Every finding on record at Ocean Park Healthcare

Based on observation, interview, and record review, the facility failed to ensure the food handling practices and proper sanitation were maintained in the kitchen according to the facility's policies and procedures (P&P) titled, Refrigerators and Freezers, with a review date of 5/2026, Sanitization, reviewed on 5/2026, and, Food Preparation and Service, reviewed on 3/2026, when:1. A bag of brussels sprouts was stored in Reach-in Freezer (RF) 1 without a label to indicate the received date. 2. The paint of the top metal rack in RF 1 was chipped, exposing the gray metal part of the rack. 3. A jar of mayonnaise that was stored in Reach-in Refrigerator (RR) 1 was labeled with the incorrect use-by date.4. The thermometer found in RF 2 was physically broken and could not accurately record temperatures in RF 2. 5. A kitchen sanitizer bucket containing a chemical cleaning solution was found stored on the same shelf immediately adjacent to clean pitchers for beverages. These failures had the potential to spread pathogens (a germ that causes disease) to 35 out of 37 residents who consume food prepared by the facility's kitchen, increasing their risk of developing foodborne illnesses (any sickness caused by eating or drinking contaminated foods or beverages) that could lead to medical complications and hospitalization. Findings: During a concurrent observation and interview on 8/10/2026 at 7:47 AM with the Dietary Services Supervisor (DSS - manages daily food service operations, ensuring safe, nutritious, and appealing meals while supervising staff, controlling budgets, and upholding health regulations) in the kitchen, RF 1 contained an unopened frozen bag of brussels sprouts that was not labeled with a received date by the kitchen and stored in RF 1. DSS stated the bag of brussels sprouts should have been labeled with the date it was received and stored in RF 1. DSS stated without a food item labeled date, kitchen staff will not know how long the bag of brussels sprouts has been stored in RF 1 for, when the bag of brussels sprouts expires, and the bag of brussels sprouts should be disposed. DSS further stated if residents consume expired foods, the residents can contract foodborne illnesses. During a concurrent observation and interview on 8/10/2026 at 7:51 AM with the DSS in the kitchen, the top metal storage rack of RF 1 was painted white. Along the storage rack, was a section about one inch (unit of measuring length) in length where the white paint was chipped away exposing the gray metal of the rack. DSS stated the paint of the storage rack of RF 1 is chipped away and DSS needs to call maintenance to repaint the storage rack. DSS further stated the facility must ensure the storage racks of refrigerators and freezers in the kitchen do not have chipped paint because the pieces of paint could fall into the food that the residents eat, which could cause the residents to get sick. During an observation on 8/10/2026 at 7:54 AM in the kitchen, RR 1 contained an opened jar of mayonnaise labeled by the kitchen staff with a received date of 8/7/2026, an opened date of 8/9/2026, and a use-by date of 7/6/2027. The jar of mayonnaise was also labeled with a manufacturer's expiration date of 7/6/2027. During a concurrent interview and record review on 8/10/2026 at 7:55 AM with the DSS, the kitchen's reference sheet titled, Dry Goods Storage Guidelines, undated, was reviewed. The reference sheet indicated mayonnaise can only be stored for two months in the refrigerator after being opened. The DSS stated this reference sheet is what the kitchen staff use for reference when labeling food with use-by dates after being opened. The DSS stated the jar of mayonnaise in RR 1 was incorrectly labeled, and the correct use-by date is 10/9/2026. The DSS stated, it is important to label foods with the correct use-by date to know when they are expired and should be disposed. The DSS further stated residents could contract foodborne illnesses if they eat foods beyond the use-by date because they are expired. During a concurrent observation and interview on 8/10/2026 at 8:01 AM in the kitchen with the DSS, RF 2 contained a freezer thermometer that indicated a temperature of 32 degrees Fahrenheit (F - a unit of measuring temperature). The DSS stated the freezer thermometer inside RF 2 looks physically broken because the temperature gauge was stuck at 32 degrees. DSS stated he knows the thermometer is inaccurate and the temperature of RF 2 is not actually 32 degrees because when the temperature of RF 2 was checked in the morning it was 0 degrees F, all the food stored inside RF 2 is frozen solid, and the thermometer built into RF 2 indicates 0 degrees F. The DSS stated, it is important to have a working thermometer in the freezer to ensure the food stored inside is stored at the correct temperature. If food is not stored at the correct temperature, it could spoil and cause foodborne illnesses in the residents that consume the food. During a concurrent observation and interview on 8/10/2026 at 8:13 AM in the kitchen with the DSS, a red bucket containing a liquid was stored immediately adjacent to clean pitchers for beverages on a metal shelf. The DSS stated the metal shelf is used to store freshly washed beverage pitchers. The DSS stated the red bucket is the kitchen's sanitizer bucket, containing chemical cleaning solution used to clean the kitchen. The DSS stated the red bucket should not be stored on the same shelf as the pitchers for beverages because the chemical solution in the red bucket may contaminate the pitchers for beverages, which then may cause illness to the residents. During an interview on 8/13/2026 at 3:20 PM with the Director of Nursing (DON), DON stated, The kitchen must be clean and sanitary at all times. If not, it could lead to foodborne illnesses in the residents. The DON further stated foods stored in the kitchen must be labeled appropriately to know the food is still consumable and to prevent foodborne illness to the residents. The DON further stated, It is important to have working thermometers in the freezers and refrigerators to be able to monitor the temperatures food is stored at to ensure food does not spoil. The DON further stated cleaning chemicals should not be stored in the same area as dishware that is used for food and beverages because the chemicals may contaminate the dishware and cause illness in residents if consumed. During a review of the facility's policy and procedures (P&P) titled, Refrigerators and Freezers, with a reviewed date of 5/2026, the P&P indicated, All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturer guidelines are scheduled and followed. During a review of the facility's P&P titled, Sanitization, with a reviewed date of 5/2026, the P&P indicated, The food service area is maintained in a clean and sanitary manner. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. During a review of the facility's P&P titled, Food Preparation and Service, with a reviewed date of 3/2026, the P&P indicated, Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned.

Based on observation, interview and record review the facility failed to follow its policy and procedures (P&P) titled, Activity Programs, by not performing a comprehensive resident-centered activity assessment that addressed the residents preferences for one of three sampled residents (Resident 1). This deficient practice had the potential not to meet the highest practicable psychosocial well-being of the resident.Findings: A review of Resident 1's admission record indicated the facility admitted the resident, on 1/2/2026 and readmitted the resident on 7/7/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 1's History and Physical (H&P), dated 7/24/2026, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's New to healthcare facility care plan, initiated 7/13/2026, indicated the resident had little to no involvement due to physical limitations and activity staff will provide support through sensory stimulation and music time. The care plan interventions included to encourage, invite and assist as needed to activities of choice/interest as tolerated by the resident. A review of Resident 1's Quarterly Minimum Data Set (MDS- a resident assessment tool), dated 7/14/2026, indicated Resident 1's cognition was moderately impaired. During an observation on 8/11/2026 at 8:23 AM Resident 1 was observed laying in bed. During an observation on 8/12/2026 at 11:39 AM Resident 1 was observed sitting in a wheelchair in the facility's activity room watching the news. During a concurrent interview and record review on 8/13/2026 at 8:10 AM, Resident 1's activity review forms were reviewed with the Activities Director (AD). The AD stated activity staff perform a comprehensive assessment of the resident's activity preferences within the first five days of admission. The AD stated the resident's activity care plan is based on this assessment. The AD stated the comprehensive assessment should encompass the resident's cognition, favorite foods, what the resident likes, how they enjoyed spending time at home. The AD also stated Resident 1 comes to activities approximately every other day. Upon review of Resident 1's electronic chart, The AD stated there was no comprehensive assessment of Resident 1's activity preferences.During the same interview and record, Resident 1's Activities Review Assessments dated 1/8/2026, 4/8/2026 and 7/14/2026 were reviewed. The AD stated Resident 1's Activities Review forms, indicated the activities Resident 1 participated in at the facility but did not assess the activities Resident 1 likes to participate in. During an observation on 8/13/2026 at 2:01 PM Resident 1 was observed sleeping in bed. During an interview on 8/13/2026 at 2:41 PM, the Director of Nursing (DON) stated residents should have a standardized assessment of the activities a resident prefers. The DON further stated, it is important to know the resident's preferences as it contributes to their overall wellbeing. The DON also stated not having the resident's activity preferences assessed could lead to the resident psychosocial needs going unmet. A review of the facility's policy and procedures (P&P) titled, Activity Programs, undated, indicated, It was the policy of the facility that activity programs are designed to meet the interests of and support the physical, mental and psychosocial wellbeing of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.

Based on interview and record review the facility failed to complete an elopement (the act of leaving a facility unsupervised and without prior authorization) risk assessment for one of three sampled residents (Resident 1) who was exhibiting exit seeking behaviors and verbalized wanting to leave the facility. This deficient practice placed Resident 1 at increased risk for elopement.Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1, on 1/2/2026 and readmitted the resident on 7/7/2026 with diagnoses that included dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 1's History and Physical (H&P), dated 7/24/2026, indicated Resident did not have the capacity to understand and make decisions. A review of Resident 1's Quarterly Minimum Data Set (MDS- a resident assessment tool), dated 7/14/2026, indicated Resident 1's cognition (the mental ability to make decisions of daily living) was moderately impaired. The MDS also indicated the resident did not have the behaviors of pacing or wandering. A review of Resident 1's Elopement Risk Assessments, dated 4/8/2026 and 7/13/2026 indicated the residents risk score was 0 (zero). A further review of the Elopement Risk Assessment form indicated a score of 6 or more an indication that Resident 1 should be considered high risk for elopement. A review of Resident 1's Elopement Risk/Wanderer care plan (CP), initiated 8/1/2026, indicated Resident 1 was at risk for elopement due to the resident's diagnosis of Alzheimer's. The CP goal indicated to maintain Resident 1's safety and that the resident will remain free of injury related to elopement. The CP interventions included to allow Resident 1 to vent feelings and provide safe environment, check for WanderGuard (is an electronic safety monitoring tool worn by a resident in nursing homes and memory care facilities that tracks at at-risk residents and alerts staff instantly if a resident approaches an unauthorized exit or restricted area) placement on Resident 1 every shift, and may have WanderGuard to alert staff if Resident 1 is trying to leave the facility unassisted. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 8/1/2026, indicated Resident 1 was exhibiting exit-seeking behavior which included, pacing near exit doors, attempting to leave the unit and verbalizing How do I get out of here. A review of Resident 1's electronic health chart indicated the facility did not complete an elopement risk assessment after Resident 1's SBAR dated 8/1/2026, indicated that Resident 1 was exhibiting exiting seeking behaviors. During a concurrent interview and record review on 8/12/2026 at 10:15 AM with Licensed Vocational Nurse (LVN) 1, Resident 1's SBARs and elopement risk assessments were reviewed. LVN 1 stated LVN 1 completed the SBAR form due to Resident 1's wandering behavior, going into different resident rooms and staying at the facility exits (doors). LVN 1 stated, these behaviors (wandering and staying at exit doors) were new.During the same interview and record review, Resident 1's elopement risk assessments was reviewed. LVN 1 stated an elopement risk assessment was not completed for Resident 1 after Resident 1 started exhibiting wandering and exit seeking behaviors. LVN 1 stated Resident 1's previous elopement risk assessments indicated Resident 1 was not an elopement risk. LVN 1 stated an elopement risk assessment should have been completed after the SBAR dated 8/1/2026, in order to figure out the level of monitoring for elopement Resident 1 would require. LVN 1 also stated not completing elopement risk assessment could lead to Resident 1 eloping from the facility. During an interview on 8/13/2026 at 2:04 PM, the Director of Nursing (DON) stated an elopement risk assessment should have been completed when Resident 1 was having wandering behaviors. The DON stated, the elopement assessment is a standardized form used to ensure we (facility) properly assess and identify the resident's needs. The DON further stated not completing an elopement risk assessment had the potential for the facility to not develop the correct interventions for the resident. A review of the facility's policy and procedures (P&P), Safety and Supervision of Residents, reviewed 3/2026, indicated, the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.

Based on observation, interview and record review, the facility failed to provide daily suprapubic (above the pubic bone- anatomical location on the lower abdomen) urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) flushing (using a syringe to gently push sterile water or salt water into the tube) per physician's orders for one of one sampled residents (Resident 8). This deficient practice placed Resident 8 at increased risk for developing urinary tract infection (UTI- an infection in the bladder/urinary tract).Findings: A review of the Resident 8's admission Record indicated the facility re-admitted the resident on 1/21/2026, with diagnoses that included benign prostatic hyperplasia (BPH- prostate gland enlargement), obstructive and reflux uropathy (condition in which the one-way flow of urine is disrupted causing urine to back up into the kidneys and dementia (a progressive state of decline in mental abilities). A review of Resident 8's Physician Progress Note, dated 1/22/2026, indicated the resident had a recent UTI and the resident had a urinary catheter due to the resident having obstructive uropathy. A review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 7/1/2026, indicated the resident's cognition (ability to think and reason) was severely impaired. The MDS also indicated the resident had an indwelling catheter. The MDS also indicated Resident 8 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance) with oral hygiene, toileting hygiene, bathing, dressing and personal hygiene. A review of Resident 8's Order Summary Report, dated 8/1/2026, indicated a physician ordered the facility to provide Resident 8 with the following care:Suprapubic catheter for obstructive uropathy size 16 French 10 milliliter for obstructive uropathySuprapubic catheter: ensure urinary catheter securement device is in place to prevent movement and urethral tractionFlush suprapubic catheter with 100ml of normal saline (NS - a saltwater solution) every day and evening shiftChange suprapubic catheter and drainage [NAME] as needed for dislodgement or non-patency A review of Resident 8's alteration in urinary elimination care plan, initiated 6/29/2026, indicated the resident had the catheter due to obstructive uropathy and BPH. The care plan also indicated Resident was at risk for UTI due to the indwelling urinary catheter. The care plan indicated the goal was to reduce the risk of infection. The care plan indicated interventions included catheter care as ordered, maintain proper alignment of catheter to promote proper drainage and to monitor urine for sediment cloudiness, odor, blood and amount of output. During a phone interview on 8/11/2026 at 9:25 AM, Resident 8's Family Member (FM) 1 stated Resident 8 has had multiple UTIs while at the facility. During a concurrent interview and record review on 8/13/2026 at 9:51 AM with Licensed Vocational Nurse (LVN) 3, Resident 8's Treatment Administration Records (TAR - a log used by healthcare professionals of all treatments given to a resident) for the month of August 2026 was reviewed. LVN 3 stated Resident 9 had a suprapubic catheter and there was an order to flush the catheter every morning and evening. Upon review of Resident 8's August 2026 MAR, LVN 3 stated the there was no documentation that Resident 8's resident's catheter was flushed per physician order on 8/5/2026, 8/7/2026 and 8/8/2026. LVN 3 also stated there was no documentation that Resident 8 refused the treatments. LVN 3 further stated Resident 8 could re-develop a UTI if the catheter was not flushed as ordered. During an interview on 8/13/2026 at 2:40 PM, the Director of Nursing (DON) stated Resident 8 had a physician order for urinary catheter flushing in order to assist in the prevention of a UTI. The DON stated staff are to follow the physician orders and document the treatments given. A review of the facility's policy and procedures (P&P), Catheter Care, Urinary, reviewed 5/2026, indicated catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. The P&P also indicated under the section, Documentation:The following information should be recorded in the resident's medical record:1. The date and time that catheter care was given.2. The name and title of the individual(s) giving the catheter care.3. All assessment data obtained when given catheter care. A review of the facility's P&P, Charting and Documentation, reviewed 5/2026, indicated the following information is to be documented in the resident medical record:a. Objective observations;b. Medications administered;c. Treatments or services performed;d. Changes in the resident's condition;e, Events, incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and objectives.

Based on observation, interview, and record review, the facility failed to conduct background checks (a formal review of a job candidate's record [such as criminal history/criminal convictions, sex offender, education, and past employment] that is heavily regulated by state worker protection laws) prior to employment and direct access to residents for two out of 108 staff (Certified Nurse's Aide [CNA] 2 and Registered Nurse [RN] 1) as indicated in the facility's policy and procedures (P&P) titled Background Screening Investigations last revised on 3/2026. This deficient practice of failing to conduct background checks placed increased the risk for psychosocial, physical, emotional, and financial harm to the residents in the facility. Findings: During a concurrent interview and record review of employee records of CNA 2 on 8/13/2026 at 1:25 PM with Director of Staff Development Assistant (DSDA), DSDA stated and confirmed that the facility hired CNA 2 on 3/01/2021, and that the facility did not conduct a background check for CNA 2 until 8/30/2023, two years after CNA 2 date of hire. During a concurrent interview and record review of employee records of RNS 1 on 8/13/2026 at 1:31 PM with Payroll Manager (PM), PM stated and confirmed that the facility hired RNS 1 on 3/08/2023 and that the facility did not conduct a background check for RNS 1 until 10/13/2023, seven months after RNS 1 date of hire. Furthermore, PM stated and confirmed that RNS 1 background check was missing the sex offender registry under the criminal background check. During a concurrent interview and record review of employee records of RNS 1 and CNA 2 on 8/13/1026 at 1:55 PM with the DON, the DON stated that the facility is supposed to conduct employee background checks upon hire, before they (the staff) start their orientation. The DON stated that, we won't know if the patients (residents) may be affected when the background check lie criminal thing is not checked. The DON stated that the Director of Staff Development (DSD - a licensed nurse who is responsible for planning and implementing the facility's orientation and educational programs for all employees) is ultimately responsible. The DON also stated that the sex offender registry list should be done for the safety of the residents. During a review of the facility's P&P titled Background Screening Investigations revised on 3/2026, the P&P indicated the following: Policy Statement: .Facility conducts employment background screening checks, reference checks criminal conviction investigation checks on all applicants for positions with direct access to residents ( direct access employees). Policy Interpretation and Implementation: 2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment.and completed prior to employment.

Based on interview and record review, the facility failed to report an unusual occurrence to the state survey agency (SSA) within 24 hours for one of two sampled residents (Resident 1), who was diagnosed with a right humerus fracture and right scapular fracture one month after falling on 4/12/2026. Resident 1 continued to have pain weeks after the fall and an magnetic resonance imaging (MRI - a non-invasive scan that uses a giant magnet and radio waves to take 3D pictures inside of the body) completed on 5/5/2026 (3 weeks after the fall) indicated Resident 1 had a right nondisplaced humeral fracture and a right nondisplaced scapular fracture. This deficient practice had the potential to result in a delay of an investigation by the SSA to determine if abuse or neglect had occurred for Resident 1.Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/3/2026 with diagnoses abnormalities of gait and mobility, unspecified psychosis and a history of falling. A Review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/9/2026 (prior to the resident's fall), indicated that the resident's cognition (ability to think, understand and reason) was moderately impaired. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, showering/bathing, dressing and personal hygiene. The MDS further indicated Resident 1 had no falls in the last 6 months, had no falls since entering the facility and had no fractures related to a fall in the past 6 months. A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among residents) Communication Form, dated 4/12/2026, indicated Resident 1 had a fall incident and was found on the floor. The SBAR form also indicated Resident 1 complained of 10/10 (zero being no pain and 10 being the worst pain possible) to the right shoulder. The SBAR form further indicated Resident 1 reported tripping on the way back to the resident's room. The SBAR form indicated the resident was transferred to a general acute care hospital (GACH) via 911 (a telephone number used to reach emergency medical, fire, and police services). A review of Resident 1's GACH History and Physical (H&P) Note, dated 4/13/2026, indicated the resident had a ground level fall with resolving right shoulder and arm pain without any fracture as x-ray did not show any positive findings. A review of Resident 1's Physical Therapy Treatment Encounter Note, dated 4/30/2026, indicated the resident's physical therapy interventions focused on dynamic balance activities while standing, crossing midline to facilitate independence in functional skill performance, placement of objects out of reach to increase dynamic skill performance and range of motion techniques to increase functional task performance. The note further indicated therapy staff were awaiting MRI results of Resident 1's right humerus. A review of Resident 1's Progress Note, dated 5/5/2026 indicated the resident left the facility and went to the MRI appointment via private transportation with a facility staff member as escort. A review of Resident 1's Progress Note, dated 5/6/2026, indicated facility staff called the imaging center and was notified that Resident 1's full imaging report would be available in three days. A review of Resident 1's Radiology Report, dated 5/7/2026, indicated the resident had a nondisplaced humerus fracture and a nondisplaced scapular fracture. A review of the Assistant Director of Nursing's email indicated the imaging center notified the facility of Resident 1's imaging results on 5/11/2026 at 1:34 PM. A review of Resident 1's SBAR form, dated 5/12/2026, indicated the MRI results diagnosed Resident 1 with a proximal humerus nondisplaced fracture involving the surgical neck, greater tuberosity and lesser tuberosity. The MRI also indicated Resident 1 had a scapular non displaced fracture extending through the glenoid (the shallow, pear-shaped socket in the shoulder blade), scapular (shoulder blade) neck and scapular body. During an interview on 5/27/2026 at 1 PM, Licensed Vocational Nurse (LVN) 1 stated after the fall, Resident 1 continued to guard her right arm and was keeping it close to the body. LVN 1 stated this instigated her to speak to physical therapy and ask about the plan for Resident 1. LVN 1 stated it was decided that Resident 1 to get an MRI so as to clear the resident prior to making changes on the resident's therapy plan. LVN 1 stated she arranged for the MRI and followed up with the imaging company on 5/6/2026 and the imaging company told LVN 1 that the results would take 3 days to come back. LVN 1 stated the imaging company emailed Resident 1's MRI results to the Assistant Director of Nursing's (ADON), however, LVN 1 did not know when the MRI results was emailed to the ADON. During a concurrent interview and record review on 5/27/2026 at 1:46 PM, the ADON stated Resident 1's MRI results was emailed to the ADON's work email on 5/11/2026 at 1:34 PM. The ADON stated the facility did not report to the Resident 1's MRI results to the physician on 5/12/2026 because the ADON left the facility prior to the email coming in and that no one else in the facility has access to the ADON's email. The ADON stated critical test results are relayed to the physician immediately. The ADON further stated that on 5/12/2026, ADON notified the Director of Nursing (DON) of Resident 1's MRI results. The ADON did not respond when asked what would to residents if the ADON is not at work and or unable to access the residents' diagnostic tests results. During an interview on 5/27/2026 at 2:50 PM, the DON stated Resident 1 fell on a Sunday, 4/12/2026, and was transferred to a GACH that day. The GACH performed an x-ray which did not show a fracture. The DON stated Resident 1 continued to have pain, so the physician ordered an MRI for the resident. The DON further stated Resident 1's MRI result was emailed to the ADON work email. The DON further stated the facility reported Resident 1's fractures on 5/13/2026 to the SSA. The DON further stated that, we must report a fracture to the SSA within 24 hours to allow the state can investigate and make sure we competently cared for the resident. The DON stated, we must work on this (accessing results) when asked what can happen to residents if the DON is not at work and or unable to access the residents' diagnostic tests results. A review of the facility's policy and procedures, Unusual Occurrence Reporting, dated 2/2026, indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. The P&P also indicated, our facility will report the following events to appropriate agencies:g. Allegations of abuse, neglect and misappropriation of resident property; andh. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

Based on interview and record review and interview, the facility staff failed to promptly check the magnetic resonance imaging (MRI-a noninvasive medical test that uses a strong magnetic field, radio waves, and a computer to produce detailed, cross-sectional images of the body's internal organs, tissues, and skeletal system) scan results and immediately notify the ordering physician of the MRI scan results for one (1) of two sample residents (Resident 1). On 4/12/2026 Resident 1 suffered an unwitnessed fall and complained of pain to the right shoulder pain., Xray completed at a general acute care hospital (GACH) showed no fracture/s. On 5/5/2026, Resident 1's MRI scan results indicated Resident 1 had suffered right humerus (is the long bone located in the upper arm) and scapula (shoulder blade) fractures (broken bones). The MRI results were emailed the facility on 5/11/2026 at 1:34 PM. The facility did not notify the physician of Resident 1's physician of the MRI results until 5/12/2026 at 10:26 AM. This deficient practice resulted in 21 hours physician notification delay placing Resident 1 at increased risk of delay of necessary care and needs.Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/3/2026 with diagnoses including abnormalities of gait and mobility, unspecified psychosis and a history of falling. A Review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 2/9/2026 (prior to the resident's fall), indicated that the resident's cognition (ability to think, understand and reason) was moderately impaired. The MDS also indicated the resident required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, showering/bathing, dressing and personal hygiene. The MDS further indicated Resident 1 had no falls in the last 6 months, had no falls since entering the facility and had no fractures related to a fall in the past 6 months. A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 4/12/2026, indicated Resident 1 had a fall incident and was found on the floor. The SBAR form also indicated Resident 1 complained of 10/10 (zero being no pain and 10 being the worst pain possible) to the right shoulder. The SBAR form further indicated Resident 1 reported tripping on the way back to the resident's room. The SBAR form indicated the resident was transferred to a general acute care hospital (GACH) via 911 (a telephone number used to reach emergency medical, fire, and police services). A review of Resident 1's GACH History and Physical (H&P) Note, dated 4/13/2026, indicated the resident had a ground level fall with resolving right shoulder and arm pain without any fracture as x-ray did not show any positive findings. A review of Resident 1's Physical Therapy Treatment Encounter Note, dated 4/30/2026, indicated the resident's physical therapy interventions focused on dynamic balance activities while standing, crossing midline to facilitate independence in functional skill performance, placement of objects out of reach to increase dynamic skill performance and range of motion techniques to increase functional task performance. The note further indicated that the therapy staff were awaiting MRI results of Resident 1's right humerus A review of Resident 1's Progress Note, dated 5/5/2026 indicated the resident left the facility and went to the MRI appointment via private transportation with a facility staff member. A review of Resident 1's Progress Note, dated 5/6/2026, indicated facility staff called the imaging center and was notified that Resident 1's full imaging report would be available in three days. A review of Resident 1's SBAR form, dated 5/12/2026, indicated Resident 1 was observed with right upper extremity range of motion limitations and complained of 3/10 pain. The Nurse Practitioner (NP) ordered a right humerus MRI. The SBAR also indicated the MRI results diagnosed Resident 1 with a proximal humerus nondisplaced fracture involving the surgical neck, greater tuberosity and lesser tuberosity. The MRI also indicated Resident 1 had a scapular non displaced fracture extending through the glenoid, scapular neck and scapular body. A review of Resident 1's Radiology Report, dated 5/7/2026, indicated the resident had a nondisplaced humerus fracture and a nondisplaced scapular fracture. A review of Resident 1's Physician Order, dated 5/11/2026, indicated the resident was to receive a right humerus MRI related to pain status post (after a) fall. A review of Resident 1's PT (Physical Therapy) Progress Report, dated 5/13/2026, indicated the changes the resident was experiencing included a right upper extremity range of motion. A review of Resident 1's Progress Notes, dated 5/7/2026 through 5/10/2026, did not indicate any documented that the facility followed up Resident 1's imaging report. During an interview on 5/27/2026 at 12:02 PM, Certified Nursing Assistant (CNA) 1 stated prior to Resident 1 falling, Resident 1 walked well, was able to shower independently, and required set up assistance with her ADLS. CNA 1 stated that after the fall, Resident 1 requires more assistance and that the facility staff have to help the resident take showers. During an interview on 5/27/2026 at 12:38 PM, the Director of Rehabilitation (DOR) stated prior to the Resident's falling on 4/12/2026 the resident was very functional. The DOR stated since the resident sustained the fracture, Resident 1's range of motion is limited and the resident has lost strength and started having difficulty reaching the arm over the head. The DOR stated Resident 1 was receiving occupational therapy (OT- therapy to improve a person's everyday life activities). During an interview on 5/27/2026 at 1 PM, Licensed Vocational Nurse (LVN) 1 stated after the fall, Resident 1 continued to guard the right arm and kept the right arm close to the body. LVN 1 stated this instigated her speaking to physical therapy and asking about the plan for Resident 1. LVN 1 stated this instigated her to speak to physical therapy and ask about the plan for Resident 1. LVN 1 stated it was decided that Resident 1 to get an MRI so as to clear the resident prior to making changes on the resident's therapy plan. LVN 1 stated she arranged for the MRI and followed up with the imaging company on 5/6/2026 and the imaging company told LVN 1 that the results would take 3 days to come back. LVN 1 stated the imaging company emailed Resident 1's MRI results to the Assistant Director of Nursing's (ADON), however, LVN 1 did not know when the MRI results was emailed to the ADON. During an interview on 5/27/2026 at 1:30 PM, CNA 3 stated that Resident 1 fell on a Sunday, 4/12/2026 between 1 PM and 1:50 PM. CNA 3 stated CNA 3 was in the activities room, when CNA 3 heard Resident 1 scream. CNA 3 stated CNA 3 went to the hallway and saw Resident 1 on the floor. CNA 3 stated the nurses assessed the resident and Resident 1 started screaming when the nurses attempted to lift the residents right arm. CNA 3 further stated that after the fall, Resident 1 required more help with ADL. During a concurrent interview and record review on 5/27/2026 at 1:46 PM, Resident 1's MRI results was reviewed with the Assistant Director of Nursing (ADON). The MRI results indicated Resident 1 had a right nondisplaced humeral fracture and a right nondisplaced scapular fracture. The ADON stated Resident 1's MRI results was emailed to the ADON's work email on 5/11/2026 at 1:34 PM. The ADON stated the MRI results were not reported to the physician on 5/12/2026 because the ADON left the facility prior to the MRI results email came in. The ADON stated that no one else in the facility has access to the ADON's work email. The ADON further stated that on 5/12/2026, ADON notified the Director of Nursing (DON) of Resident 1's MRI results. The ADON did not respond when asked what would to residents if the ADON is not at work and or unable to access the residents' diagnostic tests results. The ADON stated that critical test results must relayed to the physician immediately. During an interview on 5/27/2026 at 2:50 PM, the Director of Nursing (DON) stated Resident 1 fell on a Sunday, 4/12/2026, and was transferred to a GACH the same day. The DON stated that the x-ray at GACH did not show a fracture. The DON stated Resident 1 continued to experience pain, so the physician ordered an MRI. The DON further stated Resident 1's MRI result was emailed to the ADON's work email. The DON stated, we must work on this (accessing results) when asked what can happen to residents if the DON is not at work and or unable to access the residents' diagnostic tests results. The DON further stated nursing should follow up on test results and there can be a delay in care. A review of the facility's policy and procedures, Lab and Diagnostic Test Results - Clinical Protocol, revised 11/2025, indicated:Assessment and Recognition The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.Review by Nursing Staff1. When test results are reported to the facility, a nurse will first review the results.a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. Identifying Situation that Warrant Immediate Notification1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the physician has requested to be notified as soon as a result is received. Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison.

Based on interviews and record review, the facility failed to ensure that one out of three sampled residents (Resident 1), who has a diagnosis of dysphagia (difficulty swallowing), was provided with nutritional and hydration care and services consistent with resident's comprehensive assessment by failing to:Ensure Resident 1 was closely monitored and evaluated when Resident 1 refused to eat.Ensure Resident 1's weight was closely monitored according to Resident 1's comprehensive care plan.Ensure Registered Dietitian (RD-is a credentialed, regulated healthcare professional authorized to provide medical nutrition therapy, counselling, and and evidence-based dietary planning to threat disease) followed-up when Resident 1 refused to eat. These deficient practices placed Resident 1 at increased risk for impaired nutrition, weight loss, and dehydration (when the body uses or loses more fluid than it takes in).Findings:During a review of Resident 1's Face Sheet (FS), the FS indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia, urinary tract infection (UTI- an infection in the bladder/urinary tract), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 12/17/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Care Plan (CP) for actual/potential nutritional problem and dehydration risk related to (r/t) cognitive impairment and recent hospitalization, date initiated 12/17/2025, the CP indicated a goal of, The resident (1) will have no signs and symptoms (s/sx) of malnutrition through next review date, and interventions that included, RD (Registered Dietitian) to evaluate and make diet change recommendations as needed. Weight the resident weekly or monthly as ordered. During a review of Resident 1's Order Recap Report (ORR), dated 12/26/2025, the ORR indicated, physician ordered, Monitor episodes of poor oral intake (meal intake less than 50% and/or meal refusal) every shift - document percentage of meal. During a record review of Resident 1's Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Care Conference Notes, dated 7/24/2025, the Registered Dietitian (RD) noted that Resident 1's weight was 97 pounds (lbs - unit of measurement) was admitted on a regular diet, mechanical soft, finely chopped texture. Resident (1) usual body weight range (UBWR - balances weight against height to indicate lower risk for weight-related health issues) is 120 - 130 lbs. Will continue to monitor weights and PO (oral/mouth) intake. During a record review of Resident 1's Amount Eaten for January 2026, the log indicated, Resident 1 ate most meal about 0-25% and 25 - 100% on other times of her meal. During a record review of Resident 1's Weight Record (WR) indicated the following:Dated 12/4/2025, the WR indicated, Resident 1's weight was 106 lbs.Dated 9/3/2025, the WR indicated, Resident 1's weight was 110 lbs.Dated 8/5/2025, the WR indicated, Resident 1's weight was 105 lbs.Dated 7/29/2025, the WR indicated, Resident 1's weight was 102 lbs. During a record review of Resident 1's Weight Record (WR) indicated there was no Resident 1's weight recorded and documented for the month of 10/2025 and 11/2025. During an interview with Certified Nursing Assistant (CNA) on 1/21/20226 at 2:47 p-m., CNA 1 stated, Resident 1 refused to eat during the morning shift. CNA 1 stated, he would attempt to give Resident 1 food and feed her, but the resident would spit it out or throw the food away. CNA 1 stated, it is difficult to get her to eat. During an interview with CNA 2 on 1/22/2026 at 1:29 p.m., CNA 2 stated, Resident 1 would eat about 25 percent during dinner time and sometimes, she would not eat at all. CNA 2 stated they would try to give alternate food tray for Resident 1 since she won't eat her meal but Resident 1 would still refuse and would say she was not hungry. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/21/2026 at 2:55 p.m., LVN 1 stated, Resident 1 does not eat much and has little appetite. LVN 1 stated, Resident 1 would mostly just drink Ensure (ready-to-drink supplements) and would not eat food on her tray. During a concurrent interview and record review with Director of Nursing (DON) on 1/21/2026, the DON stated, according to Resident 1's meal intake, Resident 1 eats only about 0-25% to sometimes more the resident was not consistently eating according to their (facility) documentation. DON further stated the last progress notes by RD was on July 2025 and there was no follow-up done regarding Resident 1's nutritional needs with risk of nutritional problems and dehydration. DON further stated, Resident 1's nutritional and hydration needs were not closely evaluated by the dietitian as there were no follow-up notes by the RD after July 2025. DON stated, there should a follow-up notes by the RD especially that Resident 1 was not consistently eating her meal and with no appetite. DON stated, if residents are not eating, they (facility) must check with residents the reason of why they are not eating and notify the physician then have an IDT meeting. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2025, the P&P indicated that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The IDT reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. During a review of the facility's P&P titled, Food and Nutrition Services, revised 11/2025, the P&P indicated that, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. During a review of the facility's P&P titled, Dietitian, revised 11/2025, the P&P indicated that, A qualified, competent, and skilled dietitian will help oversee the food and nutrition services in the facility. Dietitian is responsible for, but not necessarily limited to: assessing nutritional needs of residents; developing and evaluating regular and therapeutic diets, developing and evaluating regular and therapeutic diets.

Based on interview and record review, the facility failed to provide an effective discharge with a safe and orderly discharge planning for one of three sampled residents, (Resident 1) by failing to:1. Implement the facility's policy and procedures (P&P), titled, Transfer or Discharge, Facility-Initiated to ensure Resident 1's discharge criteria was met with required orientation and documentation as specified in the policy. 2. Ensure a post-discharge plan was developed, documented and reviewed in discharge summary/post discharge plan of care at least 24 hours before resident's discharge or transfer from the facility.These deficient practices placed residents in an unsafe and ineffective discharge.Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), dysphagia (difficulty swallowing), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). The admission Record also indicated that Resident 1 was discharged on 1/14/2026. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/17/2025, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate to maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Care Plan (CP), there was no CP initiated regarding Resident 1's plan of discharge with goal and interventions. During a review of Resident 1's Progress Notes, dated 1/14/2026, the Progress Notes indicated, Resident (1) was discharged to Board and Care Facility (BCF) 1. During a review of Resident 1's Discharge summary/post discharge plan of care (DSPOC), undated, the DSPOC form was missing information on the following documentation: Discharge Plan, effective date, discharge date , where resident is being discharge to, physician's appointment follow-up visit, post discharge plans/community agencies (referral), equipment needs, special considerations, medication reconciliation, nursing details such as functional status, most recent discharge vital signs, activity, nutrition status, and skin assessment. During a concurrent interview and record review with Director of Nursing (DON) on 1/21/2026 at 4:28 p.m., DON stated, the discharge process consists of the IDT meeting held prior to discharge to ensure the resident will be discharge safely to the appropriate placement. DON reviewed Resident 1's IDT meeting, dated 1/13/2026, and DON confirmed, the IDT meeting form did not have the information of where Resident 1 was discharged , the date of the discharge, post discharge plans and equipment needs, physician follow-up visits and functional status. DON stated the discharge plan was incomplete and there was no information of continuity of care. The DON further stated, there was no CP initiated regarding Resident 1's CP for discharge. During a review of the facility's P&P, titled, Transfer or Discharge, Facility-Initiated, date reviewed by facility on 4/2025, the P&P indicated, Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least 24 hours before the resident's discharge or transfer from the facility. A member of the IDT will review the final post-discharge plan with the resident and family at least 24 hours before the discharge is to take place. When a resident is transferred or discharged from the facility, the following information is documented in the medical record: The basis for the transfer or discharge; That an appropriate notice was provided to the resident and/or legal representative; The date and time of the transfer or discharge; The new location of the resident; The mode of transportation; A summary of the resident's overall medical, physical, and mental condition; Disposition of personal effects; Disposition of medications; Others as appropriate or as necessary; and the signature of of the person recording the data in the medical record. During a review of the facility's P&P, titled, Discharging the Resident, date revised on 3/2025, the P&P indicated, The following information should be recorded in the resident's medical record:1. The date and time the discharge was made.2. The name and title of the individual(s) who assisted in the discharge.3. All assessment data obtained during the procedure, if applicable.4. How the resident tolerated the procedure, if applicable.5. If the resident refused the discharge, the reason (s) why and the intervention taken.6. The signature and title of the person recording the data.

Based on observation, interview, and record review, the facility failed to follow its policy and procedures for medication storage by failing to ensure proper disposal expired medical supplies from intravenous (IV, a method of administering fluids, medications, or nutrients directly into a vein) medication cart by failing to disposed of: 1. One StatLock catheter stabilization device (device that adheres to the skin where the tubing of the catheter is locked in preventing accidental removal), 2. Nine (9) StatLock PICC (Peripherally Inserted Central Catheter, a long, thin tube inserted into a vein in the arm and threaded upwards through the vein into a larger vein near the heart) Plus catheter stabilization devices (device the adheres to the skin locking in the PICC tubing preventing accidental removal), and 3. Four (4) IV start kits (contains items for starting an IV line). These failures had the potential to result in nursing staff using expired supplies which could expose the residents to infection. Findings During a concurrent observation and interview on [DATE] 10:21 am, with Registered Nurse Supervisor (RNS) 1, the IV medication storage cart reviewed for expired supplies. During the review the following expired supplies were noted: 1. One StatLock catheter stabilization device with use by date of [DATE], 2. Nine (9) StatLock PICC plus catheter stabilization devices with use by date of [DATE], and 3. Four (4) IV start kits with expiration date of [DATE]. RNS 1 verified supplies were expired, gathered them to throw out and stated they could lead to infection and he will remove them to have them incinerated. During a record review of the facility policy and procedures (P&P), titled Storage of Medications, Biologicals, and Medical Supplies, revised [DATE], indicated, The facility shall store all drugs, biologicals and medical supplies in a safe, secure and orderly manner . The facility shall not use discontinued, outdated, or deteriorated drugs, biologicals or medical supplies . shall be returned to the dispensing pharmacy or removed and/or destroyed.

Based on observation, interview, and record review, the facility failed ensure proper sanitation and food handling practices by failing to ensure: 1. Juice gun (also known as a bar gun, is a device used to dispense various types of carbonated and non-carbonated drinks, including juices) tubing was free of grime build up, 2. Two bulk juices were not labeled with use by dates and, 3. One dry food scoop was being stored on top of a dry food bin in the dry food storage room. This deficient practice had the potential to result in unsafe food management, and foodborne illness. Findings: During an observation in the kitchen on 5/2/25 at 5:38 pm, the juice/soda gun dispenser tubing observed to have brown grime build up. During an observation with concurrent interview on 5/3/25 at 4:11 pm with Dietary Aide (DA) 1, the juice/soda gun dispenser tubing was observed to have brown grime build up, DA 1 verified the finding and stated the person responsible for cleaning the juice/soda gun dispenser tubing was supposed to be the person who cleans ice machine. During the same concurrent observation and interview there was apple juice box connected to the juice gun system with no received or use by dates indicated on the box, there was also a bag of red colored juice marked sugar free that also was lacking the received and use by dates. DA 1 verified the finding and stated they should have the dates and it typically takes a week to go through the bag or box of juice. During a observation with concurrent interview on 5/4/25 at 9:48 am with the Dietary Supervisor (DS), a picture of the juice/soda gun dispenser tubing was reviewed. The DS verified the grime on the tubing and stated the gun should be cleaned by the company that comes out to maintain the juice/soda gun dispenser. During the same concurrent observation and interview with the DS a large dry food storage scoop was observed sitting on top of a dry food storage container in the dry food storage room. The DS verified the scoop was on top of the container and stated it should be somewhere where it doesn't touch the outside of the containers. During a record review of the facility policy and procedures (P&P), titled Sanitization, revised November 2022, indicated, The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris . 2. All utensils, counters, shelves and equipment are kept clean and maintained in good repair .

Based on observation, interview, and record review, the facility failed to post the actual nursing hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for three of three sampled days (5/2/2025, 5/3/2025, and 5/4/2025). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing. Findings: During an observation of the facility on 5/2/2025 at 6:23 p.m., observed Direct Care Services Hours Per Patient Day (DHPPD) posted by the nursing station with only the projected hours posted. The information on the forms was incomplete for each shift. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (5/1/2025). During an observation of the facility 5/3/2025 at 9:23 a.m., observed DHPPD dated 5/3/2025 posted on the wall with only the projected hours. The information on the forms was incomplete for each shift. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (5/2/2025). During observation of the facility on 5/4/2025 at 6:23 p.m., observed DHPPD dated 5/4/2025 posted by the nursing station with only the projected hours posted. The information on the forms was incomplete for each shift. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (5/3/2025). During an interview with Director of Staff and Development (DSD) on 5/4/2025 at 6:25 p.m., DSD stated, he is responsible on the DHPPD posting and making sure that the information posted are accurate and complete. DSD stated, the projected hours are posted and does not include the actual hours worked by licensed and unlicensed staff in the facility. DSD then reviewed facility's policy and procedures, and stated, the actual hours worked by staff must be calculated and posted on the NHPPD posting and must be updated two hours after each shift starts. During a record review of the facility policy and procedures (P&P) titled Posting Direct Care Daily Staffing revised on 3/2025, the P&P indicated, Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format format . Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility . Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the Iocation(s) designated by the Administrator.

Based on interview and record review, the facility failed to ensure that the nursing staff met the skills and staff competency evaluation requirements. This deficient practice had the potential for knowledge, training, and certification deficit among the nursing staff, leading to inadequate or delayed care for the residents. Findings: During a concurrent interview and record review, on 5/4/2025, at 9:06 A.M., with the Director of Staff Development (DSD), the DSD, the facility's employee files were reviewed. The employee files indicated that four of five employee files reviewed did not have documented proof of annual competency training for the employees. The DSD stated employee competency training was done upon hire and annually thereafter to assess the staff's competency when providing care to the residents, if the staff need assistance or improvement in their skill. DSD stated if competency training is not done, the facility staff will not be assessed in the way their skills are done when providing resident care in areas including but not limited to activities of daily living (ADL), medication administration and intravenous infusion. The DSD stated lack of skills competency training may lead to a decline in the way care is provided to the residents. During an interview on 5/4/2025, at 6:38 P.M., with the Director of Nursing (DON), the DON stated employee competencies are about ensuring that nursing staff are assessed in their skills when it comes to resident care, this is done to ensure that the staff are on par with how they perform their skills, the staff are upto date and are competent to perform their job duties. The DON stated that the employee competency training is supposed to be done annually and as needed. The employee's skill training process is that the facility utilizes a form that guides the facility on what skills that need to be checked for the facility nursing staff, and needed to be completed with the check mark, may be a narrative note to state whether the employee met or did not meet the required skills assessment. The DON stated if competency training is not done, there may be inaccuracies and delays in the care of the residents. During a record review of the facility policy and procedures (P&P), titled Competency of Nursing Staff, revised 3/2025, indicated, Policy statement: l. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. Participates in a facility-specific, competency-based staff development and training program; and b. Demonstrates specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.

Based on interviews and record review, the facility failed to ensure the assessment entries were accurate for one of one sampled resident reviewed for resident's assessment (Resident 12) by failing to appropriately assess residents' diagnosis in the Minimum Data Set (MDS - resident assessment tool). This deficient practice had the potential to result in a negative effect on residents' plan of care and delivery of services. Cross Reference F658 Findings: During a record review of the Admission Record indicated Resident 12 was originally admitted to the facility 4/1/2021 and readmitted on [DATE] with diagnoses including chronic pulmonary edema (a condition caused by excess fluids in the lungs usually caused by a heart condition), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). During a record review of the MDS dated [DATE], Resident 12's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 12 had an active diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During an interview and observation of Resident 12 on 5/2/2025 at 6:12 p.m., Resident 12 stated, she is doing well and likes participating in the Activity room. Resident 12 appeared calm, compliant with care and followed direction. During an interview with Minimum Data Set Nurse (MDSN) on 5/4/2025 at 10:36 a.m., MDSN stated MDSN mistakenly quoted Resident 12's MDS assessment with a diagnosis of schizophrenia but they don't have all documentation that supports the diagnosis according to DSM-V (officially known as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition - a book used by mental health professionals to diagnose and classify mental health disorders). MDSN further stated, Resident 12 is cooperative and does not show any hallucinations, and delusions. During an interview with the Director of Nursing (DON) on 5/4/2025 at 3:58 p.m., DON stated, Resident 12's needs to meet all criteria before they quote them with a schizophrenia diagnosis on the MDS. DON stated, they need to have a medical professional that will provide the supporting documents. During a record review of the facility policy and procedures (P&P), titled, Resident Assessment Instrument, revised 3/2025, the P&P indicated, The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements . The interdisciplinary team uses the MDS form currently mandated by federal and state regulations to conduct the resident assessment. Other assessment forms may be used in addition to the MDS form.

Based on observation, interview, and record review, the facility failed to ensure that one out of three sampled residents (Resident 10) was free from physical restraint by failing to ensure the use of bed siderails and geriatric chair with lap tray informed consent was completed per individualized assessment. This deficient practice violated resident's right to be treated with respect and dignity with the use of physical restraints. Findings: During a record review of the Admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and unspecified dementia (a progressive state of decline in mental abilities). During a record review of the Minimum Data Set (MDS - resident assessment tool) dated 4/22/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 10 required moderate assistance to supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review of Resident 10's Order Summary Report indicated: i. As of 5/4/2025, there was no physician order for the use of bed siderails. ii. Physician's order dated 4/18/2025 indicated, Up on geriatric chair (geri-chair - a large, padded chair that is designed to help people with limited mobility) for mobility issues due to difficulty seating on upright positioned. During a record review of Resident 10's Medical Record as of 5/4/2025, there was no Informed Consent for the use of bed siderails and geri-chair with lap tray. During a record review of Resident 10's Care Plan (CP) as 5/4/2025, indicated there are no CP developed for the use of bed siderails. During a review of Resident 10's Physical Restraint Assessment, dated 4/18/2025, it indicated that, Resident 10 has poor safety awareness/judgement; Restraints recommended: Geri chair with tray; Summary: Geri-chair with a tray is recommended for this time, because of poor safety judgement due to inability to consider lack of independence, disorientation and impaired cognition. During the initial tour of the facility and observation of Resident 10 on 5/2/2025 at 5:55 p.m., Resident 10 was observed sitting on a geri-chair with a lap tray in the hallway by herself. Resident 10 was observed talking noncoherently. During an observation of Resident 10 on 5/3/2025 at 10:05 a.m., Resident 10 was sitting on a geri-chair ( is a large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) with a lap tray on in the hallway, right leg was dangling on the side, and no staff was observed assisting Resident 10. Resident 10 appeared confused and was talking incoherently to herself. During an observation of Resident 10 on 5/4/2025 at 9:10 a.m., Resident 10 was observed lying on bed with a bed siderails up. During a concurrent observation and interview with Registered Nurse (RN) 1 on 5/4/2025 at 9:26 a.m., RN 1 observed Resident 10 in the room, lying on a bed with a bed side rails up. RN 1 stated, there should be an order and a Care Plan for the use of bed siderails. RN 1 further stated, Resident 1 also uses a geri-chair with a lap tray on to get her up on bed, but it should be used for mobility. RN 1 stated the side rails and geri-chair with lap tray may cause harm to Resident 10 if it's being used in a wrong way like restricting resident's movement. RN 1 stated, an informed consent must be obtain from the resident and/or resident's representative for any device used that may restrict resident's mobility. During a concurrent interview and record review with Director of Nursing (DON) on 5/4/2025 at 3:50 p.m., DON reviewed Resident 10's Physical Restraint Assessment and stated, they (facility) are not using any restraints to Resident 10. DON stated the geri-chair with lap tray are to be used for mobility and the assessment for Physical Restraint was not properly documented. DON stated, there must be an informed consent for the use of geri-chair with laptray and bed siderails. DON stated, the use of these devices restricts resident's movement. During a record review of the facility policy and procedure (P&P) titled, Use of Restraints, revised on 8/2024, the P&P indicated, If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint . Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed; b. Tucking sheets so tightly that a bed-bound resident cannot move; c. Placing a resident in a chair that prevents the resident from rising; and d. Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising . Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint . Treatment restraints may be used for the protection of the resident during treatment and diagnostic procedures if the resident and/or representative have consented to the treatment or procedure and the use of treatment restraints. Treatment restraints shall be applied for no longer than the time required completing the treatment. During a record review of facility's P&P titled, Health, Medical, Treatment, Informing Residents of, revised 12/2024, the P&P indicated, Every resident is informed of his or her options for treatment and/or care.

Based on observation, and interview, the facility failed to maintain a clean, odor-free, well-kept environment for one of five sampled residents (Resident 1), by failing to ensure the resident's room and adjacent hallway were odor free. This failure resulted in a foul-smelling environment in Resident 1's room and the adjacent hallway. Findings: During a record review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/23/2024 and Resident 1 was readmitted to the facility on [DATE] with diagnoses including anxiety (a feeling of worry, fear, or unease, often accompanied by physical symptoms like a rapid heartbeat or shortness of breath), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/24/2025, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation on 5/3/3035, at 7:46 A.M., in Resident 1's room and adjacent hallway, a foul odor of urine was perceived by two surveyors. During a concurrent observation, and interview on 5/3/2035, at 7:50 A.M., with Certified Nursing Assistant (CNA) 4, in Resident 1's room, a foul-smelling urine odor was perceived and Resident 1's beddings were wet. CNA 4 stated that the foul-smelling odor was come from Resident 1, it was the smell of urine, and that when changing Resident 1, Resident 1's draw sheet (a special sheet placed on top of a bed's fitted sheet to make it easier to move someone who is having trouble moving themselves), under pad (using an absorbent pad, also called an under pad or chux, to protect bedding from moisture and accidents, especially related to incontinence) and Resident 1's pants were wet. CNA 4 stated that the strong foul-smelling odor of urine may have been strong because Resident 1 was not changed. CNA 4 stated residents need to be changed every two hours because if not done, this may lead to a urinary tract infection (UTI - an infection in the bladder/urinary tract) skin opening or wounds. During an interview on 5/4/2025, at 6:56 P.M., with the Director of Nursing (DON), the DON stated that the facility needs to maintain a home-like environment with comfort, space and pleasant smell that does not bother the residents, staff and visitors During a record review of the facility policy and procedure (P&P) titled Homelike Environment revised 2/2024, indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use theirpersonal belongings to the extent possible. 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. e. clean bed and bath linens that are in good condition. f. pleasant, neutral scents;

Based on observation, interview, and record review, the facility failed to ensure that two of three sampled residents reviewed for restraints (Residents 3 and 10) were free from physical restraint by: A. Failing to ensure the physician's order for bed siderails was in place and geriatric chair (geri chair - a large, padded, often wheeled chair designed to help seniors or individuals with limited mobility) with lap tray were properly assessed and evaluated for Resident 10. B. Resident 3 was observed with a geri chair parked alongside Resident 3 while she was in bed that restricted the resident's movement. These deficient practices had the potential to result in entrapment and injury with the use of restraints for Residents 3 and 10. Cross Reference F656, F552 Findings: 1. During a record review of the Admission Record indicated Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and unspecified dementia (a progressive state of decline in mental abilities). During a record review of the Minimum Data Set (MDS - resident assessment tool) dated 4/22/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 10 required moderate assistance to supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review of Resident 10's Order Summary Report indicated the following: i. As of 5/4/2025, there was no physician order for the use of bed siderails. ii. Physician's order dated 4/18/2025 indicated, Up on geri-chair for mobility issues due to difficulty seating on upright positioned. During a record eview of Resident 10's Medical Record as of 5/4/2025, there was no Informed Consent for the use of bed siderails and geri-chair with lap tray. During a record review of Resident 10's Care Plan (CP) as 5/4/2025, indicated there are no CP developed for the use of bed siderails. During a record review of Resident 10's Physical Restraint Assessment, dated 4/18/2025, it indicated that, Resident 10 has poor safety awareness/judgement; Restraints recommended: Geri chair with tray; Summary: Geri-chair with a tray is recommended for this time, because of poor safety judgement due to inability to consider lack of independence, disorientation and impaired cognition. During the initial tour of the facility and observation of Resident 10 on 5/2/2025 at 5:55 p.m., Resident 10 was observed sitting on a geri-chair with a lap tray in the hallway by herself. Resident 10 was observed talking noncoherently. During an observation of Resident 10 on 5/3/2025 at 10:05 a.m., Resident 10 was sitting on a geri-chair with a lap tray on in the hallway, right leg was dangling on the side, and no staff was observed assisting Resident 10. Resident 10 appeared confused and was talking incoherently to herself. During an observation of Resident 10 on 5/4/2025 at 9:10 a.m., Resident 10 was observed lying on bed with a bed siderails up. During a concurrent observation and interview with Registered Nurse Supervisor 1 (RNS 1) on 5/4/2025 at 9:26 a.m., RN 1 observed Resident 10 in the room, lying on a bed with a bed side rails up. RN 1 stated, there should be an order and a Care Plan for the use of bed siderails. RN 1 further stated, Resident 1 also uses a geri-chair with a lap tray on to get her up on bed, but it should be used for mobility. RN 1 stated the side rails and geri-chair with lap tray may cause harm to Resident 10 if it's being used in a wrong way like restricting resident's movement. RN 1 stated, an informed consent must be obtain from the resident and/or resident's representative for any device used that may restrict resident's mobility. During a concurrent interview and record review with Director of Nursing (DON) on 5/4/2025 at 3:50 p.m., DON reviewed Resident 10's Physical Restraint Assessment and stated, they are not using any restraints to Resident 10. DON stated the geri-chair with lap tray are to be used for mobility and the assessment for Physical Restraint was not properly documented. DON stated, there must be an informed consent for the use of geri-chair with laptray and bed siderails. DON stated, the use of these devices restricts resident's movement. During a record review of the facility policy and procedures (P&P) titled, Use of Restraints, revised on 8/2024, the P&P indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint . Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed; b. Tucking sheets so tightly that a bed-bound resident cannot move; c. Placing a resident in a chair that prevents the resident from rising; and d. Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising . Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint . 45528 2. During a record review of Resident 3's Admission Record indicated the facility admitted Resident 3 on 12/4/2023 and Resident 3 was readmitted to the facility on [DATE] with diagnoses including abnormality of gait and mobility (having trouble walking or moving around smoothly and efficiently), Parkinson's (a condition where nerve cells in the brain that produce dopamine [a chemical messenger] start to die off or become damaged), and unspecified psychosis (someone is experiencing symptoms of psychosis, like hallucinations [seeing or hearing things that aren't real) and delusions (holding strong, false beliefs]). During a record review of Resident 3's MDS dated [DATE], indicated Resident 3 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 3 was dependent on staff for ADL. During a concurrent observation and interview on 5/4/2025, at 1:56 P.M., with Certified Nursing assistant (CNA) 3 in Resident 3's room, a geri chair was observed parked alongside Resident 3's bed. CNA 3 stated that the geri chair should not be placed alongside the bed of Resident 3 for safety reasons. CNA 3 stated the geri chair at the bedside may lead to Resident 3 bumping into the chair, trip, fall, it is dangerous. During a concurrent interview and record review, on 5/4/2025, at 2:01 P.M., with the RNS 1, a picture of the geri chair parked alongside Resident 3's bed was reviewed. RNS 1 stated that the geri chair should not be placed alongside Resident 3's bed as it is a restraint when used in that manner. RNS 1 stated Resident 3 may fall trying to get out of bed. During an interview on 5/4/2025, at 6:52 P.M., with the DON, the DON stated the geri chair should not be at the bedside as Resident may not be able to get out of bed, their access may be blocked and get the resident entrapped or trapped. During a record review of the facility's P&P titled, Use of Restraints, revised 8/2024, indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline or staff convenience, or for the prevention of falls. 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint.

Based on interview and record review, the facility failed to ensure residents' notice of proposed transfer/discharge notification was sent to the Office of the State Long-Term Care Ombudsman (public advocate) on a timely manner for one of three sampled discharged residents reviewed (Resident 39) as indicated in the facility's policy. This deficient practice had the potential to deny Resident 39's protection from being inappropriately discharged . Findings: During a record review of the Admission Record, Resident 39 was admitted to the facility 11/18/2024 with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), chronic pancreatitis (a long-lasting inflammation of the pancreas, a gland behind the stomach that helps with digestion and regulates blood sugar), and muscle weakness (weakening, shrinking, and loss of muscle). During a record review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/24/2025, indicated Resident 39's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 39 required moderate assistance to supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review of Resident 39's Discharge Summary Plan of Care, dated 2/11/2025, it indicated, Resident 39 was discharged at an Assisted Living Facility (ALF - provides housing and personal care services for individuals who need help with daily tasks like bathing, dressing, and eating, but don't require the 24-hour medical care of a nursing home) on 2/11/2025. During a record review of Resident 39's Notice of Proposed Transfer/Discharge indicated the notification was sent to Ombudsman via facsimile transmission dated 5/4/2025. During an interview with the Director of Nursing (DON) on 5/4/2025 at 1:15 p.m., DON stated, Resident 39's discharge notification was sent today (5/4/2025) via fax to the Ombudsman's office. DON stated that they have 30 days to send the notification to the Ombudsman after discharge. DON then reviewed the policies and procedure (P&P) and stated, the written notifications to the Ombudsman and residents/resident's representative shall be given with an advance 30-day written notice of an impending transfer or discharge. DON further stated, Ombudsman must be given an advance notice so that they may be able to assist residents if they don't agree with the discharge planning. During a record review of the facility policy and procedures (P&P) titled, Transfer or Discharge Notice, reviewed/revised on 3/20/2025, the P&P indicated, Our facility shall provide a resident and/or the resident's representative (sponsor) with a 30-day written notice of an impending transfer or discharge . A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on interview and record review, the facility failed to ensure that a Pre-Admission Screening Resident Review level II (a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) was obtained and maintained in the residents chart for two of three sampled residents (Residents 1 and 25). This deficient practice had the potential to negatively affect the appropriate care and services rendered to Residents. 1 and 25 Findings: During a record review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/23/2024 and Resident 1 was readmitted to the facility on [DATE] with diagnoses including anxiety (a feeling of worry, fear, or unease, often accompanied by physical symptoms like a rapid heartbeat or shortness of breath), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/24/2025, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review, on 5/4/2025, at 10:32 A.M., with the Minimal Data Set Nurse (MDSN) nurse, Resident 1's PASARR level I and chart were reviewed. The PASARR level I dated 11/11/2024, indicated Resident I was positive for PASARR level I and required to have an evaluation for PASARR level II. The MDS nurse stated that the facility process for a PASARR level II is that the PASARR level II office will call within three days for a follow up however, it they do not call, then the facility has to follow up. The MDSN stated that there was no documented evidence that the PASARR level II office called or that the facility made a follow up with the PASARR level II office. The MDSN stated that the facility should have followed up with the PASARR level II off to ensure that Resident 1's care was customized to the resident so that Resident 1 can be given care that Resident 1 is supposed to be receiving. During a record review of Resident 25's Admission Record indicated the facility admitted Resident 25 on 6/29/2023 and readmitted Resident 25 on 4/8/2025 with diagnoses including hypertension (HTN-high blood pressure), anxiety (a feeling of worry, fear, or unease, often accompanied by physical symptoms like a rapid heartbeat or shortness of breath), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a record review of Resident 25's MDS dated [DATE], indicated Resident 25 had cognitive impairment. The MDS indicated Resident 25 was dependent on staff for activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review, on 5/4/2025, at 11:07 A.M., with MDSN nurse, Resident 25's PASARR level I and chart were reviewed. The PASARR level I indicated that Resident 25 was positive for PASARR level I and required to have an evaluation for PASARR level II. The MDSN stated that the facility process for PASARR level II is that the PASARR level II office will call within three days for a follow up however, it they do not call, then the facility has to follow up. The MDSN stated that there was no documented evidence that the PASARR level II office called or that the facility made a follow up with the PASARR level II office. The MDSN stated that the facility should have followed up with the PASARR level II office to ensure that Resident 25's care was specialized to the residents so that Resident 25 did not have missing information needed to provide Resident 25 with the care that is needed. During an interview on 5/4/2025, at 6:46 P.M., with the Director of Nursing (DON), the DON stated that the PASARR is an assessment that evaluates the placement of the resident's care into the facility, if they residents need a referral to mental health and obtain resources needed for the residents. The DON stated that the facility process for PASARR level II is that the facility will make a referral to the PASARR office for level II and follow up with them. The DON stated not having a PASARR level II follow up may lead to a delay in care and the residents will not have proper follow-up care like mental health care for instance. During a record review of the facility Policy and Procedures (P&P) titled, Pre-Admission Screening Level II Resident Review (PASRR Level II, dated 3/20/2025, indicated, To coordinate assessments with the pre-admissions screening and resident review (PASRR) program under Medicaid/Medical to the maximum effort possible to avoid duplicative testing and effort .The facility staff will coordinate the recommendations from the level II PASRR determination and the PASRR evaluation report with the residents' assessment, care planning and transitions of care.

Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of 12 sampled residents (Resident 10) by failing to develop a comprehensive (CP) with the use of bilateral bed siderails for Resident 10. This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received. Findings: During a record review of the Admission Record indicated Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and unspecified dementia (a progressive state of decline in mental abilities). During a record review of the Minimum Data Set (MDS - resident assessment tool) dated 4/22/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 10 required moderate assistance to supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review of Resident 10's Order Summary Report indicated: i. As of 5/4/2025, there was no physician order for the use of bed siderails. During a record review of Resident 10's Care Plan (CP) as 5/4/2025, indicated there are no CP developed for the use of bed siderails. During an observation of Resident 10 on 5/4/2025 at 9:10 a.m., Resident 10 was observed lying on bed with bed siderails up. During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 5/4/2025 at 9:26 a.m., RN 1 observed Resident 10 in the room, lying on a bed with a bed side rails up. RN 1 stated, there should be an order and a Care Plan for the use of bed siderails. RN 1 stated the side rails may cause harm to Resident 10 if it's being used in a wrong way like restricting resident's movement. During a concurrent interview and record review with Director of Nursing (DON) on 5/4/2025 at 3:50 p.m., DON stated, there must be a CP developed for the use of devices that may restrict resident's movement. DON stated, there was no CP developed for Resident 10's used of bed siderails. During a record review of the facility policy and procedures (P&P) titled, Use of Restraints, revised on 8/2024, the P&P indicated, If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint . Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed . Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). During a record review of the facility P&P titled, Care Planning - Interdisciplinary Team, reviewed 3/20/2025, the P&P indicated, Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).

Based on interview and record review, for one of five sampled resident (Resident 1), Resident 1 who fell in the facility on 1/15/2025, the facility failed to ensure: 1) Certified Nurse's Aide (CNA) 2, closely monitored and supervised Resident 1 while assigned as Resident 1's one to one (1:1- a caregiver provides dedicated, focused attention and assistance to a single individual, ensuring their needs and well-being are met with personalized support) sitter on 3/02/2025 on the 11 PM to 7 AM shift. 2) CNA 2 immediately notified a licensed nurse that Resident 1 fell on [DATE] at 4:30 AM to ensure timely assessment and intervention(s) for the resident. 3) CNA 2 was not assigned as a 1:1 sitter for two residents (Residents 1 and 5) on 3/02/2025 on the 11 PM to 7 AM shift 4) Resident 1, who was a high risk for falls, had a care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) for 1:1 sitter to closely monitor and supervise to prevent the resident from falling. 5) CNA 2 was close and at arm's length to immediately assist Resident 1 when the resident was getting out of bed on 3/03/2025 at 4:30 AM As a result, on 3/03/2025 at 4:30 AM, Resident 1 fell and sustained a left hip fracture (break in a bone). Resident 1 suffered severe pain and mild swelling to the left hip on 3/03/2025 at 11:58 PM. Resident 1 sustained a comminuted (broken in three or more pieces) mildly displaced intertrochanteric fracture (a type of hip fracture where the broken pieces of the bone have moved or separated between the two bones that protrudes [sticks out]) of the left hip. On 3/04/2025, Resident 1 was transferred to a GACH) for further evaluation and care. Findings: A review of Resident 1's (Resident 5's roommate) Admission Record was admitted to the facility on [DATE] with the following diagnoses: generalized muscle weakness (lack of physical or muscle strength), difficulty in walking (inability to walk which includes problems standing, moving, and loss of balance), and unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of Resident 1's MDS dated [DATE], indicated, Resident 1 had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS also indicated, Resident 1 used a walker and a wheelchair (devises used to assist a person walk or move from place to place when one has a disability or injury). The MDS also indicated, Resident 1 needed maximal assistance with toileting hygiene (maintaining cleanliness before and after using the toilet) due to urinary and bowel incontinence (lack of voluntary control over urination or bowel movement). A review of Resident 1's initial Fall Risk assessment dated [DATE], indicated, Resident 1 fall risk score was 18 (a fall risk score of 10 or above represents high risk for falls). A review of Resident 1's Fall Risk assessment dated [DATE] indicated, Resident 1 score for fall was 19 (high fall risk). A review of Resident 1's Interdisciplinary Team (IDT - a group of different healthcare professionals working together towards a common goal for a resident) Progress Notes dated 1/15/2025 at 2:27 PM, indicated, IDT recommended a 1:1 sitter to ensure safety for Resident 1. A review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) sign-in sheet dated 1/09/2025, indicated, CNA 2 signed confirming that CNA 2 received training on Preventing falls in the elderly. A review of Resident 1's history and physical (H&P - a physician's complete patient examination) dated 1/15/2025, indicated, Resident 1 was confused and disoriented , had impaired mobility (a condition that limits or prevents a person's ability to move or perform physical tasks, ranging from fine motor skills to gross motor skills like walking) and activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and generalized weakness. The H&P also indicated Resident 1 lacked the capacity to make medical decisions. A review of Resident 1's CP on impaired ambulation (act of walking) dated 1/15/2025, indicated, Resident 1 had difficulty in walking. The CP goal indicated stand-by assist (SBA) for ambulation, and that Resident 1 used a front wheel walker (FWW) for mobility. The CP interventions included gait training (focuses on improving a person's ability to walk, often involving exercises to strengthen muscles, improve balance, and enhance overall mobility), and caregiver education (equip caregivers with the knowledge and skills needed to effectively care for others). A review of Resident 1's CP on ADLs dated 1/16/2025, indicated, Resident 1 demonstrated ADL decline because of generalized weakness, decreased overall safety awareness, and fall risk. The CP goal indicated Resident 1 will demonstrate improved safety awareness and decreased risk of fall. The CP interventions included caregiver education. A review of the facility's In-Service Education sign-in sheet dated 2/04/2025 indicated, CNA 2 signed in and received education on What to do when a patient fall. The In-service education lesson plan indicated that after a fall, the resident is not moved until assessed by a physical therapist (PT - healthcare professional who helps people improve their movement and physical function, manage pain, and recover from injuries and chronic conditions through a variety of treatments) or charge nurse. A review of Resident 1's Psychology Notes (a standardized tool used by psychologists to record resident's mental and emotional state, behavior and any changes in their condition, to inform care planning and treatment) dated 2/07/2025, indicated, Resident 1's dementia impacted Resident 1's awareness (not specified) requiring continued monitoring. A review of the facility Nursing Assignment Sheet dated 3/02/2025 for the 11 PM to 7 AM shift, indicated, CNA 2 was assigned as a 1:1 sitter for Resident 1 and Resident 5. A review of Resident 5's Sitter Log Sheet dated 3/02/2025 from 11 PM to 7 AM shift, indicated, CNA 2 was assigned as 1:1 sitter for Resident 5. A review of the facility Sitter Log Sheet (a document used to record information about the observation and/or assistance to a resident during a specific shift or period) dated 3/02/2025 on the 11 PM - 7 AM shift, indicated CNA 2 documented that Resident 1 was awake from 1 AM until 5 AM on 3/03/2025. There was no documentation that Resident 1 fell on [DATE] at 4:30 AM. A review of Resident 1's CP on alteration in musculoskeletal (a system of muscles, bones, tendons, ligaments, joints, and cartilage that work together) status dated 3/03/2025, indicated, Resident 1 had a fracture (a break or crack) of the left trochanter/femur (left hip bone) and pain to the left lower extremity (the part of the body that includes the hip, thigh, knee, leg, ankle, and foot) during movement. The CP goal indicated Resident 1 will remain free from pain or at a level of discomfort acceptable to Resident 1. The CP interventions included to assist Resident 1 with ADLs, mobility (ability to move freely and easily), and immobilize (reduce or eliminate movement) the left lower extremity, provide pain medicine as ordered by the physician, and transfer Resident 1 to GACH for further evaluation and treatment. A review of Resident 1's Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time) dated 3/03/2025 at 9:20 AM, indicated, Licensed Vocational Nurse (LVN) 1 documented that CNA 1 approached LVN 1 because Resident 1 complained of pain during perineal care (washing of the private parts). The Nursing Progress Notes indicated LVN 1 assessed Resident 1 who had pain on the left hip area .and left leg area noted with mild swelling. The Nursing Progress Notes indicated LVN 1 instructed CNA 1 to not to mobilize (move) patient (Resident 1), LVN 1 then notified Registered Nurse Supervisor (RNS), and Resident 1 was medicated with pain medicine, acetaminophen (mild pain reliever) 1000 mg (milligram - a unit of measure of mass [amount of material it contains] in the metric system) by mouth (PO) on 3/03/2025 at 9:21 AM. A review of Resident 1's Nursing Progress Notes dated 3/03/2025 at 9:25 AM, indicated, RNS assessed, and that Resident 1 had left hip area with pain upon touching the area, of 5 out of 10 pain level (5/10 - a numerical pain assessment tool where 0 [zero] pain is no pain, and 10 pain is the worst possible pain). RNS stated MD ordered for an x-ray (pictures of the inside of a body to look at bones and joints). RNS stated RNS called and left a message to family member of Resident 1 (FMR1) to call RNS back. A review of Resident 1's x-ray report dated 3/03/2025 indicated, Resident 1 had a comminuted (broken in three or more pieces) mildly displaced intertrochanteric fracture (a type of hip fracture where the broken pieces of the bone have moved or separated between the two bones that protrudes [sticks out]) of the left hip. A review of Resident 1's Nursing Progress Notes documented by LVN 2, dated 3/03/2025 at 11:09 PM, indicated, Resident 1 complained of left leg pain with a pain scale of 4/10, pain medicine, acetaminophen 1000 mg, was given on 3/03/2025 at 5:30 PM. The Nursing Progress Notes that on 3/04/2025 at 6:30 PM, x-ray result was received which confirmed Resident 1 sustained a left hip fracture, and a medical doctor (MD) was informed who ordered to transfer Resident 1 to GACH for further evaluation. A review of Resident 1's Physician Order Summary Report dated 3/04/2025, indicated, a physician ordered Resident 1 to be transferred out from the facility to GACH on 3/03/2025 due to left hip fracture. A review of the facility Sitter Log Sheet dated 3/03/2025 at 11:58 PM, indicated, a sitter documented that Resident 1 was transferred to a GACH. During an interview on 3/17/2025 at 1:24 PM with CNA 1, CNA 1 stated that on 3/03/2025 at around 9 AM when CNA 1 attempted to turn Resident 1 onto the right side to perform perineal care (washing of the private parts) because Resident 1 was wet, but Resident 1 started to scream. CNA 1 stated Resident 1 said something in Resident 1's native language. CNA 1 stated CNA 1 asked CNA 4 (who speaks Resident 1's native language) to translate what Resident 1 was saying. CNA 1 stated Resident 1 told CNA 4 pain, pain, pain in Resident 1's native language and immediately notified LVN 1 who immediately went to Resident 1's room and assessed Resident 1. CNA 1 stated LVN 1 instructed CNA 1 [Resident 1] should not get up .because of pain. CNA 1 stated Resident 1 has dementia and forgets a lot . I've seen [Resident 1] try to get out of bed without assistance. CNA 1 stated Resident 1 needs assistance from staff to get out of bed, because the resident is not stable on the feet, he [Resident 1] is weak, he's [AGE] years old . During an interview on 3/17/2025 at 1:52 PM with LVN 1, LVN 1 stated that on 3/03/2025 at 9:20 AM CNA 1 called LVN 1 to Resident 1's room because Resident 1 was complaining of pain. LVN 1 stated Resident 1 was in the bed and was crying. LVN 1 stated LVN 1 asked CNA 4 (speaks Resident 1's native language) to translate what Resident 1 was saying. LVN 1 stated CNA 4 reported that Resident 1 said that Resident 1 was in pain, Resident 1 fell in the middle of the night and that a man picked up the resident and put Resident 1 back to bed. LVN 1 stated Resident 1 made noises (did not specify) when touched on the left hip and when LVN 1 and CNA 1 attempted to perform perineal care because Resident 1 was wet from urine and that LVN 1 notified RNS of Resident 1's change of condition (COC - a significant change in a resident's health or functional status) and administered acetaminophen 1000 mg to Resident 1. LVN 1 stated Resident 1 has episodes of trying to get out of bed sometimes; that's why there is a sitter. During an interview on 3/17/2025 at 2:25 PM with RNS, RNS stated that on 3/03/2025 at 9:25 AM LVN 1 reported to RNS that Resident 1 had pain to the left hip area. RNS stated RNS assessed and identified that Resident 1's left hip and left leg areas was swollen with no discoloration (any change in your natural skin tone). RNS stated Resident 1 said dolor (pain) and ouch during the assessment. RNS stated RNS asked CNA 4 to translate what Resident 1 was saying. RNS stated CNA 4 told RNS that Resident 1 answered yes when asked if in pain and then pointed to the [Resident 1's] the left hip area. RNS stated [Resident 1] said a guy picked [Resident 1] up from the floor [NAME] (night). RNS stated, I was called into [Resident 1's] at 9:30 AM. I know nothing bad happened to [Resident 1] from the time we started our shift at 7 AM. RNS stated RNS instructed LVN 1 to administer pain medicine to Resident 1, instructed the nursing staff not to move Resident 1, and contacted the MD and Resident 1's family regarding Resident 1's COC. RNS stated MD ordered an x-ray of Resident 1's left hip which was completed after RNS left work at 3:30 PM on 3/03/2025. RNS stated [Resident 1] climbs out of bed, this is a daily thing and that is why we put a 1:1 sitter for the resident. RNS did state for how long CNA 2 was assigned as a sitter for Resident 1. During a telephone interview on 3/17/2025 at 3:35 PM with CNA 2, CNA 2 stated that on 3/03/2025 at around 4:30 AM, Resident 1 got out of bed and I rushed to [Resident 1] because [ Resident 1] was struggling. [Resident 1] started lowering himself, so I assisted [Resident 1] to the floor. CNA 2 stated CNA 2 asked CNA 5 to assist CNA 2 place Resident 1 back in bed and that CNA 3 assisted CNA 2 clean Resident 1 because Resident 1 had a bowel movement (stool/feces). CNA 2 stated, Resident 1, There is nothing to report (about the fall). CNA 2 then stated, it was important to report a fall incident so the resident can be evaluated right away. CNA 2 also stated if the fall incident is not reported, Resident 1, may get hurt, more sick. CNA 2 stated Resident 1 never got out of bed until that time (fall incident on 3/03/2025 at 4:30 AM). CNA 2 also stated that on 3/02/2025 on 11 PM to 7 AM shift, the facility assigned CNA 2 as a sitter for Resident 1 and Resident 5 and also to care for Resident 1 and Resident 5. CNA 2 stated that Resident 1 and Resident 5 were roommates. A review of the facility undated document titled Assisted Falls, indicated, . If a resident is going down to the ground and you assist them to the floor , this is a fall and must be reported. During a phone interview on 3/26/2025 at 11:19 AM with CNA 2, CNA 2 stated that on 3/03/2025 at around 4:30 AM, I was sitting in a chair against the wall by the bedside by the door in Resident 1's room. CNA 2 stated, I rushed to [Resident 1] when I saw [Resident 1] trying to get out of bed on the other (opposite) side. I was sitting by the side of the resident's bed, between the resident's bed and the door. CNA 2 stated Resident 1 took two to three steps, was struggling to balance and held on to CNA 2. CNA 2 stated as a 1:1 sitter CNA 2 is responsible in making sure Resident 1 does not fall because the resident is a fall risk, keep an eye on the resident, take Resident 1 to the bathroom, and perform care on Resident 1. During an interview on 3/26/2025 at 12:05 PM with CNA 2, CNA 2 stated, I was sitting close to [Resident 1's] feet, at the foot of the bed. CNA 2 as a 1:1 sitter, the only thing I need to do is sit close to the patient [Resident 1] at arm's length. When I stretch my arm and touch him that is an arm's length. CNA 2 stated during a 1:1 sitter assignment, CNA 2 is supposed to only have and care for one resident. CNA 2 stated that on 3/02/2025 on the 11 PM to 7 AM shift, CNA 2 was assigned to care for Resident 1 and Resident 5 who were in the same room. CNA 2 stated, The fact is, normally [Resident 1] does get out of bed and [Resident 5] doesn't normally get out of bed. I watch [Resident 5] because [Resident 5] is confused. CNA 2 stated that on 3/02/2025 on the 11 PM to 7 AM shift, both bed side rails were down on Resident 1's bed. CNA 2 stated, When I picked up [Resident 1], the resident was on the floor between Resident 1's bed and Resident 5's bed. That is the reason why I had to rush to him. CNA 2 did not report this incident. During a phone interview on 3/26/2025 at 1:18 PM with CNA 3, CNA 3 stated that on 3/03/2025 at almost 5 AM, CNA 3 walked into Resident 1's room to assist CNA 2 with Resident 1's perineal care. CNA 3 stated Resident 1 was crying and hurting on the left side around the hip. CNA 3 stated, I heard [Resident 1] say something in [in the resident's native language] my leg, my leg, while holding [Resident 1's] left leg. I speak a bit of (in the resident's native language). CNA 3 stated CNA 3 saw a chair used by CNA 2 by the door in Resident 1's room. During a concurrent interview and concurrent record review on 3/26/2025 at 3:21 PM with RNS, RNS stated, a 1:1 sitter is one staff that only takes care of one patient for a resident who tries to get out of bed unassisted, has periods of confusion or disorientation. RNS stated the 1:1 sitter should sit, About 5 feet away from the resident, but no more than that. As long as the sitter can stop the patient from getting out of bed to prevent from falling. RNS stated a sitter can have more than one patient (resident) to care for if the residents are in the same room, Depends on the acuity (the severity and complexity of a patient's condition, or their need for care and resources) of the patient. Some patients only stay in bed. The facility nursing assignment sheet dated 3/02/2025 for the 11 PM to 7 AM shift was reviewed with RNS. The facility nursing assignment sheet indicated CNA 2 was assigned as a 1:1 sitter for Resident 1 and Resident 5. RNS stated I think it's because (CNA 2 assigned as a sitter for Resident 1 and Resident 5) the patients were in the same room. Both patients were sleeping at night most of the time. RNS stated the main responsibility of a 1:1 sitter is to make sure the resident is safe .prevent from falling, not getting up at night without assistance. The Sitter Log Sheet for March 2025 for the 11 Pm to 7 AM was also reviewed with RNS. RNS stated that a Sitter Log Sheet is a log of what the patient is doing during the time sitter is caring for them. If awake, asleep, in bed, up in wheelchair. RNS stated CNA 2 should have documented the date and time Resident 1 fell . RNS stated, Yes, not only that, but the sitter also (CNA 2) should report to the charge nurse (LVN 1) right away. RNS stated, resident may have some injury .fracture some bones . During a concurrent interview and concurrent record review on 3/26/2025 at 3:55 PM with the DON, the DON stated a 1:1 sitter was a staff that is designated to stay or be with one resident. To make sure that there is somebody that closely checking or monitor the residents. The DON stated Resident 1 needed 1:1 sitter to make sure there is someone to assist Resident 1 whenever Resident 1 needs to ambulate . The DON stated Resident 1 is unstable on the feet and is restless at times. DON stated, a 1:1 sitter should be close enough to the resident where they can help the resident right away . within arm's length . the sitter should be within arm's length. The facility nursing assignment dated 3/02/2025 for the 11 PM to 7 AM shift was reviewed with the DON. The DON did not know why CNA 2 was assigned as a 1:1 sitter for Resident 1 and Resident 5. The DON stated, from what I know, 1:1 cannot be assigned to anyone else, one CNA to one patient (resident). The Sitter Log Sheet for March 2025 was reviewed with the DON. The DON stated, the Sitter Log Sheet is to account for what happens to a resident during that shift and day. The DON stated assisting Resident 1 to the floor by CNA 2, is considered a fall, it is an assisted fall. The DON stated if a fall incident is not reported, We can delay treatment .for fracture. Or delay identifying resident's needs. We would have missed something for [Resident 1] that needed to be assessed because we did not know it (fall) happened. The DON stated assigning CNA 2 as a sitter to Resident 1 and Resident 5, can result in one of the residents to not be closely monitored, result in accidents for the residents, and the residents' needs will not be attended to in a timely manner. A review of the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Falls-Clinical Protocol reviewed on 3/29/2024, indicated, resident may require 1:1 sitter as recommended by the IDT members and sitters will .complete the sitter log provided to them . A review of the facility P&P titled Assessing Falls and Their Causes reviewed on 3/29/2024 indicated, when a resident falls to notify the nursing supervisor on duty. A review of the facility P&P titled Safety and Supervision of Residents reviewed date on 3/29/2024, indicated, employees shall .demonstrate competency on how to identify and report .avoidable accidents. Resident supervision is the core component of the facility's approach to safety. A review of the facility P&P titled Falls and Fall Risk, Managing, review on 3/29/2024, indicated, Cognitive impairment (trouble participating in conversations), lower extremity weakness, incontinence, and balance and gait disorders (difficulties with maintaining balance and walking leading to unsteadiness, increased risk of falls, and altered walking patterns) were factors that may contribute to residents' risk of falls. A review of the facility P&P titled Care Giver/Sitter reviewed on 3/29/2024, indicated, Caregiver/sitter must report changes in a resident condition to the nurse supervisor/charge nurse immediately, and the facility's staff may serve as a caregiver/sitter when approved by the DON or facility care team. A review of the facility P&P titled Sitter Responsibilities/Accountabilities reviewed on 3/29/2024, indicated, Caregiver/sitter should be able to supervise residents, and to report any unusual occurrence to the charge nurse.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and transmitted from person to person) in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for five of eight sampled residents (Residents 2, 3, 6, 7, 8) and one of three facility staff (Licensed Vocational Nurse 2 - LVN 2), by failing to: 1. Implement a screening process, including checking for signs and symptoms of COVID-19, history of travel, any contact with positive COVID-19 persons and reminder to do hand hygiene upon entering and exiting the facility. 2. Ensure the Screener (S1) disinfected pens and thermometer between staff and essential visitors' usage. 3. Ensure Licensed Vocational Nurse 2 (LVN 2) and all facility staff were fit tested (a respirator fit test checks the right size and seal of the person who wears it, to prevent air leak) with the proper N95 masks (a particulate-filtering face piece respiratory that meets the US National Institute for Occupational Safety and Health (NIOSH) and filters at least 95% of airborne particles) and ensuring enough supply for all staff. 4. Ensure Certified Nursing Assistant 2, 3, 4 (CNA2, 3, 4) and all staff wear the proper Personal Protective Equipment (PPE - protective clothing, goggles, or other garments or equipment designed to protect the wearer's body from serious workplace injury or illnesses) to provide care to residents in specific cohorting units (imposed grouping of people, such as residents potentially exposed to a designated disease, separation areas between Covid-19 and Non-Covid unit). 5. Ensure the facility had a clear designation of Cohorting units with the use of signages such as Green zone, Yellow zone and Red zone. Residents 2, 3, 6, 8 were in the Red zone and Resident 7 was in the Yellow zone. 6. Ensure a full-time, dedicated Infection Preventionist (IP) was knowledgeable on cohorting (imposed grouping of people, such as residents potentially exposed to a designated disease) residents as per recommendation from the Public Health Nurse (PHN). 7. Properly assess Resident 6 and Resident 8, who had suspected respiratory or infectious illness, every four hours or at least twice during each shift, to quickly identify residents who require transfer to a higher level of care. These deficient practices had the potential to result in spread of COVID-19 placing all 28 residents in the facility and staff at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 11/23/2020 at 5:06 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Director of Nursing (DON), Infection Preventionist Nurse 2 (IP2), the Administrator and the Business Office Administrator, via telephone, for the facility's failure to implement interventions to prevent the transmission of COVID-19 infection that threatened the health and safety of the residents and staff. On 11/25/2020 at 5:50 p.m., the IJ situation was lifted after the facility submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices); the surveyor verified and confirmed the implementation of the POA while onsite through observations, interviews and record review. The IJ situation was removed in the presence of the Administrator. The accepted POA included the following actions: 1. All persons are being screened and notified to do hand hygiene upon entrance and exiting the facility by the assigned screener upon entering and exiting the facility. 2. Staff are disinfecting pens and thermometers between persons. 3. Staff is using proper N95. All active employees are N95 fit tested . 4. Staff is wearing the proper PPE in all zone and In- services provided to all staff. 5. Clear designation of Cohorting zones. 6. Infection Preventionist 1 became the full time, dedicated IP for the facility 7. In-services provided to all staff regarding Resident 6 and Resident8's change of condition and resident monitoring for COVID-19 signs and symptoms order changed from every shift to every four hours. Findings: A review of the facility's census during onsite visits conducted on 11/12/2020, 11/23/2020, and 11/24/2020, indicated facility had 33, 28, and 25 residents in-house, respectively. 1. On 11/12/2020 at 11:50 a.m., during an observation, one of the locked entrances of the facility indicated there was no personnel at the screening area. Licensed Vocational Nurse 1 (LVN 1) unlocked the door for the visitors, requested to complete the questionnaires and check each other's temperature via handheld thermometer. No other guidance was provided from LVN 1 to the visitors, such as hand hygiene. Upon observation, the facility had one surveillance log for both the staff and visitors. The log indicated there were missing temperatures upon exiting the facility for 5 of 6 places dated 11/11/2020. During a concurrent interview, LVN 1 stated the log should not have any missing areas since the facility staff should be checking temperatures before and after each shift to limit risk of infection. During an observation, on 11/12/2020 at 12:13 p.m., upon the other entrance to the facility, Licensed Vocational Nurse 2 (LVN 2) did not provide a reminder to the visitors regarding hand hygiene and stated that the unit did not have a screening log. LVN 2 verbalized that it was important to have a process of screening both staff and visitors for any signs and symptoms of infection before entering and exiting the facility to decrease transmission of infection. During an interview with the Director of Nursing (DON), on 11/12/2020 at 12:55 p.m., the DON stated the screening log for both the staff and visitors should be completed to monitor the spread of infection. A review of facility's Mitigation Plan (page 6), revised on 10/2/2020, indicated to limit transmission and spread of infectious disease throughout the facility, all incoming and outgoing staff shall be screened for symptoms of COVID-19, and a designee will be assigned to screen. All incoming and outgoing visitors must be screened for symptoms of COVID-19 temperature, cough and documented. 2. During an observation, on 11/23/2020 at 2:50 p.m., a facility Screener checked the visitor's temperature via the forehead, without disinfecting the thermometer between visitors. During a concurrent interview, the DON stated the screener's job was to ask all the Covid-19 related questionnaires to all the staff and visitors, check the temperature, document and sanitize all the pens and thermometers in between use. A review of the facility's Mitigation Plan (page 6), revised on 10/2/2020, indicated under the Infection Prevention and Control section, staff shall clean and disinfect reusable equipment before and after each use. 3. On 11/12/2020 at 12:13 p.m., LVN 2 was observed wearing a smaller N95 mask that appeared too tight. During a concurrent interview, LVN 2 stated staff needed to wear a N95 mask in the yellow zone and be fit tested with the proper N95 for protection. When asked about the size of his mask, LVN 2 stated he used a smaller size mask due to not having any bigger sizes in the facility. LVN 2 stated that the staff was not N95 fit tested . During an interview, on 11/12/2020 at 2:45 p.m., the DON stated the facility was waiting for a delivery of larger size N95 masks and that the Public Health Nurse provided the DON some suppliers for the N95 fit testing for the staff. The DON added that using the proper N95 fit can protect staff in getting infected with COVID-19. According to a review of the facility's line listing, LVN 2 tested positive for Covid-19 on 11/18/2020. A review of the facility's Mitigation Plan (page 7), revised on 10/2/2020, indicated under the Personal Protective Equipment (PPE) section, a designated employee would maintain a 14 day supply of PPE in the facility, would conduct daily PPE inventory, and report exact amount of PPE during the standup meeting. A review of the facility's policy titled, Pandemic Infectious disease, undated, indicated during a COVID-19 alert period, the facility will assure adequate supplies for PPE and equipment so that cross contamination from patient to patient and staff to patient will not occur. The facility will ensure all staff have access to an appropriate amount of personal protective equipment for each patient seen daily. 4. A review of Admission Record indicated Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation in the yellow zone (a designated space for patient under investigation for Covid-19 under droplet precaution), on 11/12/2020 at 2:13 p.m., inside Resident 7's room, Certified Nursing Assistant 2 (CNA2) removed the N95 mask, kept it hanging on the neck, and then proceeded to donn (put on) the surgical mask (a loose-fitting disposable mask that protects the wearer's nose and mouth from contact with droplets, splashes and sprays that may contain germs). Once CNA2 saw she was being watched, CNA2 immediately placed the N95 mask on top of the surgical mask. During a concurrent interview, CNA2 stated the N95 mask should be worn at all times while in the yellow zone to prevent any spread of infection. CNA2 added that she changed it to a surgical mask because it was hard to breathe through the N95 mask. During an interview, on 11/12/2020 at 2:20 p.m., the DON stated and verified the N95 mask, face shields, goggle, gowns and gloves were needed in the yellow zone for protection. According to a review of the facility's line listing, Resident 7 tested positive for Covid-19 on 11/13/2020. A review of the facility's policy titled, Transmission based Precautions and personal protective equipment, undated, indicated while in the yellow and red zones, N95 respirators should be worn. A review of an Inservice form, dated 11/10/2020, indicated CNA2 attended an in-service regarding review of Cohorting zones and PPE use by Infection Preventionist 1. During an observation in the red zone, on 11/24/2020 at 6:15 a.m., CNA3 was noted using a mask with an exhaust valve and not wearing a face shield. During a concurrent interview, CNA3 stated the mask with exhaust valve was not provided by the facility and that she preferred using this particular type mask because it was easier to breathe. CNA3 stated she did not like wearing the face shield because it fogs up her eyeglasses. CNA3 did not know if the mask was a NIOSH approved (National Institute for Occupational Safety and Health, responsible for conducting research and making recommendations for the prevention of work-related injury and illness.). During an interview, on 11/24/2020 at 6 a.m., LVN 3 stated that in the red zone, staff should wear N95 mask, face shield, gown and gloves at all times. A review of the in-service form dated 11/20/2020, indicated CNA3 attended an in-service regarding review of Cohorting zones and PPE use by the Infection Preventionist 1. A review of the facility's policy and procedure titled, Transmission Based Precautions and Personal Protective Equipment (PPE), undated, indicated the N95 respirators with an exhaust valve do not provide source control and should not be used in healthcare settings. During an observation on 11/24/2020 at 6:34 a.m., CNA4 was not wearing a disposable gown in the red zone. During a concurrent interview, CNA4 stated she just removed a soiled disposable gown and would get a new one by the front desk located in the PPE donning area. During an interview on 11/24/2020 at 6:40 a.m., LVN 3 stated extra disposable gowns were in the PPE donning area and the nurse's station. LVN 3 verbalized that once staff was inside the red zone, staff cannot go back in the same entrance to get PPE. LVN 3 added that staff needed to go out via one way exit and go back through the front door entrance where the location of the screening was located. During an interview, on 11/24/2020 at 7 a.m., the DON stated there was only one-way entrance going in the red zone and one-way exit out. A review of Facility's Mitigation Plan (page 7), revised on 10/2/2020, indicated necessary PPE shall be immediately available outside of the resident room for COVID-19 positive, Person Under Investigation (PUI) , and in other areas where resident care was provided and PPE was required. 5. A review of Resident 2's Admission Record indicated the facility admitted the resident with [DIAGNOSES REDACTED]. Resident 2 was located inside the red zone. A review of Resident 3's Admission Record indicated the facility admitted the resident with [DIAGNOSES REDACTED]. Resident 3 was located inside the red zone. A review of Resident 8's Admission Record indicated the facility admitted the resident on 1/28/2020 with [DIAGNOSES REDACTED]. Resident 8 was located inside the red zone. During an observation on 11/12/2020 at 12:01 p.m., the facility did not have a clear designation between COVID-19 red zone or yellow zone units. Both entrances were observed with white plastic barriers inside and no signages were noted. During a concurrent interview, LVN 1 stated they were currently standing in the COVID-19 unit (red zone) and the other entrance was the yellow zone unit. LVN 1 worked in the red zone. During an observation in the red zone, on 11/12/2020 at 12:31 p.m., there were a few transmission- based precautions signages in between the rooms. Every room located in the red zone did not have proper transmission signages. During an observation of the room for Resident 2, Resident 3 and Resident 8, on 11/12/2020 at 1:20 p.m., there was no transmission signage noted immediately outside the residents' room. A review of the facility line listing indicated Resident 2, Resident 3 and Resident 8 tested positive for Covid-19 on 11/9/2020. During an interview, on 11/12/2020 at 2:45 p.m., when asked why the signage was not immediately outside of the resident's room to indicate appropriate infection control precautions, the DON stated all staff were aware where the red and yellow zones were located and that everyone in the red zone was positive with COVID-19. A review of the facility's Mitigation Plan (page 11), revised on 10/2/2020, indicated signs were to be posted immediately outside of resident rooms indicating appropriate infection control and prevention precautions and the required PPE, in accordance with CDPH guidance. 6. During an observation on 11/12/2020 at 12:31 p.m., facility tour was provided by the DON without the Infection Preventionist (IP). During an interview with Infection Preventionist 1 (IP 1) on 11/12/2020 at 2:33 p.m., she stated that she worked as in IP for this facility (SNF 1) and for the sister facility (SNF 2). IP 1 stated she was the only Infection Preventionist Nurse for both facilities. IP 1 stated she was not able to provide a division of hours between the two facilities. During an interview, on 11/12/2020 at 2:45 p.m., the DON stated the division of facility working hours were between the DON and IP 1 since the facility had a smaller bed capacity. The DON verbalized not having the required infection preventionist certification. A review of the California Department of Public Health (CDPH) All Facilities Letter (AFL) 20-52, dated 5/11/2020, indicated CDPH was requiring all Skilled Nursing Facilities (SNF)s to include development and implementation of Covid-19 mitigation plan. AFL 20-52 indicated for infection prevention and control as part of the six elements of the mitigation plan, The SNF must have a full-time, dedicated Infection Preventionist (IP).AFL 20-52 indicated under Coronavirus Disease 2019 (Covid-19) SNF Mitigation Plan Glossary that an IP may be considered a direct caregiver only when providing nursing services beyond the hours required to carry out the duties of the IP role, as long as these additional nursing hours are separately documented. 7. A review of Resident 8's Admission Record indicated the facility admitted the resident on 1/28/2020 with [DIAGNOSES REDACTED]. A review of the facility's line listing indicated Resident 8 tested positive for Covid-19, dated 11/9/2020. A review of the weights and vitals summary form, dated 11/22/2020 for Resident 8 indicated vital signs were conducted at 9:08 a.m., 1:57 p.m. and 8:54 p.m. This indicated vital signs were not conducted every four hours. A review of Resident 6's Admission Record indicated the facility admitted the resident on 12/1/2015 with [DIAGNOSES REDACTED]. A review of the facility's line listing indicated Resident 6 tested positive for Covid-19, dated 11/9/2020. A review of the weights and vitals summary form dated 11/22/2020, indicated Resident 6's vital signs were conducted at 9:12 a.m., 10:48 a.m., 1:33 p.m., 9:41 p.m., and 9:43 p.m. During an interview, on 11/23/2020 at 2:15 p.m., the Director of Staff Development (DSD) stated vital signs were to be conducted every four hours for COVID19 positive residents. During an interview, on 11/23/2020 at 2:45 p.m., the Administrator stated vital signs were done every four hours for COVID19 positive residents. During a telephone interview with CNA6 on 11/30/2020, at 10:04 a.m., CNA6 stated vital signs were done twice per shift at 9 a.m. and again at 1 p.m. This was a discrepancy from the DSD's statement. CNA6 stated charge nurses document the vital signs as CNAs do not have access to the charting system. During a telephone interview with LVN 4, on 11/30/2020 at 10:07 a.m., LVN 4 stated vital signs were taken twice per shift or every four hours or more frequent as needed. During a telephone interview with LVN 1 on 11/30/2020 at 4:30 p.m., LVN 1 stated vital signs were done by LVNs and CNAs twice per shift at 4 p.m. and 8 p.m. LVN 1 stated if it was not documented then it was not done. A review of the COVID-19 Facility Mitigation Plan, dated 5/29/2020, addendum 7/15/2020 and 10/2/2020, indicated residents with any suspected respiratory or infectious illness were assessed (including documentation of respiratory rate, temperature and oxygen saturation) at least twice during each shift, during the day and evening shifts, to quickly identify residents who require transfer to a higher level of care.

Based on interview and record reviews, the facility failed to ensure cardiopulmonary resuscitation (CPR (an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing)), was provided for one of 35 sampled residents (1). The facility failed to; 1. Ensure Resident 1, who was a Full code status (when the resident requests in writing that CPR and other lifesaving measures be given) was not provided with CPR when she was found unresponsive by a Certified Nursing Assistants (CNA 1) Even though Licensed Vocational Nurse (LVN 1) wrote in a deleration that on the first instance noted resident is moving, when lying on the floor, face down in a pool of blood, CPR was not initiated, 2. Ensure CNA 1 and LVN 1, provided CPR immediately when Resident 1 was found unresponsive, deprived the resident the possibility of survival, 3. Ensure their CPR training was not contrary to American Heart Association (AHA) CPR guidelines by advising unlicensed staff not to start CPR when a resident was found unresponsive, and 4. Ensure CNA 1, CNA 2, CNA 3, CNA 4 and the Director of Nursing (DON) were able to demonstrate knowledge regarding the proper protocol for the initiation of CPR. These deficient practices also had the potential to adversely affect 22 of 35 residents identified on Full code status and placed them at risk for potential harm or loss of lives. Because of the facility's failure to; ensure CPR was provided in accordance to the resident's request, the facility's implementation of a policy which contradicts AHA CPR guidelines, along with the nursing staffs failure to demonstrate knowledge of professional standards regarding proper CPR guidelines and protocols, an Immediate Jeopardy (IJ) was called on [DATE] at 2:07 p.m. The Administrator, assistant Administrator and the DON were informed of the IJ. Findings: a. On [DATE] at 11:40 a. m., an unannounced visit was made to the facility to investigate an Entity Reported Incident involving Resident 1 who was found on [DATE] at around 7 a.m., unresponsive in the room, lying on the floor. The resident was found on her right side next to the corner of the night stand, lying in a pool of blood oozing from her head. The resident was pronounced dead by the emergency response team (EMS) upon arrival on the same day at 7:20 a.m. The Director of Nursing (DON) and the assistant Administrator were advised of the visit. During an interview with the DON and the assistant Administrator on [DATE] at 11:40 a.m., the DON stated Resident 1 may have hit her head on the night stand which had a sharp metal handles located on each drawer or she hit her head on the over bed table that was next to the head of the bed. On the same day at 11:55 a.m., the DON stated she received a text message on her phone, sent by LVN 1, who was the ,[DATE] nurse, indicating the facility had an emergency. The DON stated she arrived at the facility at 7:35 a.m., and met two police officers who were questioning CNA 1, who worked the ,[DATE] shift, regarding the resident's cause of death. The DON stated she saw the resident lying on the floor unresponsive, bluish in color, cold and stiff, in a lot of blood that had been oozing from her head. The DON stated the coroner's office (inquire into and determine the circumstances, manner, and cause of all violent, sudden, or unusual deaths) was informed by the police department about the resident's death. The DON stated the resident's right side rail was down and she might had dropped from the bed to the floor in her sleep. The DON stated CPR was not initiated by the staff, but 911 (emergency dispatch) was called. When questioned if the staff had been trained how to initiate CPR, the DON stated Yes. The DON stated the staff were aware of the resident's Full code status. She further stated the facility's protocol was for CNAs not to touch any of the resident's who were on the floor, instead they had to leave and obtain help from a licensed nurse. According to the admission records Resident 1 was a [AGE] year old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. activities) and late effect of stroke (a decreased supply of blood to the brain). A review of the POLST, dated [DATE], indicated Resident 1 was Full code status which included CPR and full treatment to prolong life by all medically effective means. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], indicated Resident 1 had decreased ability to make self understood or to understand others, had impaired cognitive skills for daily decision making, needed minimum assistance from staff for transferring, dressing, toilet use, and used assistive device such as cane for ambulation. The MDS further revealed the resident was incontinent (loose control) of bowel and bladder functions. A review of the licensed nurses progress notes, dated [DATE] at 2:30 a.m., documented by LVN 2, ,[DATE] nurse, indicated Resident 1 was in bed asleep, and was offered assistance to the bathroom but did not need any assistance at that time. The notes also indicated at 7 a.m., (4 ,[DATE] hours later) LVN 2 was called to the resident's room. The resident was found unresponsive, lying on her right side with her head on the proximity of the night stand corner. The notes indicated on examination, the resident was not responsive or breathing, there was no pulse or no breathing. The notes indicated the resident was lying in moderate amount of blood which was oozing from the right side of her head which measured 3 by 3 centimeters laceration (a deep cut or tear in skin). The notes indicated 911 was called and upon examination, they pronounced the resident had expired. There was no documented evidence indicating CPR was initiated by any of the facility staff. On [DATE] at 12:30 p.m., during an interview with the Administrator, stated on [DATE] at approximately 8 a.m., he received a text message on his phone from the DON indicating Resident 1 was found on the floor next to the night stand, unresponsive, in a pool of blood oozing from her head. The Administrator stated the resident was pronounced dead by the paramedics. The Administrator was asked what was their CPR protocol when a resident was found unresponsive, he stated the staff should check the clinical records to determine if the resident was a Full code, then to get the crash cart and initiate CPR. On [DATE] at 1:45 p.m., in an interview with CNA 1, stated she went to Resident 1's room on [DATE] at approximately 7:15 a.m., opened the resident's privacy curtain to offer her milk and coffee because she drank them in the morning. CNA 1 stated she found the resident face down on the floor with her face on the metal part of the over bed table, lying in a pool of blood oozing from her head. CNA 1 stated she ran out of the room and shouted LVN 1's name. When asked what else did she do, CNA 1 stated she continued to pass the breakfast trays for the rest of the residents. When asked what is the protocol when a resident was found unresponsive, CNA 1 stated she was instructed by the Director of Staff Development (DSD) not to touch the resident, instead leave the resident and get help from a charge nurse. CNA 1 also stated she did not observe LVN 1 or LVN 2 obtain the vitals or perform CPR on the resident. On [DATE] at 2:07 p.m., during an interview with LVN 1, stated on [DATE] at 7:10 a.m. or 7:15 a.m., but not sure of the exact time, CNA 1 called him by his name at the top of her voice k come . come. LVN 1 stated he ran to Resident 1's room. LVN 1 stated LVN 2 followed him and found the resident on the floor unresponsive, face down next to her bed, lying in a lot of blood that was oozing from the head. LVN 1 stated he shook the resident's leg while saying, are you ok but the resident did not respond. LVN 1 instructed LVN 2 to call the EMS while he stayed with the resident. When asked how long he stayed with the resident, LVN 1 stated he was not sure. LVN 1 stated after 911 was called, LVN 2 came back to the room and stayed with the resident so he could resume his morning assignments. When asked why he did not initiate CPR, LVN 1 stated CPR was not provided because the resident was unresponsive and did not have a pulse (a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck). LVN 1 further stated when he felt the resident with his gloves, the resident was cold, blue and stiff. When asked if he was aware of resident's Full code status, LVN 1 responded yes but there was no signs of life. During a review of LVN 1's declaration notes, dated [DATE] it revealed when CNA 1 shouted for assistance, both LVN 1 and LVN 2 found Resident 1 on the floor, lying face down in a pool of blood. The notes by LVN 1 revealed On the first instance noted resident is moving. LVN 1 wrote he stayed with the resident but instructed LVN 2 to call 911. Even though LVN 1 noted the resident is moving, there was no indication her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate and blood pressure that indicate the state of a patient's essential body functions) were obtained and no documentation as to CPR had been initiated. On [DATE] at 10 a.m., during an interview with LVN 2, stated on [DATE] at 11 p.m., Resident 1 was observed in her room lying in bed. On the same dat at 1 a.m., he saw the resident in bed. At 3 to 3:30 a.m., he offered the resident a trip to the bathroom but she refused and stated she was ok. LVN 2 stated the last time he did rounds around 5 a.m., he saw the resident sorting magazine from her night stand top drawer. LVN 2 stated at 7:05 a.m., CNA 1 who worked morning shift found the resident on the floor when she went to the room to offer her breakfast. LVN 2 stated CNA 1 found the resident unresponsive lying on the floor, in a pool of blood, oozing from the right corner of her head in the proximity of the night stand metal drawers handles. When asked what was the facility's protocol when a resident was found unresponsive, LVN 2 stated he would check the resident's vital signs, call a code blue (requiring a team to rush to the specific location and begin immediate resuscitative efforts), call for help, review the medical records to ensure if the resident was a do not resuscitate (no CPR) or a Full code and then start CPR. When questioned why he did not initiate CPR when he found the resident unresponsive, LVN 2 stated CPR was not immediately initiated due to the color on her face indicating she had expired for quite sometime. When asked how he knew that, LVN 2 stated there was no sign of circulation and the resident's body was cold and stiff. LVN 2 stated at 7:30 a.m., he was instructed by LVN 1 to call 911 but when the paramedics arrived at 7:35 a.m., they pronounced the resident dead. On [DATE] at 1:10 p.m., during an interview with CNA 4 stated when the round was made on [DATE] at 11:30 p.m., he saw Resident 1 in bed. CNA 4 stated but the last time he saw the resident was at 4 a.m., as she was sitting on the bed with her legs on the floor. CNA 4 stated he left the facility at 6:55 a.m., and was not aware of the incident involving the resident. CNA 4 stated the resident usually used the restroom by herself and even dressed herself but used a cane when walking. CNA 4 stated the resident held objects like bed or over the bed table when attempting to go from sitting to standing position. On [DATE] at 6:02 a.m., during an interview with CNA 4 when asked what was the facility protocol when a resident was found unresponsive, CNA 4 stated he was instructed by DSD not to touch the resident and go and get help from the charge nurse. When asked how to perform CPR, CNA 4 stated twenty chest compressions, give oxygen and remove tight clothes and open the mouth. Because of the facility's failure to; 1. Ensure Resident 1, who was a Full code status (when the resident requests in writing that CPR and other lifesaving measures be given) was not provided with CPR when she was found unresponsive by a Certified Nursing Assistants (CNA 1) and a Licensed Vocational Nurse (LVN 1), while lying on the floor, face down in a pool of blood, 2. Ensure CNA 1 and LVN 1, provided CPR immediately when Resident 1 was found unresponsive, deprived the resident possibility of survival, 3. Ensure their CPR training was not contrary to American Heart Association (AHA) CPR guidelines by advising unlicensed staff not to start CPR when a resident was found unresponsive, and 4. Ensure CNA 1, CNA 2, CNA 3, CNA 4 and the Director of Nursing (DON) were able to demonstrate knowledge regarding the proper protocol for the initiation of CPR. These deficient practices also had the potential to adversely affect 22 of 35 residents identified on Full code status and placed them at risk for potential harm or loss of lives an IJ was called. The facility provided an acceptable plan of correction which included the following: 1. CPR Course provided for CNAs. 2. A lecture held to demonstrate and return demonstration CPR 3. The Inservice consisted of immediate response to someone/resident found unresponsive on the floor 4. Life and Safety Guide- included eight signs of abuse, immediate response for unresponsive resident, codes for disasters-which will be placed on the back of name tags. 5. Skilled testing checklist from American Heart Association (AHA)-Demonstrated with return demonstration which includes but not limited to immediate cardiopulmonary resuscitation. Handouts which include skill description 6. Emergency crash cart-Placed an order for [REDACTED].>The immediate jeopardy was lifted on [DATE], at 5:15 p.m. The facility administrator and director of nursing was notified. b. During an interview on [DATE] at 7:05 a.m., Restorative Nurse Assistant (RNA 1) was asked when what to do when a resident was found unresponsive, RNA 1 stated to call the License Vocational Nurse (LVN 1), or the Director of Nursing (DON), do not touch or move them. RNA 1 stated that was what they told us to do. When asked to explain how they performed CPR, RNA 1 stated push ten times on chest bring head back pinch nose blow thru the mouth three to four times and repeat. During an interview on [DATE] at 7:25 a.m., CNA 1 was asked what to do when a resident was found unresponsive, stated call the charge nurse, check the resident to see if alive and call 911. CNA 1 further stated the Designated Staff Developer (DSD) told them not to move or touch the resident. When asked to explain how they performed CPR, CNA 1 stated chest compression five times two breaths and repeat. During an interview on [DATE] at 7:45 a.m., CNA 2 was asked what to do when a resident was found unresponsive, CNA 2 stated call for help, not allowed to move the resident instructed by DSD to call 911. When asked to explain how to perform CPR, CNA 2 stated ten chest compressions listen for breath five breaths and repeat. During an interview on [DATE] at 7:50 a.m., CNA 3 was asked what to do when a resident was found unresponsive, CNA 3 stated call the charge nurse and do not move the resident. When asked to explain how to perform CPR, CNA 3 stated pressing hands spread apart not sure ten compressions and three breaths and repeat. On [DATE] at 8: 10 a.m., during an interview with the Director of Nursing (DON) when asked what to do a resident was found unresponsive, stated to assess for pulse and respiration, check full code order, initiate CPR and call for help. When asked if DON knew how to perform CPR, DON stated she would if performed by one staff they had to give 100 compression and two breaths but if performed by two staff, 60 compressions and one breath would be given. DON was asked how did the nursing staff determine which resident was DNR (to withhold CPR) or Full code status during an emergency. The DON stated the nursing staff would have to look in the resident' medical records to check for a code status before performing CPR. The DON was asked what would happen if a resident did not have a code status in their medical records, DON stated the resident was automatically considered a Full code status. The DON further stated if a licensed nurse was unable to locate a resident's code status the nurse would call the family and instruct another licensed nurse to perform CPR. Due to the facility's failure to ensure LVN 1, LVN 2 and CNA 1 responded immediately to begin CPR for Resident 1 who was unresponsive, in need of immediate emergent care and was full code. The , and to ensure CNAs 1, 2, 3, 4 and DON were properly trained in when and how to initiate CPR according to professional standards which entails to respond to life threatening medical emergency situations in a timely and effective manner. An immediate jeopardy was called on [DATE] at 2:07 p.m., with the Administrator, Assistant administrator and the Director of Nursing. On [DATE] at 4:55 p.m., the administrator, DON and assistant Administrator presented an acceptable plan of correction action which consisted of the following: LVN 1, LVN 2, CNA 1 who did not respond immediately to begin CPR for Resident 1 were provided one-to-one inservice by the DON on emergency procedures in accordance with the facility's policy. The insevice began immediately on [DATE] and was completed on [DATE], which will be repeated on a bimonthly basis. CNAs 1, 2, 3, 4 and DON were retrained on how to properly respond when a resident was found unresponsive. The staff also obtained a new CPR Cards. The admission licensed nurse will verify and clarify the residents code status, license nurses will conduct daily rounds to assess each resident's condition and making sure the proper code status identification was in place. On [DATE] at 5:15 p.m., the Surveyor team met with the Administrator, assistant Administrator and the DON, informed them the IJ was lifted. c. During an interview and review of the clinical records for 35 sampled residents indicated 22 residents had a Full code status. The DON on [DATE] at 12 p.m., stated the facility does not have a crash cart (supplies for CPR) and promised to order one and educate staff on how to use it. A review of the employees files indicated the following employees possed the cards but did not perform CPR on Resident 1 when she was found unresponsive, face down on the floor in a pool of blood; LVN 1 CPR Card issued on [DATE] with a recommenced renewal date [DATE] LVN 2 CPR Card issued on [DATE] with a recommenced renewal date [DATE] CNA 1 CPR Card issued on [DATE] with a recommenced renewal date [DATE] CNA 2 CPR Card issued on [DATE] with a recommenced renewal date [DATE] (EXPIRED) CNA 3 CPR Card issued on [DATE] with a recommenced renewal date [DATE] CNA 4 CPR Card issued on ,[DATE] with a recommenced renewal date [DATE] The facility's policy and procedure revised [DATE] titled Emergency Procedure - Cardiopulmonary Resuscitation indicated CPR is immediately initiated in case of recognized cardiac and or [MEDICAL CONDITION] arrest until medical emergency personnel are available to take over the resuscitation efforts. The first certified CPR staff to arrive and find a resident unresponsive and breathless and pusleless will identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling his or her name. The policy indicated to respond to the resident immediately and send available staff to call 911, and return for help. According to the Vocational Practice Act 2518.6 Performance Standards; a licensed vocational nurse shall safeguard the patient's health and safety by actions that include maintaining current knowledge and skill for safe and competent practice. A review of the American Heart Association CPR guidelines, dated 2015 revealed the first thing to recognize [MEDICAL CONDITION] (a sudden, unexpected loss of heart function, breathing and consciousness) was to check for responsiveness. If there was an unwitnessed collapse; where there was no breathing or only gasping for breath, no definite pulse felt within 10 seconds, the instructions were to send someone for help and to begin CPR immediately.

Based on interview and record review, the facility failed to provide cardiopulmonary Resuscitation (CPR) for Resident 1, who was a full code and found by certified staff unresponsive (without a heart beat and without respiration), laying face down in her room, with blood oozing from her head. Failure to follow Resident 1's physician's orders [REDACTED]. This deficient practice resulted in Resident 1 not being afforded the opportunity to survive and receive the full benefit of CPR per her request. Consequently, Resident 1 expired at the facility. Findings: On [DATE] at 11:40 a. m., an unannounced visit was made to the facility to investigate an Entity Reported Incident involving Resident 1 who was found on [DATE], at around 7 a.m., unresponsive in the room, lying on the floor. The resident was found on her right side next to the corner of the night stand, lying in a pool of blood oozing from her head. The resident was pronounced dead by the emergency response team (EMS) upon arrival on the same day at 7:20 a.m. The Director of Nursing (DON) and the assistant Administrator were advised of the visit. On [DATE], at 11:40 a. m., unannounced visitation was made to the facility to investigate a complaint / Entity Reported Incident (ETI) for a resident who was found on the floor on her right side next to the corner of the night stand in her room unresponsive, laying in a pool of blood oozing from her head. Resident was pronounced death by the Emergency Response Team on [DATE]. Surveyor met with the Director of Nursing (DON) and the assistant administrator at the nurses' station one. During an interview with the DON and the assistant in the resident's room, she stated the resident may have hit her head on the night stand that had a sharp oval metal handle on each drawer, that was closer to the be,d or the over head table that was next to the head of the bed. At 11: 55 a. m. on the same date, DON stated she received a text message on her phone sent by Licensed Vocational Nurse 1(LVN) noting the facility has an emergency. The DON stated she arrived at the facility at 7:35 a.m and met two police officers questioning CNA 1 regarding the resident's cause of death. The DON stated she saw the resident laying on the floor unresponsive, in a lot of blood oozing from her head. The DON stated the resident looked bluish, cold and stiff. DON stated the CONER Office was informed by the Police Department (). The DON stated the resident's right bedside rail was down and the resident might have dropped from the bed to the floor in her sleep. The DON stated CPR was not initiated by the staff, but 911 was called. When questioned if the facility's staff had been trained on CPR, the DON stated Yes. The DON was asked if staffs were aware of the resident's full code status to which she responded Yes and stated staffs are not to touch any resident on the floor, instead, they had to leave and get help from other licensed staffs. According to the admission record, Resident 1 was an [AGE] year old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- standardized assessment and care screening tool) dated [DATE], indicated Resident 1 had decreased ability to make self-understood or to understand others. Resident 1 had slow or minimal cognitive skills for daily decision making, required minimum assistance from staff for transferring, dressing, toilet use and personal hygiene,and was decline in continence (control) of bowel and bladder functions due to dementia A review of the Physician order [REDACTED].) dated [DATE], indicated Resident 1 wished an attempt of (CPR) and full treatment for [REDACTED]. A review of the nurse's noted dated [DATE] at 2: 30 a. m., indicated Resident 1 was noted in bed asleep, offered assistance to the bathroom, no assistance needed at this time. Progress notes also indicated at 7 a. m., found resident unresponsive, lying on her right side with head on the proximity of the night stand corner, no pulse and no breathing, lying in moderate amount of blood oozing from the right side of resident's head. resident sustained [REDACTED]. At 7: 30 a. p m., 911 was called for assistance. 911 arrived after 35 minutes and pronounced resident dead. There was no documented evidence indicating the resident's vital signs were assessed, or CPR was initiated and or code blue was called. Delete: Failure to initiate CPR immediately after the facility's staff realized that Resident 1 was breathless and pulseless, resulted in insufficient of oxygen to the resident's brain. A review of the clinical records of 35 sampled residents indicated 22 residents were identified as a full code status per the physician's orders [REDACTED]. m., she stated the facility does not have a crash cart, but promised to order one and educate staff on how to use it. On the same date at 12:30 p. m., during and interview with the administrated in room (3c), he stated he received a text message on his phone from the DON approximately 8 a.m. stating that resident 1 was found on the floor, unresponsive, in a pool of blood oozing from her head and was pronounced death by the paramedics. In an interview with the administrator, he was asked when a resident is found unresponsive and breathless what should be done? he stated CPR was not necessary at the time resident was found because she had expired for quite sometime. The Administrator further stated, staff failed to call code blue, get the crash cart and then, initiate CPR. On [DATE] at 1: 45 p. m., in an interview CNA 1 stated she went to resident 1's room on [DATE] at 7: 15 a. m., opened the privacy curtain to offer her milk and coffee because the resident preferred coffee and milk in the morning. CNA 1 stated Resident 1 was found on the floor with her head raised on the metal bar part of the over bed table, breathless and pulseless, laying in a pool of blood oozing from her head. CNA 1 stated she ran out of the room,shouted LVN 1'S name. When CNA 1 was asked what else did she do, CNA 1 stated she continued to pass the breakfast trays to the rest of the resident. CNA 1 was asked when a resident is found unresponsive and pulseless what will she do, CNA 1 stated she was instructed by the director of staff development not to touch the resident, leave the resident and get help from charge nurse. On [DATE] at 2: 07 p. m., during an interview with LVN 1, he was asked, how he assessed Resident 1 when he first saw the resident on the floor unresponsive? LVN 1 stated, he shook the resident's leg, are you ok, but the resident remained unresponsive. LVN 1 stated he instructed LVN 2 to call Emergency Response Team (911), then he stayed with the resident. He said after 911 was called, LVN 2 came back to the room and stayed with the resident and he left to resume his morning shift assignment, blocked the room and kept all the other residents in the dinning room until fire department arrived at 9 a. m. When asked why didn't he initiates CPR? LVN 1 stated CPR was not provided due to his assessment of unresponsive. LVN 1 was asked how he conducted resident's assessment, LVN 1 stated by visual observation. When asked it vital signs were taken, LVN 1 stated, resident's skin was cold, blue and stiffen when he felt with his gloved hand. When asked if he was aware of resident's full code order, LVN 1 responded yes but was no sign of live. On [DATE] at 10 a. m. to 12 p.m., during an interview with LVN 2, stated that on ,[DATE]/ 2017 Resident was observed during round at 11 p. m. in her room lying in bed. At 1 a. m .on [DATE] stated he saw resident in bed. At 3 to 3: 30 a. m. stated he offered Resident 1 a trip to the bath room but resident refused and stated she was ok. He stated the last time he did round and saw Resident 1's sorting magazine from her night stand top drawer was at 5 a. m. on [DATE]. on [DATE] at 11a. m., LVN 2 was questioned regarding Resident 1's activity prior to her discovered on the flood death LVN 2 stated Resident 1 usually had the ability to make self-understood and usually had the ability to understand others. Ambulates to the bath room sometime with assistant but sometimes uses pull- ups. LVN 2 at 12 p. m., stated on [DATE] at 7:05 a. m, CNA 1 who worked morning shift found Resident 1's on the floor when she went to the room to offer her breakfast but unfortunately, found the resident unresponsive lying on the floor in a pool of blood, oozing from the right corner of her head in the proximity of the night stand metal plate that was attached to the drawers as hand holders. LVN2 was asked when a resident found unresponsive and breath less what should be done?LVN 2 stated he would check the resident's vital signs, call a code blue, call for help, and check resident's medical record to ensure if resident is a DNR or a full code, then start CPR. When questioned why he did not initiate CPR? LVN 2 stated CPR was not immediately initiated due to the color of her face and she had expired for quite sometime. When asked how did he know, LVN 2 stated the was no sign of circulation, body was cold and stiffen. LVN 2 stated, at 7: 30 a.m he was instructed by LVN 1 to call Emergency Respond Team (ERT) that arrived at 7: 35 a. m. and pronounced resident death. LVN2 stated, Santa Monica Police Department(SMPD)was notified and the informed the Corner office and at 10 : 15 a. m. On [DATE] at 1:10 p. m., during an interview with CNA 4 stated rounds were done on [DATE] at 11 : 30 p. m., and she saw the resident in bed. CNA 4 stated the last time he saw Resident 1 was on [DATE] at 4 a. m. sitting on her bed with legs on the floor. He stated resident usually used the restroom by her self and even dresses herself. CNA 4 stated Resident 1 uses a cane when walking and held onto objects like a bed or bed table when sitting to a standing position. CNA 4 stated he left the facility at 6:55 a. m. on [DATE] and he was not aware of Resident 1's death until his return to work. On [DATE] at 6:02 a. m., during an interview with CNA 4 when asked when a resident is found unresponsive what should be done, CNA 4 stated he was instructed by DSD not to touch the resident, go and get help from the charge nurse. When asked if CNA 4 knows how to perform CPR, CNA 4 stated to administer twenty chest compressions, give oxygen and remove tight clothes and open the mouth. On [DATE] at 3 : 25 p. m., in an interview with the director of nursing, she stated if the resident was found with a change of condition, the staff should have checked the vital signs; if the resident was not breathing, staff should have performed CPR and administered oxygen. The facility policy and procedure revised [DATE] and titled Emergency Procedure - Cardiopulmonary Resuscitation indicated CPR is immediately initiated in cases of recognized cardiac and or [MEDICAL CONDITION] arrest until medical emergency personnel are available to take over the resuscitation efforts. The first certified CPR staff to arrive and find a resident unresponsive and breathless and pusleless will identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling his or her name. Respond to the resident immediately and send available staff to call 911, and return for help. The policy does include the most recent changes from the American Heart Association ( C-A-B- chest compressions, airway, breathing). According to the American Heart Association Adult Basic Life Support for Healthcare Providers Manual dated 2016, when the resident is unresponsive with no breathing or no normal breathing, the first step is to check for alertness, Start compressions, check airway check breathing, check pulse, shout for help/Activate emergency response system. Procedures include to place hand on lower half of the sternum (breast chest area); give 30 compressions in less than 15 and no more than 18 seconds; Compresses at least 2 inches (5 centimeters) and ensure the chest rises that would indicate the resident is receiving the oxygen. Give two breaths with a bag - mask device - a method of delivering rescue breath at one second. Compression should be resumed in less than ten seconds.

Based on observation, interview and records reviews, the facility failed to provide adequate supervision and to ensure the environment was free of accident hazards in order to minimize the injuries when a fall occured, resulting in laceration (a deep cut or tear in skin or flesh) to the forehead with massive amount of blood loss for one of 35 sampled residents (1). The paramedics (provide advanced emergency medical care) upon arrival, pronounced the resident had expired. The facility failed to: 1. Ensure Resident 1's siderail was up to prevent a fall while resident was in bed, 2. Ensure Resident 1's over the bed table and the night stand was not placed close to the bed to prevent accidents, 3. Ensure plan of care developed for at risk for falls/injury related to impaired cognition, poor balance and poor safety awareness / judgement was specific about the frequency of visual observation of the resident, 4. Ensure to implement its own policy and procedures for fall prevention and management program that included all residents' environment shall remain as free of accident hazard as possible and all residents shall receive adequate supervision and assistive to prevent accidents. These violations resulted in Resident 1's fall from bed to the floor. The resident sustained [REDACTED]. Findings: During an unannounced visit to the facility on [DATE] at 11:40 a.m., was made to investigate an Entity Reported Incident (ERI). The ERI indicated on [DATE] at about 7 a.m., Resident 1 was found face down on the floor, in her room, oozing blood from her head. The resident was pronounced dead. According to the admission records Resident 1 was a [AGE] year old female, who was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS), a standardized assesment and care screening tool, dated [DATE] indicated Resident 1 had decreased ability to make self-understood or to understand others. The resident had problems with cognitive skills for daily decision making, needed minimum assistance from staff for transferring, dressing, toilet use and personal hygiene. The resident was incontinent (lost control) of bowel and bladder functions. A review of Resident 1's plan of care initiated on [DATE] and revised [DATE], indicated the resident was at risk for falls related to limited mobility, impaired cognition (thinking problem), poor balance and needing limited assistance with care. The goal was to demonstrate preventive measures to minimize injury on a daily basis, keep the environment clear anf free from harzard at all times and monitor the resident when ambulating. The interventions included the following; frequent visual observation of the resident, proper fitting shoes, safe and clutter-free environment and to keep call ligt within easy reach. However, the plan of care did not show frequency of monitoring of visual observations and checks was to be made. A review of the fall risk assessment, dated [DATE] indicated Resident 1 scored ranged between 17, with a total score of 10 or greater represented a high risk for falls. A review of the facility's incident report, dated [DATE] indicated Resident 1 fell in the hallway when walking with a cane. The report indicated a right hip with pelvis (the large bony structure near the base of the spine) x-ray was done on on the same day which revealed no fracture (broken bone). However, there was no documented evidence in the residet's clinical records indicating interdeciplinary team (experts from several different fields who work together toward a common business goal) meet to revise the interventions on the care plan after the fall. The physician's orders [REDACTED]. The order indicated to give 1 tablet by mouth at bedtime for insomnia (inability to sleep) at 8:30 p.m. A review of the Medication Administration Records, dated for the month of January and February, March, April and [DATE] indicated Resident 1 had been taken Melatonin every night at 8:30 p.m. On [DATE] at 11:45 a.m., during an observation of Resident 1's room (3 C) indicated a night stand next to the bed. The night stand had four drawer and each draw had a metal plate with sharpe edges. The bed was unlocked and the over bed table had two wheels that were not locked when pushed to the side. The call light was not within an easy reach of anyone lying in bed and it was tied down to bed B. During an interview with the director of nursing (DON) stated the resident might had fallen out of bed in her sleep since the right upper side rail was in an upright position. The DON stated the resident had poor balance and when reaching the over bed table, the table might had moved because the wheels were broken, causing her to slip and fall. When asked how often does the staff monitor or do rounds, DON stated rounds are made every two hours. The DON further stated the resident fall should have been prevented if the night staff did rounds every two hours per their policy titled Routine Rounds. On [DATE] at 4:25 p.m., in an interview with Licensed Vocational Nurse (LVN 1) stated Resident 1's goal that addressed the plan of care for falls was revised after the first fall on [DATE]. However, he stated the nursing intervention for the fall care plan was not revised to prevent another fall. LVN 1 further stated the right siderail should have been raised to prevent the resident from falling out of bed. During an interview with LVN 2 on [DATE] at 11:50 a. m., LVN 2 stated he made the last round to Resident 1's room at 1:30 a.m., by peeking through the privacy curtain. He stated the resident was standing next to the night stand, sorting out magazines from the top night stand drawer. LVN 2 stated he believed the resident must had fallen and hidden her head on the night stand's metal handel. When asked if the resident was provided assistance to the bathroom, LVN 2 stated the resident usually used the restroom by herself using a care. When LVN 2 was asked if the resident was wearing proper fitting shocks or shoes, he stated she had no socks or shoes on her feet. LVN 2 stated he failed to provide rounds to the resident per their own facility's policy. He further stated the resident's fall should had been prevented if they provided frequent rounds and more assistance to her. When questioned about the call light, LVN 2 said residents here do not have the capacity to use call light, call light are jut for formality. When asked if the resident took medication that could enhance sleep, LVN 2 stated she took Melatonin (a hormone used to regulates sleep and wakefulness) every night at 8:30 p.m., for an inability to sleep. LVN 2 stated resident might had fallen due to dizziness or drowsiness of the sleeping medication. On [DATE] at 1 p.m., in an interview with Certified Nursing Assistant (CNA 4) stated he put down the right bedrail in order to enable Resident 1 to get out of bed so she could use the restroom unattended. CNA 2 stated if the right bedrail was in an upward position it should have prevented the resident falling from her bed. On [DATE] at 2:30 p.m., in an interview with DON, stated the bed side tables and over the bed tables would be replaced to prevent further injuries to other residents. The DON stated she believed if this plan of not having the bed side and over the bed table, Resident 1 would not had fallen, sustained head injury and bled to death. A review of the facility's Incident / Accident Report, dated [DATE] at 8 a.m. and a letter by the Administrator addressed to the Department of Public Health (DPHS), dated [DATE], indicated CNA 1 was fetching the residents from her room for breakfast at 7 a.m., when she found Resident 1 lying on the floor. The letter indicated the resident was on her right side next to the corner of the night stand, unresponsive, oozing blood from her head. LVN 2 checked the residet, called [DATE] and at 7:20 a.m., paramedics arrived and prononounced the resident had expired. The report concluded the resident must have fallen, hitting the corner of the night stand as she was waiting to be fetched for breakfast. The report indicated the resident fell and sustained a skin tear of 3 by 3 centimeters on the right side of her forehead which was bleeding. The resident was dead. According to an undated facility's policies and procedures titled Fall Prevention and Management Program indicated all resident's environment shall remain as free of accident hazard as possible and all resident shall receive adequate supervision and assistive devices to prevent accidents. All resident shall be assessed for being at risk for falls. And resident indentified as at risk for fall shall have an individual plan of care that included interventions to prevent falls from occuring. A review of a facility's policy and procedures titled Patient Rounds indicated rounds shall be made to promote comfort, and monitor well being of all resident while in the facility. Nursing staff shall make rounds every two hours to check the needs of residents, and address the needs as required. At night, nursing staff shall follow a turning/repositioning program that includes changing of the resident's position and realignment of body.