CNA C stated the impact was so hard the coffee cup broke into pieces. CNA C stated he got a towel and placed it on Resident 1's head while CNA A held Resident 2 back from Resident 1 because he was still cursing at Resident 1. CNA C stated LN B assessed Resident 1 and performed first aid. CNA C stated Resident 1 had a medium amount of blood on his head. During an interview on 4/30/25 at 1:55 p.m., the Director of Nursing (DON) stated she had investigated the incident between Resident 1 and Resident 2. The DON stated she spoke to LN B, CNA A, and CNA C. The DON stated CNA A and CNA C both witnessed the incident and reported to her Resident 2 struck Resident 1 on the head. The DON stated one of the CNAs described the impact on Resident 1's head was hard. The DON stated Resident 1 sustained a scrape on his head as a result of the strike. A review of a facility policy and procedure titled, Abuse Prevention and Management, dated 2022 indicated, The facility does not condone any form of resident abuse .and/or mistreatment. The facility develops policies, procedures, training programs and .prevention systems .Abuse is defined as the willful, deliberate infliction of injury .

Based on interviews and record reviews, the facility failed to identify risks, evaluate, and analyze risks and implement interventions to reduce risk when the facility did not provide physical supervision to prevent avoidable accident for one out of three sampled residents (Resident 1), while he was eating his sandwich alone in his room. This failure resulted to Resident 1 choking on his sandwich. Due to this choking incident, Resident 1 was sent to the hospital twice. Resident 1 was then diagnosed with multiple rib fracture which resulted to Resident 1 experiencing shortness of breath (SOB, the frightening sensation of being unable to breathe normally or feeling suffocated), desatting (a term used to mean that saturations (oxygen levels) are dropping) and complaining of 10 out of 10 pain level (the worst pain you have ever felt). Findings: A review of Resident 1 ' s face sheet (demographics, statistics that describe populations and their characteristics), indicated he was [AGE] years old with a diagnoses of Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and Anxiety (persistent and excessive worry that interferes with daily activities). His Minimum Data Sheet Assessment (MDS, a federally mandated (requirements imposed on state, local, or tribal governments) process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated [DATE], Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 6 indicating severely impaired cognition (cognitive impairment that is severe enough to limit function, usually defined as social or occupational function. In its severe forms, a person with dementia/SCI may not be able to recognize people, use language, or execute purposeful movements). During a concurrent interview, progress notes dated [DATE] and [DATE], MDS assessment dated [DATE] and care plan (summarize a person's health conditions, specific care needs, and current treatments, the care plan should outline what needs to be done to manage the care needs) record review on [DATE] at 10:05 a.m., the Director of Nursing (DON) stated Resident 1 had a choking incident on [DATE]. The DON stated Resident 1 was sent out to the hospital after the choking incident, came back on the same day but was sent out to the hospital again the following day, [DATE] due to SOB, desatting and ,d+[DATE] pain. The DON stated the hospital diagnosed Resident 1 with multiple rib (a curved bone in a person's chest) fracture (a break in bone) after the staff at the facility performed cardiopulmonary resuscitation (CPR, an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) on him when he lost consciousness and the Heimlich maneuver (the manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea- a long, U-shaped tube that connects your larynx (voice box) to your lungs) performed by staff to dislodge a food stuck into Resident 1 ' s throat was unsuccessful. The DON stated Resident 1 choked on a peanut butter spread brought by his family. The DON stated Resident 1 was at risk for choking incidents. The DON stated Resident 1 had dementia and had poor safety awareness. The DON stated, although Resident 1 was independent with eating, he should be supervised when eating. The DON stated this meant Resident 1 should be in line of sight from the clinical staff when he was eating. The DON stated it was housekeeping who noticed the resident was choking. The DON stated Resident 1 was in his room eating a peanut butter spread and there was no clinical staff to monitor Resident 1 while he was eating. A brief review of the care plans with the DON indicated there was no specific care plan to address Resident 1 ' s risk for choking. During an interview on [DATE] at 10:50 a.m., Licensed Staff A stated residents with dementia, and who had poor safety awareness should be monitored and supervised during meals. Licensed Staff A stated, if these residents were not supervised or not within line of sight during meals, it could increase the risk of these residents having choking incidents which could lead to hospitalization and death. Licensed Staff A stated it was the facility ' s responsibility to keep residents safe. During an interview on [DATE] at 11:00 a.m. Unlicensed Staff B stated Resident 1 ' s choking incident occurred while he was providing one on one care (1:1, a type of care where one staff member is attending to your needs on a 1 to 1 basis) duty with another resident. Unlicensed Staff B stated he heard a staff member yelling someone was choking. Unlicensed Staff B stated one of the Certified Nursing Assistant (CNA, a staff that helps patients with direct health care needs, often under the supervision of a nurse) asked for his help so he went to Resident 1 ' s room and he saw Resident 1 on his wheelchair. Unlicensed Staff B stated Resident 1 appeared like he was choking, was not able to talk and was having a hard time breathing. Unlicensed Staff B stated he initiated the Heimlich maneuver which was ineffective. Unlicensed Staff B stated Resident 1 lost consciousness so he, another male CNA and the nurse assigned to Resident 1 put him back to bed where the CNA initiated the CPR. Unlicensed Staff B stated Resident 1 choked on a peanut butter jelly sandwich (PBJ, a sandwich that consist of peanut butter and fruit preserves or jelly) provided by the facility kitchen. Unlicensed Staff B stated residents with decreased safety awareness and residents at risk for choking should be supervised when eating. When asked if there was a staff present who was monitoring Resident 1 for choking at that time, Unlicensed Staff B responded no. When asked if this choking incident could have been prevented if there was a staff monitoring Resident 1 while he was eating his sandwich, Unlicensed Staff B was silent. During an interview on [DATE] at 11:10 a.m., Unlicensed Staff C stated she does not know how to perform the Heimlich maneuver. Unlicensed Staff C stated for safety purposes, resident with dementia who had poor safety awareness should be supervised during meals. Unlicensed Staff C stated residents with dementia and had poor safety awareness who were not monitored during meals had increased incidents of choking, hospitalization and death. Unlicensed Staff C stated it was the facility ' s responsibility to ensure resident ' s safety. During an interview on [DATE] at 11:15 a.m., Unlicensed Staff D stated it was the housekeeper and a staff from laundry that reported Resident 1 was choking. Unlicensed Staff D verified he did not perform the Heimlich maneuver but did provide CPR for Resident 1. Unlicensed Staff D stated Resident 1 was independent with eating but needed supervision of staff when eating for safety purposes. Unlicensed Staff D stated Resident 1 was at risk for choking because he had a behavior of eating too fast and stuffing his mouth with food. Unlicensed Staff D stated Resident 1 choked on a PBJ sandwich provided by the facility kitchen. Unlicensed Staff D stated, if Resident 1 was eating within the staff line of sight, staff could have reminded him to eat slowly and not stuff his mouth with food and the choking incident could have been prevented. Unlicensed Staff D stated it was the facility ' s responsibility to keep residents safe. During an interview on [DATE] at 11:25 a.m., Resident 3 stated he did not trust the staff to know how to perform CPR correctly and safely. Resident 3 stated staff does not appear to always promote resident ' s safety. During an interview on [DATE] at 11:28 a.m., Licensed Staff E stated it was the facility ' s responsibility to always ensure residents safety. Licensed Staff E stated, residents who had dementia, was eating food too fast and was stuffing his mouth with food indicated these residents were at risk for choking incidents. Licensed Staff E stated, to decrease the risk of choking incidents for these residents, they should be supervised during meals. Licensed Staff E stated not having a resident who was at risk of choking within line of sight could be a safety issue and could result to resident choking, hospitalization , fractures from performing CPR or Heimlich maneuver or death. During a phone interview on [DATE] at 1:28 p.m., the DON stated residents who had a habit of eating too fast or stuffing their mouth with food were at risk for choking. The DON stated she was not aware Resident 1 had these behaviors. The DON stated, if Resident 1 indeed had these behaviors, then Resident 1 was at risk for choking. The DON verified that although Resident 1 was independent with eating, he still needs to be supervised during meals. The DON stated this meant staff should be watching Resident 1 when he was eating. The DON stated Resident 1 was in his room when he choked, and he was not in the line of sight of any clinical staff. The DON stated there was no CNA or nurse in his room when he was initially choking. The DON also did not know Resident choked on a PBJ sandwich provided by the facility ' s kitchen. The DON verified there was no care plan to address Resident 1 ' s behavior of eating too fast and stuffing his mouth with food. During a telephone interview on [DATE] at 1:52 p.m., Unlicensed Staff F stated Resident 1 had always been at risk for choking as he had a habit of eating too fast and stuffing his mouth with food. He stated Resident 1 was independent with eating but needed supervision. Unlicensed Staff F stated Resident 1 choked on a PBJ sandwich provided by the facility kitchen and that Resident 1 choked on this sandwich in his room. Unlicensed Staff F stated Resident 1 was not in staff line of sight when he choked on his sandwich. He stated Resident 1 should be monitored during meals for safety reasons. Unlicensed Staff F stated Resident 1 choking incident could have been prevented if staff were present to supervise him while he was eating his sandwich. Unlicensed Staff F stated it was the facility ' s responsibility to ensure residents safety. During a telephone interview on [DATE] at 1:59 p.m., Licensed Staff G stated Resident 1 had a habit of eating too fast and stuffing his mouth with food which made him at risk for choking. Licensed Staff G stated Resident 1 choked on a sandwich provided by the facility ' s kitchen. Licensed Staff G stated it was the facility ' s responsibility to keep residents safe. Licensed Staff G stated Resident 1 was independent with eating but needed supervision during meals or while eating for safety. Unlicensed Staff G stated Resident 1 ' s choking episode could ' ve possibly been prevented if Resident 1 was in staff line of sight when he was eating his sandwich. During a telephone interview on [DATE] at 2:08 p.m., the DON verified Resident 1 ' s choking incident occurred at around 10:30 a.m. on [DATE]. The DON stated Resident 1 was sent out to the hospital on [DATE] for further evaluation and treatment, came back to the facility on the same day, [DATE] with a diagnosis of choking and multiple rib fracture. The DON stated Resident 1 was sent out to the hospital again on the following day, [DATE], for complaints of ,d+[DATE] pain on his ribs, SOB and desatting. The DON stated Resident 1 did not come back to the facility at that time. The DON stated Resident 1 ' s family brought him home straight from the hospital. During a telephone interview on [DATE] at 2:21 p.m., the Dietary Manager (DM) stated residents with behaviors of stuffing food into their mouth and eating too fast placed them at risk for choking and should be always supervised during meals. The DM stated these residents should be monitored while eating and should be eating meals within staff line of sight to decrease risk of choking. The DM stated Resident 1 ' s choking incident could have been prevented if staff was there to supervise him while he was eating and reminding him to eat slowly and not stuff his mouth with food. A request was made on [DATE] for the DON to give a copy of the facility ' s policy and procedure for Preventing Choking incidents but it was not provided. Based on F tag 689, the facility must ensure that the resident environment remain as free of accident hazards as possible, and that each resident receive adequate supervision to prevent accidents.

Based on observation, interview and record review, the facility failed to follow its own policies & procedures when one of three sampled residents (Resident 1) was not allowed to return to the facility, after being taken into police custody for a few hours, without any prior notices of pending discharge. As a result, Resident 1 was hospitalized twice, and left homeless without health care services, medications, shelter or food, placing his life at serious risk for harm and death. Findings: Record review revealed Resident 1 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 1 ' s MDS (Minimum Data Set-An Assessment tool) dated 2/22/22, indicated his BIMS (Brief Interview of Mental Status-A Cognition assessment) score was 15, which indicated his cognition was intact. Record review of a Health Status Note dated 1/19/22 at 7:44 p.m., indicated, Resident [Resident 1] picked up [From the nursing facility] and escorted by 6 [Name of city] Police officers around 1:50 PM today. During a phone interview with Witness AA, he stated Resident 1 called him from a supermarket parking lot the evening of 1/19/22, after he was released from police custody. Witness AA stated Resident 1 was taken into police custody because he had an outstanding warrant for failure to appear in court in another county, but was released by police the same day. Witness AA stated he met with Resident 1 at a supermarket parking lot, and noticed Resident 1 had no medications, no meals, and his wheelchair, which the facility had provided, did not have rubber in one of the wheels, therefore Resident 1 could not move well with it. Witness AA stated he went immediately to the facility and found out facility staff had been instructed not to accept Resident 1 back. During a concurrent observation and interview with Resident 1 on 3/09/22 at 1:10 a.m., he confirmed Witness AA ' s story and stated that after meeting with Witness AA at the supermarket parking lot, he wheeled himself (using his wheelchair) back to the facility on his own, at nighttime, a process which took him 2.5 hours. Resident 1 was observed during the interview, with below the knee amputations on both legs, sitting in his wheelchair. Resident 1 stated he got back to the facility at approximately 5 a.m., in the morning of 1/20/22, and entered the building. According to Resident 1, he was in his room at the Skilled Nursing Facility (SNF) when police showed up [The facility had called the police] and told him he needed to leave. Resident 1 stated he was hurting, real bad, and decided to call an ambulance because he could not be left in the cold. During a phone interview with the Administrator on 3/17/22 at 10:36 a.m., he confirmed the Director of Nursing (DON) called the police after Resident 1 showed up at the facility on 1/20/22. He stated the facility had been instructed by the police officers that arrested Resident 1 on 1/19/22, to call the police again if he went back. The Administrator stated Resident 1 wanted to go to a Hospital when police arrived. Record review of a Social Services Note dated 1/20/22 at 12:34 p.m., indicated, Since it was an arrest (Police took Resident 1 into custody on 1/19/22, for having an outstanding warrant after failing to appear in court in another county), he [Resident 1] was discharged when the police took him from our facility, we cannot taking (Sic) him back and Admin (Administrator), DON, Nursing, entire IDT (Interdisciplinary team) is aware. This note was written by the Social Services Director (SSD). First hospitalization : Record review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .bilateral BKA (Below the knee amputations) .presents to [GACH] ER (emergency room ) after being discharged from his skilled nursing facility. Record review of a note written by a Licensed Clinical Social Worker at the GACH, dated 1/22/22 at 1:39 p.m., stated, [Resident 1] is homeless .He has been resident at [SNF] since January 2021. [Director of Business Development] in admissions at [SNF] informed SW (Social worker) he [Resident 1] was told he was discharged from their facility. During an interview with the Director of Business Development on 3/09/22 at 12:45 p.m., she confirmed she told the GACH Licensed Clinical Social Worker, Resident 1 had been discharged from their facility, as the interdisciplinary team from the facility had informed her of this. The Director of Staff Development did not specify what staff made up the interdisciplinary team. Record review of a note written by a Licensed Clinical Social Worker at the GACH, dated 1/24/22 at 3:02 p.m., indicated Resident 1 was discharged from the GACH to a Motel with services set up with assistance from a community-based program. Record review of a document from the State of California Department of Health Care Services, titled, BEFORE THE STATE OF CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES OFFICE OF ADMINISTRATIVE HEARINGS AND APPEALS, dated 2/07/22, indicated a representative from the county Long-Term Care Ombudsman Program, filed an appeal on behalf of Resident 1 for his involuntary discharge from the facility. This document indicated, On January 19, 2022, Resident [Resident 1] was taken into custody by the [Police Department] for an outstanding warrant. On January 20, 2022, Resident returned to Facility but was refused readmission .Facility did not provide to the resident a copy of the notice of transfer/discharge, medical records, or the documents that reflect discharge planning that it was relying on in the hearing before January 25, 2022 .During the hearing, [Administrator] testified Facility did not issue Resident a written notice for the discharge of Resident. For the reasons stated above, for the purposes of this hearing, Facility has failed to meet the requirements to involuntarily discharge Resident .Facility did not meet the requirements to involuntarily discharge Resident. Therefore, the discharge [On 1/19/22] in this case is improper and resident shall be permitted to return to Facility. A form of this document titled, Certification of Compliance, indicated, Facility was served the hearing decision on the following date: 2/07/22, yet, the facility failed to comply with this hearing decision on 2/09/22, when Resident 1 returned to the facility (below). Record review of a Health Status Note dated 2/9/22 at 2:38 p.m., indicated, When I[Licensed Nurse writing this note] came to work this AM (Morning) EX-resident [Referring to Resident 1] was sleeping at front door partially blocking entrance with belongings spread out around him. When I informed him that he could not stay there he became upset and abusive. I informed him he needed to leave the property .I informed him that I was going to call the police. I exited the situation and called [Police Department]. [Police Department] later showed up and escorted him off the property. Second hospitalization : During an interview with Resident 1 on 3/09/22 at 1:15 p.m., he confirmed he went back to the facility the night of 2/09/22, and again, facility staff left him outside the building without medications, or food. Resident 1 stated another resident of the facility provided him with some blankets. In the morning of 2/09/22, according to Resident 1, staff called the police on him again, and he decided to call an ambulance. Record review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . This document indicated, He reported he has been compliant with his medications but has missed his doses last night and today due to encounters with law enforcement yesterday and today. He had been panhandling for money to pay for additional days in the hotel but has now run out of money .He slept out doors (Note did not specify what doors) last night. He called EMS (Emergency Medical Services) today to take him to the ER as he didn ' t know what else to do. Record review of an e-mail the Medical Director sent the Administrator on 2/09/22 at 2:46 p.m., indicated, The physicians are very reluctant to re-admit [Resident 1] who was last at our SNF on [DATE] at which time he was admitted to [GACH] .The attending staff agrees that we should not take him back until he has had the benefit of an inpatient admission with full psychiatric evaluation. During a phone interview with the Medical Director on 3/16/22 at 5:13 p.m., he confirmed he made the recommendation not to readmit Resident 1 without a psychological assessment (Performed outside the skilled nursing facility) and in stable condition. The Medical Director stated Resident 1 had an aggressive and disruptive behavior. During an interview with the SSD on 2/10/22 at 3:15 p.m., she stated Resident 1 was not considered discharged from the facility, however, the facility could not accept him back from the street without an assessment. This contradicted her note written on 1/20/22 at 12:34 p.m., which indicated, Since it was an arrest, he [Resident 1] was discharged when the police took him from our facility, we cannot taking him back and Admin, DON, Nursing, entire IDT is aware. During another interview on 2/10/22 at 3:20 p.m., the SSD stated the facility physician would not admit Resident 1 back without been assessed in a GACH. She also stated she could not understand why they lost the appeal since they never truly discharged Resident 1 from the facility. She confirmed Resident 1 was not provided discharge notifications, or documents regarding the discharge. During an interview with Resident 1 on 3/09/22 at 1:20 p.m., Resident 1 stated he spent $1,500 of his money while outside the SNF on hotels and food from 1/24/22 to 2/09/22. He also stated he had lost several items that were left in the SNF upon his initial arrest, including a TV, laptop and prescription eyeglasses. Resident 1 stated he felt neglected, abused and discriminated against. Record review of the facility policy titled, Bed Hold, last revised in July of 2017, indicated, Upon admission, the Facility advises residents and/or their representatives in writing that the Facility has a bed hold policy and will hold the resident ' s bed for up to seven (7) days if the resident is transferred to an acute care hospital or goes on therapeutic leave (Leaving the facility for non-medical reasons) . as long as the resident or his/her representative notifies the Facility within twenty-four (24) hours of the transfer/leave that they wish to have the Facility hold the resident ' s bed. Record review of the facility policy titled, Discharge and Transfer or Residents, last revised in February of 2018, indicated, The resident/resident representative will be provided with Notice of Propose Transfer and Discharge 30 days prior to discharge or as soon as practicable .Upon transfer to the hospital the resident/resident representative will be given an opportunity to execute a Bed Hold .The facility may transfer or discharge a resident with an order from the resident ' s physician for reason A, B, E and F. A. The discharge is necessary for the welfare of the resident, and needs cannot be met in the facility. B The resident ' s health has improved significantly and services provided by the facility are no longer required .E. The resident failed after reasonable and appropriate notice to pay for their stay in the facility .F. The facility ceases to operate.

Based on interview and record review, the facility failed to ensure Licensed Staff identified a fracture for one of three residents (Resident 1), who showed obvious signs of a change in condition. As a result, treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This delay in treatment caused pain and suffering to Resident 1, for weeks. Findings: Resident 1 was initially admitted to the facility on [DATE], according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Set-An assessment tool), dated 5/29/21, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 5, which indicated her cognition was severely impaired. Resident 1's MDS also indicated she required extensive assistance of one staff with transfers, walking in the room, toilet use and personal hygiene. In addition, Resident 1's MDS indicated her medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Nursing Notes from 5/23/21 through 10/06/21, indicated Resident 1 was admitted to the facility on [DATE], and suffered a fall that resulted in fracture of the left radius (Outer of the two bones of the forearm) on 7/03/21. On 7/03/21, as a result of this fall, Resident 1 was transferred to an acute care hospital. On 8/04/21, Resident 1 was readmitted to the facility. During a phone interview with Family Member AA on 11/16/21 at 1:05 p.m., she stated that after Resident 1's hospitalization in July, 2021, Resident 1 was taken home with 24-hour private care, and at the end of July, Resident 1 suffered a fall, for which she received a CT (Computed Tomography-A computerized x-ray imaging procedure) scan of the pelvis (The bones that connect the trunk and the legs). No fractures were noted on that CT scan, and on 8/04/21, she was readmitted to the Skilled Nursing Facility. No other falls or incidents occurred from the time the CT scan was performed to the time she was readmitted to the facility on [DATE], according to Family Member AA. Record review of Resident 1's admission assessment, titled, Admission Data Collection Tool, dated 8/04/21 at 9:46 p.m., documented by Licensed Staff A, indicated, Does the resident have any limitations in Lower Extremity Range of Motion (Movement of the legs and thighs)? Limited bilateral (Limited on both sides). During record review and interview with the Director of Nursing (DON) on 11/10/21 at 2:30 p.m., she was asked if she could find any documentation of limping of the legs, or abnormal rotation (Anatomical variation) of the legs on the admission assessment, dated 8/04/21. The DON confirmed this information was not present in the admission assessment, only that Resident 1 had limited bilateral range of motion in the lower extremities. Record review revealed a Nursing Note written by Licensed Staff A, on 8/12/21 at 5 p.m., which indicated, Resident [Resident 1] became violent, aggressive, delusional, yelling, screaming, Leave me alone, .She was limping on L (Left) leg, I tought (Sic) maybe she fell again. During a concurrent interview and record review with Licensed Staff A on 11/10/21 at 3 p.m., she stated, on 8/12/21, when she wrote the note, it was the first time she saw Resident 1 limping on the left leg, but did not know if she had suffered a fall or what caused the limping to start. Licensed Staff A also confirmed that after this incident, on 8/12/21, Resident 1 stopped walking. Licensed Staff A stated she did not initiate a change of condition for this issue because family had informed her Resident 1 had suffered a fracture a long time ago. When asked if she had notified the physician about it, Licensed Staff A stated she should have, and she was unable to provide any evidence of it [notification]. The DON was present during this interview. During an interview with the DON on 11/10/21 at 3:10 p.m., she stated an observation of limping of the left leg for the first time on a resident, warranted a change of condition. The DON was asked to provide all documentation of changes of condition for Resident 1 during her stay at the facility, on 11/10/21 at 3:12 p.m. The DON provided all documentation on changes of condition, as requested, but none included information related to limping, pain or abnormal rotation of the left leg. During a phone interview with Family Member BB on 10/29/21 at 12:41 p.m., she stated she visited Resident 1 at the facility sometime during her second admission to the facility and noticed her left leg was, crooked, as it did not seem to be straight up like the other leg was. Family member 1 stated she was not a clinician herself, but was concerned about it, and more so because Resident 1 complained of pain on that leg. During an interview with Family Member CC on 11/05/21 at 10:45 a.m., she stated she visited Resident 1 on 10/06/21, and noticed her leg was, crooked, as well. Family Member CC also stated Resident 1 had complained of pain to her left leg for weeks. During an interview with Resident 2, Resident 1's roommate, on 11/24/21 at 11:30 a.m., she stated Resident 1 used to scream stating her left leg hurt a lot. When asked how often this happened, Resident 2 stated this would happen daily for a few weeks, when she was being changed by staff. Record review of Resident 1's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Yet, an Occupational Therapy note, dated 9/13/21 (no time documented), indicated, Pain intensity = 4/10 (Four of ten level possible, which stands for moderate pain); Frequency = Intermittent; Location: Low back, BLE (Bilateral Lower Extremities-thighs/legs). Record review of an e-mail sent by Family Member DD on 10/23/21 at 8:01 a.m., indicated, sometime between june july through sept something happened to my aunts [Resident 1's] hip as my sister (Family Member BB) noticed my aunts ankle was looking funny we found out my cousin [Family Member AA] had asked multiple times as to why she is not walking what was wrong with her leg and her pain in her leg they told her by nursing personal that everything was fine .I made an appointment with her orthopedist for weds oct (October) 6 to check her leg when i went to the facility [Skilled Nursing Facility] she [Resident 1] was sitting in a wheelchair .she was in pain in her left leg and appeared weak .her left leg exhibited a left external rotation she could not stand .I immediately took her to see [Orthopedist] .she had a hip fx (Fracture). Another e-mail sent by Family Member DD on 11/10/21 at 12:13 p.m., indicated Resident 1 did not suffer any falls or incidents from the time she was picked up from the Skilled Nursing Facility to the time she was evaluated by her Orthopedist (who discovered the fracture) on 10/06/21. This was corroborated by Family Member CC during a phone interview on 11/05/21 at 10:45 a.m. Family Member CC was present with Resident 1 during her visit to the Orthopedist on 10/06/21. Record review of the results of an X-ray taken of Resident 1's pelvis on 10/06/21 (ordered by Resident 1's Orthopedist), indicated, Displaced (Moved from its proper or usual place) left femoral neck subcapital (Fracture that occurs in the neck of the thigh bone) fracture .This is age-indeterminate but was not present on CT pelvis 2.5 months ago. The CT of the pelvis performed 2.5 months ago, as indicated in this document, was performed on 7/31/21, as indicated by Family Member AA during a phone interview on 11/16/21 at 1:05 p.m. Record review of an operative report for the femur fracture, dated 10/09/21 at 1:08 p.m., indicated, The patient is an 85 y.o. (year old) female with mechanical left hip pain inability to walk is taking on referral to the OR (Operating room) confirmed a displaced subcapital hip fracture with [CONDITION(S)] (Abnormal hardening of body tissue) in the head indicating avascular necrosis (Death of bone tissue due to lack of blood supply) indicating an older fracture. Preoperative physical examination .indicated shortened leg externally rotated (Rotation away from the center of the body) and pain with any range of motion (Movement). During an interview with the DON on 11/10/21 at 2:45 p.m., she stated Licensed Nurses were only required to do a head-to-toe assessment on the residents weekly, for the weekly summary assessments. Record review of the facility RN job description, undated, indicated, Conducts daily resident rounds to assess and evaluate the resident's physical, medical and emotional status and to implement or revise nursing interventions to the resident plan of care. Records care information accurately, timely and concisely. Record review of the facility LVN job description, undated, indicated, Conducts daily resident rounds to observe the resident's physical and emotional status .Records care information accurately, timely and concisely. Record review of the facility policy titled, Change of Condition Notification, last revised on 4/01/15, indicated, The Facility will promptly inform the resident, consult with the resident's Attending Physician .when the resident endures a significant change in their condition caused by, but not limited to: A significant change in the resident's physical, mental or psychosocial status .Change of Condition related to Attending Physician notification is defined as when the Attending Physician must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the Attending Physician and a change in the treatment plan.

Based on interviews and record reviews, the facility failed to ensure one out of three sampled residents, Resident 1, was free form neglect (neglect means the failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), when the facility failed follow its policy and procedure on laboratory services, after a telephone order on 7/29/2020, and a written order on 8/3/2020, for Resident 1's diagnostic tests, which were not implemented as ordered by the physicians. These failures resulted in physical harm to Resident 1 after she was sent to a hospital emergency room (ER) on 7/31/2020, and was later admitted and diagnosed with [REDACTED]. Resident 1 was discharged back to the facility on [DATE], with written orders to monitor her Complete Blood Count (CBC- test gives an overall view of general health by measuring the health of red blood cells, white blood cells, and platelets) starting on 8/4/2020, but this was not implemented as ordered. Resident 1 was sent to the ER due to Cyanosis (Cyanosis is a bluish color to the skin or mucous membrane that is usually due to a lack of oxygen in the blood) on 8/6/2020, and was admitted to the hospital. Findings: During a review of Resident 1's, Face Sheet, dated 8/24/2020, at 12:37 p.m., the Face Sheet indicated Resident 1 had multiple medical [DIAGNOSES REDACTED]. The Face Sheet indicated Resident 1 was a long-term resident of this Skilled Nursing Facility (SNF- A skilled nursing facility is an in-patient rehabilitation and medical treatment center staffed with trained medical professionals). During a review of Resident 1's, Physician Orders for Life Sustaining Treatment (POLST), dated 8/3/2020, the POLST indicated Resident 1 had the capacity and signed for herself as her own decision maker. During a review of Resident 1's, Physician and Telephone Orders, dated 7/29/2020, the Physician and Telephone Orders indicated Physician A, Resident 1's primary physician, gave a telephone order to Licensed Staff B for diagnostic blood tests for Complete Blood Count, Chem-14 (A Chem 14 blood test, also called a comprehensive metabolic panel, is a group of 14 tests used to check organ function and monitor certain health conditions), [MEDICAL CONDITION] Stimulating Hormone (TSH- A TSH test is done to find out if your [MEDICAL CONDITION] is working the way it should. It can tell you if it is overactive ([MEDICAL CONDITION]) or underactive ([MEDICAL CONDITION]), Free [MEDICATION NAME] (FT4- can assist in determining whether the [MEDICAL CONDITION] is performing properly), and Brain Natriuretic Peptide (BNP levels help your doctor figure out if you have heart failure or something else that has similar symptoms, such as shortness of breath. The test also shows if your heart failure has worsened). During a review of Resident 1's, Care Plan, dated, 7/29/2020, the Care Plan indicated Resident 1 had a change of condition as manifested by shortness of breath when standing and ambulating (to walk about or move from place to place). During an interview on 8/27/2020, at 2 p.m., Licensed Staff B stated, on 7/29/2020, at approximately 6 p.m., she received a telephone order from Physician A. Licensed Staff B explained how nurses were supposed to process telephone orders given by physicians. Licensed Staff B stated the nurse who received the order would fill out a lab request form and place the completed form on a labs' monitoring log. Licensed Staff B stated the lab technician from their contracted laboratory, would use that log to verify which residents had requests for blood tests. Licensed Staff B was asked to produce the lab monitoring log to check if she had a written the lab order for Resident 1. Licensed Staff B stated she could not find it or produce evidence that she had filled out a lab request form for Resident 1. Licensed Staff B stated there were no results found for the blood tests ordered for Resident 1 on 7/29/2020. During a review of Resident 1's, Progress Notes, authored by Administrative Staff C on 7/31/20, at 3:03 p.m., the Progress Note indicated, .Family visited resident (Resident 1) through the window yesterday .Family called the MD (Physician A) and requested resident (Resident 1) to be transferred to the ER (emergency room ) . Resident (Resident 1) was sent out to the ER today at 12:15 p.m. During a review of Resident 1's, Progress Notes, authored by Licensed Staff D on 7/31/2020, at 9:15 p.m., the Progress Note indicated Resident 1 was extremely anemic and needed a transfusion and was going to be admitted at the acute care hospital. During a review of Resident 1's, Discharge Summary, dated 8/3/2020, at 8:48 a.m., the Discharge Summary from a hospital physician indicated, Resident 1 was sent from SNF with fatigue (fatigue is a term used to describe an overall feeling of tiredness or lack of energy) and found to be anemic (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues). Resident 1's hemoglobin (hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon [MEDICATION NAME] from the tissues back to the lungs) was five (5 g/dl-grams per deciliter). Resident 1 was given blood transfusion with three (3) units of Packed Red Blood Cells (PRBC- Packed red blood cells are typically given in situations where the patient has either lost a large amount of blood or has [MEDICAL CONDITION] causing notable symptoms). Resident 1, who was alert and oriented times three (A & O x 3- Clinical shorthand for the findings in a physical examination of the patient by a healthcare worker, referring to a patient who is responsive to his or her environment (alert), and knows who he or she is, where he or she is, and the approximate time), preferred to go home (back to the SNF) to continue conservative management. Resident 1 would have her CBC and VS (Vital signs are the evidence of the current physical functioning of the body) monitored at the SNF. During a review of the facility's contracted lab service's reference range for Hemoglobin, it indicated the normal hemoglobin range was 11.2 g/dl to 15.7 g/dl. During a review of Resident 1's, Physician Orders, dated 8/3/2020, the Physician Orders indicated, CBC twice a week starting on 8/4/2020 x (times) two weeks Discontinue date: 8/31/2020. The Physician's Orders did not indicate the specific dates when the succeeding CBC blood draws were scheduled. During a concurrent interview and record review on 8/27/2020, at 3:45 p.m., Licensed Staff B was asked to look at Resident 1's medical record to check and see if there was a result for the CBC ordered for 8/4/2020, under the tab, Laboratory Results. Licensed Staff B searched for Resident 1's lab results for 8/4/2020, and stated there was no result on the chart. During a concurrent interview and record review on 8/27/2020, at 3:55 p.m., the Director of Nursing (DON) also was not able to find the result for the CBC which was supposed to be done for Resident 1 on 8/4/2020. In an earlier facility visit on 8/24/2020, at 12:22 p.m., the DON provided a lab result for Resident 1 from their contracted laboratory, but the date of specimen collection was 8/6/2020, at 4:11 p.m., and not for 8/4/2020. During a review of Resident 1's, Licensed Nurse Progress Notes, dated 8/6/2020, at 5 p.m., the Licensed Nurse Progress Note, authored by Licensed staff B, indicated, Resident 1's O2 sat was 67% . (Oxygen saturation is the fraction of oxygen-saturated hemoglobin relative to total hemoglobin (unsaturated + saturated) in the blood. The human body requires and regulates a very precise and specific balance of oxygen in the blood. Normal arterial blood oxygen saturation levels in humans are 95-100 percent). Res (Resident 1) was sent to the acute hospital ER via ambulance. During a review of Resident 1's, Progress Notes, dated, 8/6/2020, at 5:43 p.m., authored by Physician A, the Progress Notes indicated this note was a SNF Rounding Note and Discharge Note for hospital transfer .Cyanosis (Cyanosis is a bluish color to the skin or mucous membrane usually due to a lack of oxygen in the blood) .Patient (Resident 1) now wants to go to the hospital for further work up and treatment if needed. Labs (complete blood count (CBC), chemistry, BNP) ordered yesterday but it was not drawn at facility until this afternoon when patient had a change of condition. Results are pending. During an interview on 9/23/2020, at 9:35 a.m., Physician A stated that she expected her written and telephone orders were implemented by the facility's nursing staff and results communicated to her in a timely manner. During an interview on 9/29/2020, at 3:57 p.m., the DON stated the facility licensed nursing staff did not do blood draws for residents in this facility. When the DON was asked what happened if the lab order did not fall on the days the contracted laboratory did the specimen collection, the DON stated, if it was a STAT (immediately or within a limited time frame), the facility would call the company that provides laboratory services and have the specimen collected, even if it was not their scheduled lab specimen collection day. The DON stated, if the order was not STAT, it would be scheduled for the next scheduled lab day, and the physician would be notified that it was not done. The DON stated there was no assigned staff to oversee if the lab orders were being implemented, and each nurse was responsible to communicate lab orders in their 24-hour daily shift report communication tool. When the DON was asked if Resident 1's CBC order, dated 8/4/2020, was not done because it was not a scheduled lab collection day for the facility's contracted laboratory service, but the following day, 8/5/2020, where the specimen would have been collected because it was a scheduled lab specimen collection day, the DON stated that was their process, but acknowledged that there was no result found on the CBC order for Resident 1 on 8/4/2020, or 8/5/2020. During a concurrent interview and record review on 10/1/2020, at 3:40 p.m., Licensed Staff E acknowledged he worked on 8/4/2020, from 3 p.m. to 11 p.m. Licensed Staff E was asked look at the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Licensed Staff E stated, when he got lab orders from physicians, he would manually place a box on the date of collection on the MAR, to make sure that it got done on the specific date it was ordered for. When Licensed Staff E was asked if that was the practice of the nursing staff, he stated, No. Licensed Staff E acknowledged that if he had overlooked the order, it was also not communicated to the ordering physician that it was not done. Licensed Staff E verified that only lab technicians from the facility's contracted lab services performed blood draws for their residents. During a review of Resident 1's, Progress Notes, dated 8/4/2020 to 8/6/2020, the Progress Notes indicated there was no documentation written by the nursing staff informing Resident 1's physician that the CBC order was not implemented or any documented reasons why the CBC blood draw was not done as ordered. During an interview on 10/2/2020, at 1:25 p.m., Laboratory Staff F stated 8/4/2020, was not a scheduled lab collection day for the facility. Laboratory Staff F stated, if the facility would like to have laboratory services for that day, the facility must request the lab for a STAT order. Laboratory Staff F verified there was no STAT order requested for Resident 1 on 8/4/2020. During a review of the facility's policy and procedure (P&P) titled, Laboratory Services, dated 1/1/2012, sent to the California Department of Public Health (CDPH) via faxed message, from the facility, on 9/25/2020, it indicated the purpose of this document was to, Ensure the provision of laboratory services as required for residents at the facility .the policy indicated, The facility will provide laboratory services in an accurate and timely manner to meet the needs of the residents per Attending Physicians orders .Nursing Staff may utilize NP 70 Form A (Labs Monitoring Log) to monitor lab results and communicate across shifts.The procedure for documentation indicated: A). The order for the lab and the results will be maintained in the resident's medical record B). Labs ordered will be logged to ensure results are received and communicated timely.

Based on observation, interview and record review, the facility failed to ensure residents' environment remained as free of accident hazards as possible, when it failed to provide adequate supervision to prevent accidents, resulting in numerous resident injuries and one resident death: 1. Residents were allowed to leave the facility, on pass (go out into the community) without assistance and without assessment to determine if they would be safe while out of the facility (Residents 23, and 25). 2. Residents were able to leave the facility without supervision and without staff knowledge (Residents 9, 19 and 20). The facility could not provide documentation of any investigation to determine factors which allowed the residents to leave the facility undetected, in order to develop interventions to correct the situation; 3. The facility was unable to provide documentation to ensure the Wanderguard Alert System (an alarm sounds notifying staff when a resident opens a door to the outside of the building) was always functional; 4. Residents experienced multiple falls (Residents 5 and 9), some of which resulted in injury; and, 5. Residents were allowed to smoke in an outside area without staff attendance and not in direct sight (Resident 22). Findings: References used frequently in this tag include: WANDERGUARD: A device on doors of the facility which alarms when a resident, wearing an alert armband, comes close to, or exits through, the door. BIMS: (Brief Interview to determine Mental Status) with scores from ,[DATE]. A score of ,[DATE] indicates severe cognitive issues and ,[DATE] indicates moderate impairment. SBAR: Facility Communication Form - Situation, Background, Assessment, Recommendation (A form completed by the facility to address unusual incidents to determine ways to resolve a problem; used to facilitate prompt and appropriate communication). CODE GREEN: A system to assist in locating a missing resident (per the Director of Nurses). During an interview with the Director of Nursing (DON) on [DATE] at 3:15 p.m., he stated, when a resident is discovered to be missing, all areas of the facility are notified, and the facility is searched. If resident is not located, a staff person or two, will drive the areas where residents are known to wander. If the resident is not located, the facility will be notified and directed to call the Police. He stated the initial search would take 15 to 30 minutes. He stated 30 minutes would be reasonable to notify the police. DON: Director of Nursing. 1. On Pass Leaves: a. The Department received a Facility-Reported Incident (FRI) notification on [DATE], Resident 23 signed-out on pass on [DATE], to go to the Post Office. The Post Office was .6 miles from the facility. The sign-out/in sheet indicated Resident 23 left the facility at 12:45 p.m., and was expected back by 2 p.m. Resident 23 was subsequently found, deceased , by the Police at 8 p.m. An Investigation Report submitted by the facility indicated Resident 23 had gone out on pass, a couple of times. The Admission Record indicated Resident 23 was readmitted to the facility from an acute care hospital on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Assessment, completed on [DATE], assessed Resident 23 with impaired vision. On [DATE], a physician's orders [REDACTED]. The assessment did not reflect a cognitive problem but, a Behavior Management Committee Review documented Resident 23 smeared fecal material on himself and bed linen after using the bedpan. This review also documented a history of chronic mental illness. The Medication Administration Record [REDACTED]. Resident 23 had a care plan, dated [DATE], which identified a problem as, at risk for falls, related to poor vision and his independence in transfer, despite explanation of risks. The goal was to provide a safe environment. The use of a front-wheel walker was identified as an approach. The plan did not address going out on pass. The policy, Out On Pass, provided by the facility (No number, revised on [DATE]), indicated: l: .The Attending Physician will write or give an order . on the physician's orders [REDACTED]. ii: In the absence of a specific order which indicates the resident may go out on pass unaccompanied, the resident must be accompanied by a responsible person. iii: If the resident is receiving skilled service, the resident may leave for therapeutic purpose only and the reason and benefit must be documented. ii: If there is a significant change in the resident's condition, the staff will notify the physician and, A: Until the Attending Physician is able to reassess the resident, the Out On Pass order will be discontinued. The policy V., also included: Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status. Review of the physician's orders [REDACTED]. During an interview with the Director of Nurses (DON) on [DATE], he was asked if an order, which read, May go to (hypothetical location) for four hours, was understood to be a one-time order? He responded, yes (meaning this order was good for one pass out of the facility; the Physician would need to write additional orders for Resident 23 to leave the facility subsequent times). During a telephone interview with Physician A on [DATE] at 5:30 p.m., he responded it would be a one-time order. The order did not specify if Resident 23 needed to be accompanied. The physician's orders [REDACTED]. The order did not indicate a therapeutic reason for the pass. No evidence was presented the physician was asked to reassess Resident 23 after an order was written, on [DATE], documenting Resident 23 was, Legally Blind. Review of an interview by the Sheriff-Coroner, done on [DATE], included a statement by Licensed Nurse B (the nurse on duty on [DATE]) indicating she was advised of Resident 23's absence at the start of her shift, but waited several hours to report, because she thought he might return. He returned late on previous occasions. The report also reflected she knew his vision was not very good, and his hearing was impaired. She stated, in November, Resident 23 went to a convenience store, a place he often visited. The store called the facility, facility staff went to pick him up because he could not remember how to get home. When she was asked if there were other incidents when he could not remember how to get home, she said there were a few others, but she could not recall the dates. During record review, the Licensed Nurses' Notes did not reflect any information regarding any incidents in November, nor did the sign-in/out sheet reflect times when Resident 23 returned. Licensed Nurse B stated, during a telephone interview on [DATE], there was a time, in November, when Resident 23 was not able to find his way back to the facility, and staff had to go and get him. When asked if anyone else in the facility was aware of the incident, when Resident 23 could not find his way home, she stated, Of course. During a telephone interview with Licensed Nurse B, on [DATE] at 4:50 p.m., she confirmed the information she provided in the interview on [DATE]. She stated Resident 23 did not forget how to return, he just could not find the way. She stated she did not know if the facility had done an SBAR Communication. The facility was asked, on [DATE], [DATE], [DATE] and [DATE], for documentation of an assessment of Resident 23, prior to him leaving on pass. None was provided. During a telephone interview on [DATE], Licensed Nurse C stated an assessment was not done each time (a resident left the faciity on pass) and was done based on the resident's capacity and the physician's orders [REDACTED]. The documentation did not indicate any level of supervision during these outings. On only one occasion was his return to the facility documented. Record review confirmed there were no nurses' signatures documented, to indicate the nurses assessed Resident 23 prior to his leaving the facility, nor on his return. On [DATE] at 3 p.m., the DON stated the Licensed Nurse was responsible to verify if a resident returned to the facility when expected. During an interview with the DON on [DATE] at 3:15 p.m., he stated, when a resident was discovered to be missing, all areas of the facility were notified, and the facility was searched. If a resident was not located, a staff person or two, would drive the areas where residents were known to wander. If the resident was not located, the facility would be notified and directed to call the Police. He stated the initial search would take 15 to 30 minutes. He stated 30 minutes would be reasonable to notify the police. According to Nurses' Notes, the Police were not notified until 10:20 p.m., of Resident 23's missing status. Review of the Licensed Nurses' documentation, regarding Resident 23's absence from the facility, reflected: [DATE], 10:20 p.m., Resident went out on pass at 12 p.m., to go to the Post Office, but until now, 10:20 p.m., he is not back yet. Unable to reach his sister. Call to Police to report missing resident. A note, dated [DATE], 10:45 p.m., late entry for [DATE]: Resident went out on pass at 12:45 p.m., and signed 2 p.m., would be the time of return. Called sister's and resident's numbers at 4 p.m., but could not reach. Talked to other residents at 8 p.m., to see if they had seen him, but no one had. Documentation indicated the Police were not notified until 10:20 p.m. The time of death was documented as 8 p.m. Resident 23 was allowed to leave the facility, without a responsible person to accompany him. He did not have an appropriate order by a physician, as indicated in the facility policy. The facility did not provide any documentation Resident 23 was assessed for safety to go on a pass without a responsible party to accompany him. Resident 23 was identified as legally blind, required a walker, related to his risk of falls, was at risk of high/low blood sugar, related to his refusal of testing and had previously not been able to find his way to return to the facility. The failure to assess Resident 23 for safety resulted in Resident 23, being alone and unsupervised for hours after it became dark. The facility failed to notify Police for greater than eight (8) hours after Resident 23 was expected back. The failure of the facility to involve the Police to search for Resident 23, contributed to Resident 23 not being located prior to his traveling, in the opposite direction from the facility, and wandering onto the railroad track, where he was fatally struck by a train at 8 p.m. on [DATE]. b. During record review, Resident 25 had a physician's orders [REDACTED]. The sign-out/in sheets, dated [DATE]-[DATE], failed to document there was a Responsible Party accompanying Resident 25 on these outings. An Interdisciplinary Team Summary, on [DATE], documented Resident 25 experienced an unwitnessed fall, with an abrasion on his arm, on [DATE], while he was out of the facility, and he was picked up by the Police. During an interview on [DATE], Resident 25 stated he went out of the facility when he wanted to (regardless of whether there were physician's orders [REDACTED]. c. During a telephone interview, on [DATE], LN C stated there was no documentation of an assessment of the residents when they left the faciity on pass, to verify they would be safe outside the facility. LN C stated staff relied on the physician's orders [REDACTED]. The Pass Policy ([DATE]) indicated the following: Prior to leaving the facility on a pass, the LN Licensed Nurse) will assess the resident's physical and mental status. 2. Elopements: Review of Residents 9, 19, and 20's Clinical Records and Investigative Reports, indicated these residents were able to leave the facility without supervision and without staff knowledge. In addition, the facility was unable to provide documentation of any investigation to determine factors which allowed these residents to leave the facility undetected, in order to develop interventions to correct this situation. a. A review of Licensed Nurse Progress Notes, dated [DATE] at 2:20 p.m., documented Resident 20 was seen wandering outside the facility. When staff asked her why she was outside, Resident 20 responded she wanted to go home. According to physician's orders [REDACTED]. During an interview on [DATE] at 12 p.m., Staff L stated a resident reported a, little girl, was outside the facility on [DATE]. Staff L stated she went out the front door to the top of the steps and saw Resident 20 across the street at the stop sign with her walker. Staff L stated she recognized Resident 20 and returned to the lobby area. She stated, since she knew the resident she called the resident's unit to report the resident was outside. She stated she did not go after Resident 20, but notified her unit to initiate the search. She thought she may have told someone in the lobby area about seeing Resident 20, but she could not recall which staff. On [DATE], Resident 20 was found by the Police in a school across the street from the facility. In an interview at 1:05 p.m. on [DATE], Licensed Staff H stated Staff L should have gone after Resident 20 since she knew Resident 20 belonged at the facility. Staff H said staff could have used her cell phone to seek assistance (they all have cell phones), while trying to secure the resident. Review of the facility's investigation, dated [DATE], indicated there was no documentation Resident 20 had a Wanderguard in place at the time of the elopement, nor an assessment of how elderly Resident 20 eloped from the facility with an alarm in place. On [DATE] at 1:30 p.m., Staff M was asked about Resident 20's Wanderguard. Staff M stated he could not determine (if Resident 20 was wearing her Wanderguard) why the Wanderguard failed to alarm. b. The Department received a Facility-Reported Incident notification, on [DATE], Resident 19 left the facility without notifying staff. Resident 19 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His BIMS score was 6, which indicated severe cognitive impairment. Elopement Risk Assessments on [DATE] and [DATE], documented an, 8, which indicated Resident 19 was at risk. Resident 19 also was assessed as at risk of falls. The care plan [DATE], for Risk of Elopement, documented an intervention of a Wanderguard. There was no documentation indicating Resident 19 was wearing the Wanderguard during this time. During an interview on [DATE] at 11:50 a.m., the DON stated Resident 19 just walked out; he was not wearing the Wanderguard. The Investigative Report, submitted by the facility, indicated, on [DATE] at 10:30 a.m., Resident 19 was noted to be absent from the facility. The DON called a Code Green. After Resident 19 was not located in the building, staff searched the adjacent store, which they identified as the place the residents usually go. Safeway was approximately .8 miles from the facility. The Police were not notified until 12 p.m., 1-½ hours after Resident 19 was noted to be missing. At 4:30 p.m., the Police notified the facility Resident 19 was found on a street, 1.5 miles from the facility. Failure to timely notify the Police, potentially resulted in Resident 19 being unsupervised and at risk for a longer time than was otherwise necessary. c. During review of Resident 9's medical record on [DATE], it noted she left the facility, without staff knowledge, on [DATE] (after 11 p.m.). The Social Service Note, of [DATE], documented she was found by the Police and returned to the facility. The SBAR documented Resident 9 was seen in the smoking area (outside of the facility) at 11 p.m. to 11:15 p.m. She was returned to the facility by the Police at 11:45 p.m. Staff was not aware she left the facility. During record review, the Investigation Reports of elopements for Residents 9, 19 and 20, did not include an investigation of how these residents left the facility, undetected. The documentation of this information was requested on [DATE], [DATE] at 11:50 a.m., and [DATE], [DATE], [DATE], and [DATE]. The DON was able to state how these residents were able to leave, but no documentation was produced to indicate what actions were taken to prevent future incidents. On [DATE], during a follow-up telephone interview, Licensed Staff C stated no documentation had been found. 3. Wanderguard Alert System Failure: a. During observations on [DATE], [DATE] and [DATE], between the hours of 10 a.m. and 4 p.m., the front door alarm was intermittently malfunctioning. During an interview, on [DATE] at 3:05 p.m., Staff M stated the front door alarm was not functioning correctly, and he was working on it. During interview, on [DATE] at 3:05 p.m., the DON stated all the doors were alarmed. The DON stated the back door alarm was sometimes off to allow the, smokers, access to the smoking area. The DON stated, even when the alarm was functioning, a person could exit the building and not trigger the alarm, if very quick. On [DATE] at 1:35 p.m., there were four random residents present in the smoking area. The residents stated they saw other residents come and go through the back door. On [DATE] at 1:40 p.m., the door was opened and closed several times without the alarm sounding. During interview, on [DATE] at 1:40 p.m., Staff M stated he turned off the alarm so the smokers could exit and re-enter without sounding the alarm. Staff M acknowledged the alarm system had intermittently malfunctioned since the power outage and generator loss in late [DATE]. Staff M stated parts were ordered. On [DATE] at 2:30 p.m., the DON was questioned regarding alarms on all exits. His response was the doors at the front of the building (Stations 1 and 3) had alarms indicating when they were opened. The DON stated the exit doors on Station 1 went into an enclosed area. At this time the gate exiting the enclosed area was unlocked. In the presence of the DON, a Licensed Nurse on Station 3 was asked how staff would know if the person opening the door was safe to exit the facility alone, she could not reply. When asked about a book or list of residents with the identified wandering behaviors, the Licensed Nurse stated she was not aware. The DON retrieved the book from a shelf at the back of the Nurses Station. 4. Residents With Falls: a. Observation on [DATE] at 10 a.m. and at 11:30 a.m., revealed Resident 5 was up walking with a four-wheeled walker, independently. During interview, on [DATE] at 3:55 p.m., Licensed Staff C stated Resident 5 ambulated throughout the facility, independently, with her walker. Review of Resident 5's medical record revealed this resident, who had sustained a prior [MEDICAL CONDITION] in the facility, had the following falls documented in her record: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. According to Resident 5's medical record, after a witnessed [DATE], fall, with no injuries, the Interdisciplinary Team Conference Notes, dated [DATE], indicated Resident 5 lost her balance and fell . The Interdisciplinary Team Conference Notes also recorded Resident 5 fell again in the dining room the evening of [DATE]. A short-term care plan was developed indicating the goal was to, have less falls. The approach to accomplish this goal was to, keep clear hallways/rooms of equipment or supplies, in addition to performing vital sign checks and monitoring Resident 5's whereabouts. No additional interventions were listed to ensure Resident 5's safety. Further record review indicated, on [DATE], Resident 5 had an unwitnessed fall. A short-term care plan indicated Resident 5 was at risk for falls, with a score of 11 (a score of ten or greater indicated the resident was at high risk for falls). The Care Plan listed the goal as: Resident 5 would not complain of pain/discomfort related to the fall. The approaches to accomplish the goal included pain assessment, monitoring vital signs, notification of responsible parties (DON, MD) and neurological checks. There was no reference to preventing further falls, such as safety measures instituted prior to subsequent falls (e.g. increased monitoring, supervision). On [DATE], Resident 5 had an unwitnessed fall in the hallway. A [DATE], Fall Risk Evaluation care plan, dated [DATE], had a goal for Resident 5 to have less or no episodes of falls for 72 hours. The approaches for achieving this goal were: Vital signs every shift, neurological checks, monitoring for pain/discomfort, clear hallways, and hourly rounds. These approaches were to be re-evaluated the same date as the original care plan's implementation, of [DATE]. The [DATE], Physical Therapy Evaluation indicated Resident 5 had decreased lower leg strength, decreased safety awareness, cognitive deficits, and impaired standing balance. There was no reference to preventing further falls, such as safety measures instituted prior to subsequent falls (e.g. increased monitoring, supervision). Resident 5 had three subsequent falls, and received Physical Therapy: An unwitnessed fall on [DATE], an unwitnessed fall on [DATE], and an unwitnessed fall on [DATE]. The goal for the [DATE] fall was: will have less or no episodes of fall within 72 hours. The approaches were the same as [DATE], except that a urinalysis was added, and staff were to, encourage assistant with ambulation. How staff were to encourage assistance was not specified in the care plan. According to her medical record, Resident 5's [DATE], fall appeared to be related to her picking paper up from the floor and losing her balance, and the [DATE], unwitnessed fall resulted in her fracturing her left hip. There was no reference to preventing further falls, such as safety measures instituted prior to subsequent falls (e.g. increased monitoring, supervision). A review of Physical Therapy Notes, with Therapist R on [DATE] at 11:45 a.m., indicated the therapy department determined Resident 5 required a wheelchair for locomotion, as of [DATE]. The note indicated caregivers and Resident 5 were provided instruction related to the use of the wheelchair. A review of the License Nurse Progress Notes indicated, on [DATE] and [DATE], Resident 5 was self-propelling around the facility in a wheelchair. A [DATE], Physical Therapist's Note documented caregiver and resident training related to wheelchair use and an observation Resident 5 was appropriately and safely self-propelling the wheelchair with her upper and lower extremities. Review of Resident 5's License Nurse Progress Notes, dated [DATE] at 11 a.m., indicated Resident 5 was able to, walk independently (with) walker but visual supervision observed. A 12 p.m., entry, documented Resident 5 was, found, by the kitchen door, out of the line of site of the unit station, with her front-wheeled walker. In an telephone interview on [DATE] at 4:55 p.m., Licensed Staff V stated, someone, called the unit and told her a resident had fallen. Licensed Nurse V stated she and a Certified Nurse Assistant went down to the kitchen area and found Resident 5 sitting in her walker seat. She stated she did not know who found Resident 5 or how Resident 5 became seated in the walker. Upon moving Resident 5 to her bed, she complained of left pelvic pain. Licensed Nurse V stated she notified the Physician and an X-ray was done. Resident 5 was sent to the acute care hospital for surgical repair of her left [MEDICAL CONDITION] with displacement. In a telephone interview with License Staff C on [DATE] at 11:15 a.m., about the cause of the fall, Licensed Staff C stated Resident 5 had very poor safety awareness, was probably upset about current restrictions to the dining room, and was struggling with a cup of coffee at the time of the fall. She said the team considered a coffee holder to her walker as an intervention. A review of the care plan indicated the intervention of, coffee holder, was added to the [DATE], Fall care plan. There was no reference to preventing further falls, such as safety measures instituted prior to subsequent falls (e.g. increased monitoring, supervision). In a subsequent interview with Licensed Staff C on [DATE] at 3:45 p.m., she stated she re-interviewed staff involved in the incident, and she was unable to determine who found Resident 5 at the kitchen door or who had moved her into the wheeled walker. Licensed Staff C stated she believed Resident 5 may have placed herself on the walker seat. Licensed Staff C stated all staff, including kitchen staff, knew not to move a resident until the resident was thoroughly assessed. When asked who did the initial investigation of the incident, Licensed Staff C stated the Assistant Director of Nursing (ADON) had done an investigation but the Investigative Report was not correct. Licensed Staff C did not provide the investigation for review. On [DATE] at 11:45 a.m., Therapist R stated staff had been given instruction to use the wheelchair because Resident 5 was not considered to be safe in the front-wheel walker. Therapist R stated Resident 5 had poor safety awareness and, if she were to use a walker, she would require supervision. On [DATE] at 3:45 p.m., Licensed Staff C stated she did not know why there was no revision to the care plan identifying Resident 5 now required a wheelchair or supervision, while using a walker. She stated the change of status to Resident 5's method of locomotion should be on the care plan, and perhaps on the change of shift reports, or a 24-hour report (Reports notifying all staff of significant change). As of [DATE], the requested shift reports were not provided. b. Resident 9's Clinical Record reflected she had experienced at least two (2) falls. Licensed Nurses' Notes of [DATE], indicated Resident 9 stated she slipped, fell and hit her head when she was getting out of bed. Redness and swelling was noted at the left side of her eye. The care plan, dated [DATE], indicated a witnessed fall resulting in an abrasion/pain of her left hand. No new interventions to prevent falls were identified. c. Resident 25 had a physician's orders [REDACTED]. The sign-out/in sheets, dated [DATE]-[DATE], failed to document Resident 25's Responsible Party, on all outings. An Interdisciplinary Team Summary, on [DATE], documented Resident 25 experienced an unwitnessed fall, with an abrasion on his arm, on [DATE], while he was out of the facility. He stated he was picked up by the Police. The sign-out/in sheet did not indicate Resident 25 was out of the facility on that date. During an interview on [DATE], Resident 25 stated he went out of the facility when he wanted to and was not sure of the dates or the date when it (the fall) happened. 5. Smoking: Observation on [DATE] at 4 p.m. revealed four residents in the smoking area behind the facility, with no staff supervision. On [DATE] at 10:40 a.m., observation revealed one resident smoking, with no staff present in the smoking area. On [DATE] at 1:35 p.m., there were four residents present in the smoking area with two residents smoking and no staff supervision. One resident stated there was a staff person who smoked, who came out with the smokers during the week, but there was never anyone on the weekends. The other three residents nodded in agreement. Record review indicated Resident 22, with [DIAGNOSES REDACTED]. Review of a Social Service Note, dated [DATE], documented, Resident has [MEDICAL CONDITION] in the smoking area constantly, which is prevalent to his smoking. Licensed Nurse T stated, on [DATE] at 1:09 p.m., Resident 22 did go out and smoke, and sometimes a Certified Nurse Assistant would go out with him. Resident 22 stated, on [DATE] at 1:30 p.m., he did smoke, and he had [MEDICAL CONDITION] severe enough he did not recall having them. He stated he may only realize he had a [MEDICAL CONDITION], when he awoke and everything around him was, messed up. Resident 22 was not sure, but he thought there was not always a staff person present to supervise his smoking, but he wanted to continue to smoke. Review of Resident 22's Smoking Assessment, dated [DATE], indicated he was independent in smoking but needed supervision in accordance with the smoking policy. Resident 22's care plan, dated [DATE], noted he had, [MEDICAL CONDITION] during smoking hours, and monitoring was required. The facility's Smoking Policy, dated [DATE], documented, residents who require assistance and/or monitoring for smoking safety are not allowed to smoke unaccompanied.